Chronic Pancreatitis

 

             

  • Pancreatic Function Tests in Chronic Pancreatitis
  •    Direct: measure the output of enzyme/Bicarbonate from pancreas
  •    Indirect: Measure enzymes in blood

                                     

                            Direct Tests

  • – 30-50 % of functional reserve of pancreas should be preserved to be positive
  • Who should undergo pancreatic function test?
  • – Patients who did not reveal easily identifiable structural/functional abnormalities. e.g CT
  • – Patients with small duct disease
  •      Methods:
  • ♦ Intraductal secretin Test
  •       – Collect pancreatic secretion during ERCP by placement of catheter directly in the pancreatic duct
  • ♦ Standard direct pancreatic test
  •       – Measure bicarbonate in duodenum by inserting oroduodenal tube
  •       Procedure:
  •  2 µg/kg recombinant secretin
  •                     ⇓  Sample collection by dreiling tube/endoscope
  • Sample collection 15 minutes interval for 60 minutes
  •                     ⇓
  • Sample analysed for bicarbonate concentration
  •    (Test is abnormal if bicarbonate <80 mEq/L)

                         Indirect Tests

  • 1.Serum trypsinogen ( S.trypsinogen< 20ng/ml)
  • 2.Pancreatic Enzymes in stool (low fecal Chymotrypsin/Elastin)
  • 3. Fecal fat excretion
  •               Qualitative:
  • – Done by Sudan III stain in random stoolsample
  • – >6 fat globules/HPF is considered positive
  •                Quantitative:
  • – >7% ingested fat should be present to be positive

       

              Imaging studies of Chronic Pancreatitis

  •                   Plain X-ray abdomen:
  • – Diffuse (not focal) pancreatic calcification
  • – Focal calcification seen in
  •             • Cystic pancreatic tumor
  •             • Islet cell tumor
  • – Calcification occur late in the natural course of the disease. Take 5-25 years to develop
  • – Calcification is more common in
  •           • Alcoholic
  •           • Late-onset idiopathic
  •           • Hereditary
  • – Calcification is accelerated by smoking
  • – Calcification is not a static process, it wax and wane over time
  •                
  •             Abdominal USG:
  • – Dilatation of pancreatic duct
  • – Shadowing pancreatic ductal stone
  • – Gland atrophy/ enlargement
  • – Irregular gland margin
  • – Pseudocysts
  • – Changes in parenchymal echotexure

 

  •              MRCP/MRI:
  • – Improved visualization of pancreatic duct can be achieved by I.V secretin administration
  • – Gadolinium administration may improve gland image
  •    Diagnosis of Chronic Pancreatitis by EUS:
  • 1. Standard diagnostic system :
  • – Based on the presence of abnormalities in the pancreatic duct and pancreatic parenchyma
  • Parenchymal abnormalities :
  •              • Hyperechoic foci
  •              • Hyperechoic strands
  •              •Lobularity of contour
  •              •Cysts
  • – Ductal abnormalities
  •              • Main duct dilatation
  •              • Main duct irregularity
  •              • Hyperechoic ductal walls
  •              • Visible side branches
  •          
  •                          Figure: EUS of the pancreatic body in a patient with CP.
  •            – The markers on the dilated pancreatic duct (lower left) demonstrate hyperechoic margins, a diagnostic feature of CP.
  •            – The parenchyma surrounding these markers demonstrates hyperechoic strands and foci, which are additional features of CP
  •                            Rosemount EUS diagnostic criteria for chronic pancreatitis
  •  Table : Cambridge Grading of Chronic Pancreatitis Based on Findings on Pancreatography
  •                             FOLD:
  •                         F- Filling defect
  •                         O- Obstruction/Stricture
  •                         L- Large cavity
  •                         D- Dilatation or irregularity

 

           Management of Chronic Pancreatitis :

  • 1. Management of abdominal pain
  • 2. Management of maldigestion and steatorrhea
  • 3. Management of complication
  •                            – Pseudocyst
  •                            – GI bleeding
  •                            – Bile duct obstruction
  •                            – Duodenal obstruction
  •                             – Malignancy  

 

  • Management of abdominal pain
  • A. Initial evaluation should focus on :
  •    ♦ To identify associated conditions e.g
  •               – Pancreatic pseudocyst
  •               – Duodenal (possibly bile duct) compression
  •               – Superimposed pancreatic carcinoma
  •               – Gastroparesis

 

  • B. Medical Therapy :
  •            – Analgesic
  •            – Cessation of alcohol and tobacco
  •            – Antioxidant
  •            – Pancreatic enzyme therapy
  •            – Octreotide
  • C. Endoscopic Therapy :
  •            – Pancreatic duct shincterotomy
  •            – Stent placement
  •            – Pancreatic duct stone removal
  •            – Combined endoscopic therapy
  •  D. Surgical therapy
  • E. Nerve block and neurolysis

 

Endoscopic Therapy for abdominal pain of chronic pancreatitis

  •         Indication :
  • – Big duct disease
  • – Advanced structural abnormalities of the pancreatic duct
  • – Dilated pancreatic duct who also has a dominant stricture or an obstructing stone in the head of the pancreas with dilatation of the pancreatic duct upstream of the dilation
  • Stricture and calculi in the upstream body or tail of the gland are not amenable to endoscopic therapy       
  • Pancreatic duct sphincterotomy
  •                Indication :
  • – Large-calibre pancreatic stent placement
  • – Pancreatic duct stone removal
  • Pancreatic Stent placement :
  •                  Performed to:
  • – Dilate obstructing stricture
  • – Bypass an obstructing stricture 
  •         Complications of stent therapy:
  • – Clogging of stent (produces recurrent pain, acute pancreatitis, pancreatic sepsis)
  • – Stent migration
  • – Ductal perforation

 

             Pancreatic duct stone removal

  • – It is possible only in a subset of patients
  • – Contraindication of stone removal:
  •                 • Multiple stone
  •                 • Large stone
  •                 • Stone in the body and tail
  •                 • Stone in the side branches
  •                 • Impacted stone
  •                 •Stone behind a tight pancreatic duct stricture
  • Large /impacted stone removal needs  lithotripsy, ESWL, intraductal lithotripsy device

 

  • Surgical therapy for chronic pancreatitis
  •                     Indication :
  • – Intractable abdominal pain for which medical therapy has failed
  •                Surgical options:
  • 1. Pancreatic ductal drainage
  • 2. Pancreatic resection (complete/partial)

 

  • 1. Pancreatic ductal drainage procedure :
  •            – To relieve ductal obstruction
  •           – To relieve pancreatic pressure
  • Prerequisite for ductal drainage :
  •           – Dilatation of pancreatic duct > 6 or 7 mm
  • Procedures of pancreatic ductal drainage :
  •           – Lateral pancreatico jejunostomy
  •          – Partington-rochelle modification of puesto procedure

 

  • 2.Pancreatic resection
  •           – Whipple  resection
  •                  Indication
  • – Disease limited to head of pancreas
  • – Large inflammatory mass of pancreas in whom malignancy is also considered

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