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Chronic Pancreatitis


Chronic pancreatitis is a continuous, inflammatory condition with irreversible morphological changes to the pancreas. Due to the inflammation, patient experiences abdominal pain and functional deterioration of the endocrine and exocrine glands. The complication of chronic pancreatitis is often pancreatic fibrogenesis with a complex interplay of chemokines and cytokines. The disease is characterized by formation of stones in the pancreatic duct as well as the parenchyma. This causes increased pressure in the duct and causes severe pain. Usually these patients develop multiple attacks of pain.

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Causes

  • Autoimmune disorders due to elevated immunoglobulin IgG4
  • Alcoholic pancreatitis: excessive alcohol consumption and abuse
  • Hereditary: inherited disorder
  • Cystic fibrosis: common genetic abnormality
  • Acquired obstructive chronic pancreatitis: due to accidents and blunt abdominal trauma
  • Hypercalcemia
  • Tropical Calcific pancreatitis (TCP)

Signs and symptoms

  • Abdominal pain
  • Intermittent painful attacks in the upper left abdomen radiating to midback
  • Diarrhoea
  • Weight loss
  • Fatty stools
  • Nausea
  • Vomiting
  • Excessive thirst
  • Fatigue
  • Diabetes

Diagnosis

Physical examination:

Characteristic relief of abdominal pain by lying on the left side or flexing the spine

Tender mass palpated in epigastrium in the presence of a pseudocyst

Blood tests:

  • Serum amylase
  • Lipase levels
  • Serum calcium
  • Triglyceride levels
  • Cationic trypsinogen and CFTR

Fecal tests:

  • Fecal chromotrypsin
  • Fecal elastase levels for exocrine function assessment

Imaging:

  • Abdominal radiography: to check for abdominal calcifications
  • CT scan: for detecting morphologic changes of chronic pancreatitis
  • ERCP: for accurate visualization of the pancreatic duct
  • Magnetic resonance cholangiopancreatography: for information on pancreatic duct and bile ducts
  • Endoscopic ultrasonography: for visible side branches, cysts, lobules, irregularity in pancreatic duct, hyperechoic foci, dilation of pancreatic duct, hyperechoic margins of pancreatic duct

Treatment

Treatment is indicated for intractable pain or if some complications like inflammatory mass, pseudocysts or biliary strictures develop. Treatment of chronic pancreatitis is with pancreatic duct drainage, pancreatic resection or total pancreatectomy and islet autotransplantation. In a pancreatic duct drainage, a pancreaticojejunostomy with a Roux-en Y is done. In this the entire pancreatic duct is laid open, all the stones in the pancreas are removed and the duct is joined to an isolated loop of small intestine. This relieves the increased ductal pressure and gives good relief of pain. A Whipple operation is performed where only the head of the pancreas is involved. If the disease affects only the tail of pancreas distal pancreatectomy is performed. Total pancreatectomy is rarely done as it can lead to brittle diabetes.

We treat chronic pancreatitis with behavioural modifications like recommended abstinence from alcohol and has extensive experience in the surgical treatment of chronic pancreatitis and its complications.

Authored by Dr. Deepak Varma, MBBS, MS (General Surgery)

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