Pancreatitis

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Chronic pancreatitis mcq

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Abdominal pain radiated to backIf s. amylase is low it can be excludedGuarding is characteristicNSAIDs are not contra-indicted.

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All you need to know

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Chronic pancreatitis is persistent inflammation of the pancreas that results in permanent structural damage with fibrosis and ductal strictures, followed by a decline in exocrine and endocrine function. Drinking alcohol and smoking cigarettes are two of the major risk factors. Abdominal pain is the predominant symptom in most patients. Diagnosis is usually made by imaging studies and pancreatic function testing. Treatment mainly includes pain control and management of pancreatic insufficiency.

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Chronic pancreatitis can be broadly classified into 3 forms:

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• Chronic calcifying pancreatitis • Chronic obstructive pancreatitis • Chronic autoimmune pancreatitis

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Chronic calcifying pancreatitis is the most common form and is characterized by calcification of the pancreatic parenchyma, formation of intraductal stones, or both.

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Ty

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Chronic obstructive pancreatitis results from partial or complete obstruction of the pancreatic duct.

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Y

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Chronic autoimmune pancreatitis is a unique form that often responds to glucocorticoids.

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The pathogenesis of chronic pancreatitis is not well understood.The stone and duct obstruction theory

The necrosis–fibrosis hypothesis

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Both alcohol abuse and smoking increase risk of disease progression, and their risks are likely additive.

about 50% of cases of chronic pancreatitis result from alcoholism.

Cigarette smoking is an independent, dose-dependent risk factor for developing chronic pancreatitis.

A large proportion of cases of chronic pancreatitis are idiopathic.

Other causes - less common

Genetic

Autoimmune

Obstructive

Systemic

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What are the obstructive causes of chronic pancreatitis

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Pancreatic duct stricture (traumatic, iatrogenic, anastomotic, or malignant)Mass effect due to a tumor

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A genetic cause for chronic pancreatitis

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Cystic fibrosis

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What are the Complications of chronic pancreatitis

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malabsorption characterized by steatorrhea,

Glucose intolerance may appear at any time, but overt diabetes mellitus usually occurs late in the course

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What are the other complications of chronic pancreatitis

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•Formation of pseudocysts•Obstruction of the bile duct or duodenum•Disruption of the pancreatic duct (resulting in ascites or pleural effusion)•Thrombosis of the splenic vein (can cause gastric varices)•Pseudoaneurysms of arteries near the pancreas or pseudocy

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What the most dangerous complication of chronic pancreatitis

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Patients with chronic pancreatitis are at increased risk of pancreatic adenocarcinoma, and this risk seems to be greatest for patients with hereditary and tropical pancreatitis.

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Abdominal pain and pancreatic insufficiency are the primary manifestations of chronic pancreatitis.

About 10 to 15% of patients have no pain and present with symptoms of malabsorption.

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Pain can occur during the early stages of chronic pancreatitis, before development of apparent structural abnormalities in the pancreas on imaging.

Pain is often the dominant symptom in chronic pancreatitis and is present in most patients

Pain is usually postprandial, located in the epigastric area, and partially relieved by sitting up or leaning forward.

The pain attacks are initially episodic but later tend to become continuous.About 10 to 15% of patients have no pain.

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Clinical manifestations of pancreatic insufficiency include

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flatulence

abdominal distention, steatorrhea

undernutrition

weight loss, and fatigue.

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What can be used for diagnosis

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Clinical assessment

•Imaging studies

•Pancreatic function tests (Diagnosis of chronic pancreatitis can be difficult because amylase and lipase levels are frequently normal secondary to significant loss of pancreatic function)

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When should we suspect pancreatic CA

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Patients with unexplained or sustained worsening of symptoms should be evaluated for cancer, particularly if assessment reveals a pancreatic duct stricture.

Evaluation may include brushing of the strictures for cytology and measuring serum markers (eg, CA 19-9, carcinoembryonic antigen).

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Hg

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In a patient with a typical history of alcohol abuse and recurrent episodes of acute pancreatitis, detection of pancreatic calcification on plain x-ray of the abdomen may be sufficient. However, such calcifications typically occur late in the disease and then are visible in only about 30% of patients.

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CT can also be used in patients with a history of alcohol abuse and in whom plain x-rays are not diagnostic.In patients without a typical history but with symptoms suggesting chronic pancreatitis, abdominal CT is typically recommended to exclude pancreatic cancer as the cause of pain.

Abdominal CT can be used to detect calcifications and other pancreatic abnormalities (eg, pseudocyst or dilated ducts) but still may be normal early in the disease.

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MRI coupled with magnetic resonance cholangiopancreatography (MRCP) is now frequently used for diagnosis and can show masses in the pancreas as well as provide more optimal visualization of ductal changes consistent with chronic pancreatitis.

Administration of IV secretin during MRCP increases sensitivity for detecting ductal abnormalities and also allows for functional assessment in patients with chronic pancreatitis.

MRI is more accurate than CT and does not expose patients to radiation.

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ERCP is invasive and rarely used for the diagnosis of chronic pancreatitis. ERCP findings could be normal in patients with early chronic pancreatitis. ERCP should be reserved for patients who may need therapeutic intervention.

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Endoscopic ultrasonography is less invasive and enables detection of subtle abnormalities in the pancreatic parenchyma and in the pancreatic duct.

This imaging modality has a high level of sensitivity and a low level of specificity.

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Signs and symptoms

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For most patients with chronic pancreatitis, abdominal pain is the presenting symptom.

The patient experiences intermittent attacks of severe pain, often in the mid-abdomen or left upper abdomen and occasionally radiating in a bandlike fashion or localized to the midback.

The pain may occur either after meals or independently of meals, but it is not fleeting or transient and tends to last at least several hours.

Other symptoms associated with chronic pancreatitis include diarrhea and weight loss.

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Pain relief

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Pancreatic enzyme supplementation may be helpful in reducing pain.

The hypothesis is that stimulation of the pancreas by food causes pain.

Cholecystokinin (CCK) is one of the possible mediators of this response. When exogenous pancreatic enzymes are taken with a meal, CCK-releasing factors are degraded and CCK release in response to a meal is reduced. This decreases pancreatic stimulation and pain.If conventional medical therapy is unsuccessful and the patient has severe, intractable pain, celiac ganglion blockade can be considered. [1] This approach tries to alleviate pain by modifying the afferent sensory nerves in the celiac plexus, using agents that anesthetize, reduce inflammation, or destroy the nerve fibers.

Endoscopic therapy aimed at decompressing an obstructed pancreatic duct can be associated with pain relief in some patients. The rationale for this approach is based on the hypothesis that ductal hypertension due to strictures of the main pancreatic duct leads to pain.

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Management

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In patients with uncomplicated painful CP and a dilated main pancreatic duct (MPD), endoscopic therapy (ET) is recommended as the first-line treatment after failed medical therapy following discussions by a multidisciplinary team (MDT).

The clinical response should be evaluated at 6-8 wk; if it appears unsatisfactory, the patient’s case should be discussed again by a multidisciplinary team of endoscopists, surgeons, and radiologists, and surgical options should be considered, in particular for patients with a predicted poor outcome following ET.

ET is performed first in most cases, with surgery reserved for the minority of patients whose painful symptoms do not respond well to ET.

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Pain management

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Pain is the first presentation of CP in the majority of patients.

Paracetamol is the preferred level I analgesic because of its limited side effects, while nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided because of their gastrointestinal toxicity.

If necessary, PPIs should be used in patients with CP who are at high risk of developing peptic ulcers.

Tramadol is the preferred level II analgesic and was shown to be superior to morphine in patients with CP, with fewer gastrointestinal side effects for the same level of analgesia.

Level III analgesia constitutes the group of strong opioids, such as morphine, which are widely used for pain relief in CP. In general the lowest possible dose should be used and the drug should always be taken orally to avoid dose escalation and addiction.

Note: in many patients (up to 50% of chronic pain patients in general), opioids do not alleviate pain, and treatment should be stopped.ET is effective in patients with an obstructive type of pancreatic pain and in patients with a pancreatic duct dilatation.

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What

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What

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What

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What