Pancreatitis Chronic

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^T^^B^D: Chronic inflammation of the pancreas with permanent structural changes leading to impaired endocrine and exocrine function and recurrent abdominal ^^ pain.

OA: Major: Alcohol.

Others: Idiopathic in 20%. Rare: exogenous toxins, cystic fibrosis, haemachro-matosis, ai-antitrypsin deficiency, pancreatic duct obstruction (acute pancreatitis, pancreas divisum, pancreatic duct anomalies), hyperparathryroidism.

Annual UK incidence is about 1/100000; prevalence is about 3/100000. Mean age 40-50 years in alcohol-associated disease.

Recurrent severe epigastric pain, radiating to back, relieved by sitting forward. Exacerbated by eating or after an episode of binge drinking. May be associated with bloating and pale offensive stools (steatorrhoea). Diarrhoea, weight loss, thirst and polyuria.

Epigastric tenderness.

There may be epigastric fullness (due to pseudocyst). Signs of weight loss, malnutrition and alcohol abuse.

Disruption of normal glandular architecture due to chronic inflammation and fibrosis, calcification, ductal dilatation, cyst and stone formation.

Bloods: Glucose (" may indicate endocrine dysfunction), glucose tolerance test. Amylase and lipase (usually normal), LFT (" if common bile duct obstruction).

USS: Percutaneous or endoscopic.

ERCP or MRCP: Early changes include main duct dilatation and stumping of branches. Late manifestations are duct strictures with alternating dilatation ('chain of lakes' appearance).

AXR: Pancreatic calcification may be visible (see Fig. 24).

CT scan: Pancreatic cysts, calcification.

Tests of pancreatic exocrine function: Faecal elastase.

General: Dietary advice and alcohol abstinence. Acute: Analgesics for exacerbations of pain.

Chronic: Pain management may need specialist pain clinic, treatment of diabetes (e.g. insulin). Pancreatic enzyme replacements (e.g. Creon, Pancrease). Endoscopic stenting of strictures may be possible.

Pain control: As the majority of sensory nerves to the pancreas transverse the coeliac ganglia and splanchnic nerves, both coeliac plexus block and transthoracic splanchnicectomy offer variable degrees of pain relief. Surgical: Indicated if medical management has failed. Options include proximal resection (pancreaticoduodenectomy) or lateral pancreatojejunal drainage (Puestow procedure).

Local: Pseudocysts, biliary duct stricture, duodenal obstruction, pancreatic as-cites, pancreatic carcinoma.

Systemic: DM, steatorrhoea, hyperglycaemic coma. Many develop chronic pain syndromes and become dependent on strong analgesics.

Surgery improves symptoms in 60-70% but results are often not sustained. Life expectancy is reduced by 10-20 years.

Pancreatitis, Chronic continued 151

Abnormal Kub

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