July 8, 2009 | In: ABDOMINAL SURGERY
41 DIAGNOSIS AND THERAPY OF CHRONIC PANCREATITIS
Clay Cothren M.D., Jon M. Burch M.D.
1. What is chronic pancreatitis?
Show answer
The classic syndrome consists of smoldering abdominal pain and evidence of pancreatic insufficiency. Histologically, chronic inflammation results in destruction of the functioning endocrine and exocrine pancreatic cells.
2. What is the most common cause?
Show answer
Alcohol abuse accounts for 75% of cases.
3. Is chronic pancreatitis the result of acute pancreatitis?
Show answer
Patients may not have had acute pancreatitis, although alcoholism is common to both. One hypothesis is the inflammation from recurrent bouts of acute pancreatitis causes interstitial acinar fibrosis with secondary dilatation of the main pancreatic duct. The average age for chronic pancreatitis is paradoxically 13 years less than for acute disease.
KEY POINTS: CHRONIC PANCREATITIS
1. 75% of cases are due to alcohol abuse.
2. Symptoms include smoldering abdominal pain and evidence of pancreatic insufficiency (diabetes, steatorrhea).
3. 30% of patients may not mount hyperamylasemia due to “burned-out” pancreas.
4. Common complications include pseudocyst, abscess, fistula, obstructive jaundice, malnutrition.
4. What are the signs of pancreatic insufficiency?
Show answer
Insulin-dependent diabetes mellitus (found in up to 30% of patients) and steatorrhea (in 25%).
5. How much of the pancreas must be destroyed before diabetes develops?
Show answer
Approximately 90%.
6. What is steatorrhea? How does one confirm the diagnosis?
Show answer
Steatorrhea is soft, greasy, foul-smelling stools. A 72-hour fecal fat analysis may be done to confirm the diagnosis. The D-xylose test shows normal results, and the Schilling test is not sensitive for pancreatic insufficiency. Patients with steatorrhea are treated with a variable combination of low-fat diets, pancreatic enzymes, antacids, and cimetidine.
7. Is serum amylase elevated in patients with chronic pancreatitis?
Show answer
No. The serum amylase level is usually normal in cases of “burned-out” pancreatitis.
8. What are the complications of chronic pancreatitis?
Show answer
Pancreatic pseudocyst, abscess, or fistula may occur. Obstruction of the biliary tree with resultant jaundice may be caused by areas of fibrosis. Malnutrition and narcotic addiction are more likely to coexist than actual complications of pancreatic insufficiency.
9. What is a possible source of upper gastrointestinal bleeding (UGIB) in a patient with chronic pancreatitis?
Show answer
Although gastritis and peptic ulcer disease are more common causes of UGIB, splenic vein thrombosis with associated gastric varices and hypersplenism also should be considered. (Your attending will love this answer!)
10. What is the “chain of lakes”?
Show answer
In performing endoscopic retrograde cholangiopancreatography (ERCP), contrast dye is introduced directly into the pancreatic duct; sequential areas of narrowing followed by dilatation of the duct cause the appearance of a “string of beads” or “chain of lakes.”
11. What are the indications for surgery?
Show answer
There are no steadfast rules. Relative indications include unabating pain refractory to medical management, a dilated main pancreatic duct, biliary or gastric outlet obstruction, pancreas divisum, and suspicion of malignancy.
12. Which operative procedures are commonly performed?
Show answer
The Peustow procedure (a lateral Rouxen-Y pancreaticojejunostomy) lays the Roux limb of bowel directly upon the “chain of lakes” duct to provide longitudinal head-to-tail drainage. Distal pancreatectomy may be used for isolated distal disease or retrograde drainage into a pancreaticojejunostomy. A modified Whipple operation (i.e., pancreaticoduodenectomy) can also remove a nonfunctioning but painful pancreas.
13. What is the result of such operations?
Show answer
Pain relief occurs in 70% of patients at the end of 1 year and in 50% of patients at the end of 5 years.
References
WEB SITES
1. http://www.emedicinehealth.com/articles/10597-1.asp
2. http://www.ascsurgery.com/abstracts/acs/acs0304.htm
BIBLIOGRAPHY
1. American Gastroenterological Association: AGA technical review: Treatment of pain in chronic pancreatitis. Gastroenterology 115:765-776, 1998.
2. Beger HG, Schlosser W, et al: The surgical management of chronic pancreatitis: Duodenum-preserving pancreatectomy. Adv Surg 32:87-104, 1999. Medline Similar articles
3. Fernandezdel Castillo C, Rattner DW, Warshaw AL: Standards for pancreatic resection in the 1990s. Arch Surg 130:295-300, 1995.
4. Mergener K, Baillie J: Chronic pancreatitis. N Engl J Med 332:1379-1385, 1995.
5. Steer ML, Waxman I, Freedman S: Chronic pancreatitis. N Engl J Med 332:1482-1490, 1995. Medline Similar articles Full article
6. Wiersema M: Diagnosing chronic pancreatitis: Shades of gray. Gastrointest Endosc 48:102-106, 1998. Medline Similar articles
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