Makindo Medical Notes

Related Subjects:Acute Cholecystitis |Acute Appendicitis |Chronic Peritonitis |Abdominal Aortic Aneurysm |Ectopic Pregnancy |Acute Cholangitis |Acute Abdominal Pain/Peritonitis |Assessing Abdominal Pain |Penetrating Abdominal Trauma |Acute Pancreatitis |Acute Diverticulitis

In chronic pancreatitis with secondary diabetes, hypoglycaemic episodes are more serious as patients lack both insulin and the pancreatic hormone glucagon, which helps raise blood glucose levels.

About

• Chronic pancreatitis involves progressive damage to both endocrine and exocrine pancreatic functions.
• The condition is marked by irreversible scarring and fibrosis of pancreatic tissue.
• Periodic exacerbations can mimic acute pancreatitis, and distinguishing it from pancreatic cancer may be challenging.

Aetiology

• Alcohol consumption: 70% of cases, with an average age of onset at 40 years.
• Idiopathic causes: 20%.
• Recurrent episodes of acute pancreatitis.
• Metabolic conditions: hyperparathyroidism and hypertriglyceridaemia.
• Anatomic or genetic factors: pancreas divisum, familial pancreatitis (autosomal dominant), cystic fibrosis in children.
• Autoimmune pancreatitis and tropical pancreatitis.
• Post-renal transplant.

Pathophysiology

• Progressive pancreatic damage leads to diabetes mellitus and exocrine insufficiency, impairing digestion and glucose regulation.
• Inflammation and fibrosis cause chronic pain, metabolic bone disease, and increase the risk of pancreatic cancer.

Types

• Chronic calcifying pancreatitis: Commonly involves protein precipitation in pancreatic ducts, leading to plug formation, scarring, acinar destruction, and chronic inflammation. Loss of islet cells results in secondary diabetes. Abstinence from alcohol may not halt progression.
• Chronic obstructive pancreatitis: Strictures or stones obstructing ducts can be managed surgically, often improving symptoms.

Clinical Features

• Recurrent, severe epigastric and back pain, often relieved by sitting forward.
• Malabsorption: Steatorrhea, weight loss, cachexia, and malnutrition due to exocrine insufficiency.

Complications

• Diabetes and associated hypoglycaemia due to loss of insulin and glucagon production.
• Malabsorption leading to nutritional deficiencies.
• Chronic abdominal pain, often resulting in opiate dependence.
• Formation of pancreatic pseudocysts.
• Pancreatic calcification, evident on imaging.
• Increased risk of pancreatic ductal adenocarcinoma.

Investigations

• Blood tests: FBC may reveal anaemia; raised WCC suggests infection. Elevated blood sugar indicates secondary diabetes.
• Amylase levels: May be normal or elevated but are not typically useful for chronic pancreatitis.
• ↑ IgG levels (especially IgG4) in cases of autoimmune pancreatitis.
• AXR: Intraductal calcification is visible in some cases.
• ERCP or MRCP: Used to detect treatable strictures, stones, tumours, or pseudocysts. MRCP is increasingly preferred over ERCP for non-invasive imaging.
• CT scan: Detects pancreatic cysts and calcium deposition.
• Malabsorption assessment: Faecal elastase-1 is low in cases of exocrine insufficiency.

Management

• Acute admission with pain management, often requiring opiates. Cessation of alcohol and smoking is essential.
• Pancreatic enzyme supplements (e.g., Creon) aid digestion and are given with a PPI to reduce inactivation by gastric acid.
• Management of secondary diabetes mellitus: Requires careful glucose monitoring due to risks associated with lack of glucagon.
• Chronic pain management: Options include coeliac plexus block, although it may lead to challenges in managing opiate dependence.
• Longitudinal pancreaticojejunostomy: May relieve pain in some patients, particularly with continued abstinence from alcohol.
• Dietary and nutritional support: Dietician involvement for managing malabsorption and nutritional deficiencies.
• Endoscopic intervention (ERCP): Indicated for stone removal, sphincterotomy, or stenting of strictures as required.

References

• Complications of Chronic Pancreatitis