Chronic Pancreatitis

00:01 Hello. So, we're going to move from acute pancreatitis which you've hopefully already reviewed into chronic pancreatitis.

00:10 And in truth, chronic pancreatitis is lots of little bouts of acute pancreatitis leading to chronic injury and fibrosis.

00:17 So it's chronic inflammation of the pancreas.

00:20 The epidemiology of this is that it is reasonably common, 5-12 cases per 100,000 adults in the industrialized world and that is largely due to alcohol but it can be due to other causes.

00:35 Because of the association with alcohol, men are more commonly affected than women are and it's typically in the early adult years, 30-40 years of age.

00:46 In terms of the pathophysiology, it really is death by a thousand little paper cuts, lots and lots of episodes of acute inflammation leading to a chronic inflammatory state.

01:00 This can be due to pancreatic secretion obstruction.

01:05 It can be due to recurrent acute pancreatitis due to enzymatic activation such as in the setting of alcohol abuse.

01:16 We can have acute pancreatitis that causes ductal injury and obstruction that then will lead to additional episodes of pancreatitis and then eventually a chronic state.

01:28 The chronic pancreatic parenchymal damage leads to overall exocrine insufficiency.

01:34 So one bout of acute pancreatitis, it's painful, potentially fatal 5% of the time but won't typically lead to a pancreas that's totally destroyed.

01:45 But if you do this over and over and over again, then you don't have sufficient exocrine parenchymal mass to do its job, so you won't have lipase and amylase and proteases and all the other enzymes necessary for absorption.

02:00 As a result, the patient will have malabsorption, they will not get adequate vitamins for starters but they also won't be absorbing nutrition so there will be weight loss, etc.

02:10 There may also be secondary endocrine insufficiency.

02:14 So by damaging the pancreas recurrently, you're not just affecting the exocrine pancreas but those proteases and lipases are also destroying the islets of Langerhans.

02:24 So we'll lose beta cells and as a result we’ll have decreased insulin and the patient may have formally diabetes.

02:31 We will see calcifications that is due to fat saphonifications with the lipases acting on the various fats, triglycerides and other fats that are present.

02:41 We will break those down in the presence of circulating high levels of calcium.

02:46 We will make soap basically calcium associated with the lipid metabolites.

02:54 And with recurrent injury to the pancreas particularly the pancreatic duct, you can develop dysplasia and malignancy.

03:02 And that's the typical story, ongoing inflammation in the setting of epithelium that can regenerate will allow the accrual of a variety of mutations that can eventually turn into cancer.

03:14 The clinical presentation for chronic pancreatitis is in many ways very similar to that for acute pancreatitis.

03:21 So, you got acute pancreatitis, you have abdominal pain, it's initially epigastric radiates to the back.

03:27 It's exacerbated by meals because when you have a meal, you are increasing pancreatic secretions.

03:33 That's exactly the symptomatology you may have with acute pancreatitis but now it's happening over and over and over again, chronic.

03:41 There will be associated nausea and vomiting. Because of the loss of the exocrine pancreas, you will have steatorrhea; foul-smelling, floating, stools that are quite greasy and fatty.

03:52 You will have malnutrition particularly of certain vitamins and nutrients that require the enzymatic activity of the pancreas to break them down.

04:01 In some cases, patients may have enough reserved exocrine and endocrine pancreas that they are asymptomatic but that's the exception rather than rule.

04:11 In making the diagnosis, amylase and lipase may be elevated but at this point in the disease process, they're usually normal because there's not a whole lot more of pancreatic parenchyma to release these enzymes when there is pancreatic injury.

04:28 Liver function tests, there may be elevated bilirubin and alkaline phosphatase suggesting the biliary obstruction.

04:35 There need not be. Triglycerides are usually up fecal fat due to steatorrhea. It's going to be up.

04:43 If there is an autoimmune etiology for the pancreatitis, you may see elevated IgG4 and genetic testing for trypsin or trypsin-inhibitor mutations are also going to be helpful in the laboratory investigation.

04:55 In terms of making the diagnosis though, it's going to be largely based on the symptomatology and on the imaging; so ultrasound, CT, MRI.

05:05 In the event, there is chronic pancreatitis due to a stone or a stricture of something else, say in the ampulla of Vater then you will do an endoscopic retrograde cholangiopancreatography, ERCP, and hopefully remove or stent the obstruction.

05:22 In terms of management, you want to have lifestyle changes, so things that are causing the recurrent bouts of acute pancreatitis, we want to get rid of.

05:32 So no alcohol, no smoking. Low fat meals.

05:35 You don't want to be having the additional steatorrhea on top of everything else and small meals tend to give lesser amounts of required exocrine pancreatic secretions in order to digest rather than a big meal all at once.

05:55 You do want to supplement the fat soluble vitamins because there will be an overall malabsorption of A, D, E, and K.

06:01 The pancreatic insufficient management needs to include insulin for endocrine insufficiency but then pancreatic enzyme replacement, so there are a big old horse pills that have pancreatic enzymes that you can ingest that will allow you to replace everything that your exocrine pancreas would normally do.

06:21 Because recurrent bouts of pancreatitis, chronic pancreatitis can be painful. Analgesia is usually indicated.

06:28 And if there is something that can be decompressed or if there is a pseudo cyst, there are other complications related to chronic damage to the pancreas, we can certainly surgerize those and we can remove them or can decompress.

06:44 With that, this talk and the proceeding one on acute pancreatitis, we've covered the entire waterfront in terms of inflammation involving the pancreas.