Pancreas: Chronic Pancreatitis

Chronic Pancreatitis

Pathogenesis

  • Inflammation & Fibrosis Leading to Injury/Loss of Acinar & Islet Cells

Causes Mn

  • Alcohol (Most Common) – 50% (Historically 70% of Cases Due to Alcohol But Recently Found to be Only 50%)
    • Mechanisms:
      • Induces Sphincter of Oddi Spasm
      • Increases Secretion & Permeability
      • Decreases Blood Flow
    • Timing Until Onset:
      • Males: 18 Years of Drinking
      • Females: 11 Years of Drinking
  • Tobacco
  • Hypertriglyceridemia
  • Idiopathic – 10-30%
  • Genetic or Autoimmune
  • Recurrent & Severe Acute Pancreatitis
  • Chronic Obstruction

Presentation

  • Symptoms:
    • Epigastric Pain Radiating to the Back
    • Nausea/Vomiting
    • Pancreatic Insufficiency
  • Complications:
    • Pancreatic Pseudocyst
    • Pleural Effusion or Pancreatic Ascites
      • From Retroperitoneal Fluid Leak
      • May Lead to Fistula
      • Tx: Thoracentesis/Paracentesis, NPO & Octreotide
        • 50-60% Resolve in 2-3 Weeks
    • Bile Duct Obstruction
    • Splenic Vein Thrombosis
    • Pseudoaneurysm
    • Episodes of Acute Pancreatitis

Diagnosis

  • Classic Triad: Pancreatic Calcifications, Steatorrhea & Diabetes
    • Usually Only Seen in Advanced Disease
  • Lipase/Amylase Normal or Slightly Elevated
  • CT: Pancreas Sunken & Calcified with Main Duct Beading & Ectatic Side Branches
    • “Chain of Lakes” – Alternating Stenosis/Dilation
  • Pancreatic Cancer May Have Similar Presentation

Treatment

  • Initial Treatment: Non-Narcotic Pain Control
    • No Alcohol or Tobacco
    • Small Low-Fat Meals
    • Consider Pancreatic Enzyme Replacement
  • Specialized Options if Medial Treatment Fails:
    • Endoscopic Decompression – Less Effective Than Surgery
    • Celiac Nerve Block – Unproven with Limited Success
  • Severe Pain or Complications: Surgery
    • Enlarged Ducts (> 6 mm): Decompression Mn
      • Inflammatory Mass in Head: Frey Procedure
        • Fibrotic Parenchyma & Enlarged Head with Poor Drainage
      • No Mass & Good Drainage: Puestow Procedure
      • *See Pancreas: Drainage Procedures
    • Small-Normal Ducts: Resection
      • Isolated Head: Whipple or Beger Procedure
      • Isolated Tail: Distal Resection
      • Not Isolated: Total Pancreatectomy & Islet Cell Autotransplantation
    • If Other Surgeries Fails: Total Pancreatectomy & Islet Cell Autotransplantation
    • Denervation Surgery – Uncertain Benefit
  • Atypia/Cancer: Resection

MRCP with Main Duct Dilation & Ectatic Side Branches 1

Mnemonics

Causes of Chronic Pancreatitis

  • “TIGAR-O”
    • Toxic-Metabolic
    • Idiopathic
    • Genetic
    • Autoimmune
    • Recurrent & Severe Acute Pancreatitis
    • Obstruction

Decompression vs Resection for Chronic Pancreatitis

  • #6 – The Number of the Pancreas (Used in Other Mnemonics: PNET and Pseudocyst)
  • Pancreas Looks Like a #6
  • If Ducts > 6 mm Then Decompress

#6 – The Number of the Pancreas

References

  1. Griffin N, Charles-Edwards G, Grant LA. Magnetic resonance cholangiopancreatography: the ABC of MRCP. Insights Imaging. 2012 Feb;3(1):11-21. (License: CC BY-2.0)