Chronic pancreatitis diagnosis and treatment

Definition of chronic pancreatitis

Chronic pancreatitis is a chronic inflammatory disease of the pancreas, with progressive evolution to pancreatic destruction(exocrine and endocrine), evolving towards pancreatic failure.

Clinical features

• abdominal pain, with epigastric or periombilical location, sometimes in the entire upper abdominal region, often appearing after abundant meals.
• steathorrhea (voluminous, pasty, rancing- smelling)
• a chronic alcohol abuse

Etiology

• chronic alcohol abuse
• gallstones
• hypercalcemia
• ductal obstructions by: pancreatic tumors, pancreatic trauma, Wirsung calculi
• hereditary pancreatitis
• malnutrition
• hemochromatosis

Pathogenesis

In chronic alcohol abuse, the pancreatic secretion contains a bigger proteic concentration than normal. These proteins may fall out, forming proteic plugs which will generate ductal obstruction with retrograde activation of pancreatic enzymes. Some proteic plugs calcify, by impregnating with calcium carbonate. The calculi “litostatine” that hinders the nucleation and precipitation of calcium carbonate crystals from pancreatic secretion. As a consequence of obstruction, some ducts break up, with enzyme activation, other ducts dilate and periductal fibroses appear, with new stenosis. Tissue destructions and calcium deposits appear.

Pathologic anatomy

Macroscopically: the pancreas is firm at palpation, most often small. Other times it can be hypertrophic, and sometimes even pseudotumoral.
Microscopically: fibrosis and lymphoplasmocytic infiltrate appear around the acins. The ducts are not uniformly dilated, with proteic plugs and Wirsung calculi sized a few mm.

Clinical features

• abdominal pain
• obstructive jaundice
• the syndrome of malabsorbtion with steatorrhea
• secondary diabetes mellitus

Paraclinical examination

• easy or mild increase of amylasemia, amylasuria or seric lipase
• the dosage of fats in the stool may show steatorrhea
• the glycemia may be raised because of secondary diabetes

Imagistic evaluation

X-ray –the presence of pancreatic calculi

• ultrasonography it may show diffuse pancreatic calcification
• the pancreatic heterogeneity( the inhomogeneous aspect of pancreas)
• the dilatation of Wirsung duct over 3 mm 10-15 mm
• of Wirsung calculi
• of pancreatic pseudocysts( transonic images)

- computer tomography: visualizing some minor calcifications, the possibility to evaluate the obese or bloated patients makes it superior to the ultrasonography.
- endoscopic retrograde colangiopancreatography the morphologic aspect of pancreatic duct, irregular, with stenosis and dilatations that appear in CP.
- the pancreatic secretory tests allow the evaluation of pancreatic functional reserve.

Classification of chronic pancreatitis

The clinical forms of chronic pancreatitis are:

• painful chronic pancreatitis
• asymptomatic chronic pancreatitis

The anatomopathologycal forms of chronic pancreatitis are:

• obstructive chronic pancreatitis
• calcifiant chronic pancreatitis
• The mixt forms of chronic pancreatitis

Evolution
The evolution of the disease is chronic, with episodes of exacerbation. In the beginning, it may be asymptomatic, but then it becomes symptomatic, and the most important element is the pain. The complete ceasing of alcohol intakemay have a benefic effect concerning the pain, but not always. In time, maldigestion will appear, with secondary malnutrition.

Complications
The complications of chronic pancreatitis may be:

• the pancreatic pseudocyst, sometimes compressive
• the pancreatic abcess, that is produced by infecting of a pancreatic pseudocyst
• recidivating ascites
• obstructive jaundice, by compressing the common bile duct by the hypertrophic pancreatic head
• splenic vein or portal vein thrombosis, by neighborhood inflammation.

Treatment

A. Dietary
- the complete elimination of the alcohol
- abundant meals will be avoided,as well as fatty and also protein rich meals
- the acute episodes of acute pancreatitis on the background of a chronic pancreatitis will be treated by hospitalization, alimentary rest, parenteral alimentation, nasogastric tube if needed, analgesic medication, antisecretory.

B. Medical
It consist in:
- analgesics in the painful episodes

• Algocalmin
• Piafen
• Tramal
• Fortral

- enzymatic pancreatic substitutes

• Creon
• Panzytrat
• Festal
• Nutrizym
• Digestal forte

If the drugs is not gastro protected, an antisecretory (Ranitidine, Cimetidine) will be administered 30 minutes before meals.

C. Alternative therapy
May be:
1. by endoscopy: papilotomy, prothesis, extraction of calculi from Wirsung duct, echoendoscopical drainage of pseudocysts
2. surgical: in hyperalgic forms, the celiac plex may be blocked; total or subtotal pancreatectomy, different techniques of derivation or decompression(lateral pancreatojejunostomy).