medicine - mbbs

1. CHRONIC
PANCREATITIS
PRESENTOR : Adithya S
MBBS, Govt Thiruvarur Medical College

2. Definition
● Chronic pancreatitis is a progressive inflammatory disease in which there is
irreversible destruction of pancreatic tissue occurs .
● It is more common in males (4:1)
● Mean age of Onset is about 40 years

3. Etiology
1.High Alcohol consumption (60 -70% cases)
 Increased total protein concentration in pancreatic juice
 Increased glycoprotein 2
 Protein plug formation
 Stones (inside pancreatic duct)
 Decreased pancreatic secretion
 Auto digestion

4. Fatty acid ethyl esters , ROS
Fragility of intra acinar organelles ( zymogen
granules and lysosomes)
Abnormal pancreatic enzyme activation inside
the acinar cells
Acetaldehyde direct acinar injury

5. chronic inflammation
Rrelease of inflammatory mediator ( PDGF , TGE β , TNF α , IL-1 ,IL-6)
Pancreatic stellate cells
Collagen deposition
fibrosis

6. 2.PANCREATIC DUCT OBSTRUCTION
● Stricture formation after trauma
● Acute pancreatitis
● Pancreatic carcinoma
● Pancreas divisum and annular pancreas

7. 3.HEREDITARY PANCREATITIS
● Gain of function mutation in PRSS1 on chromosome 7
● Loss of function mutation in SPINK 1
● CFTR gene mutation
PRSS 1 – (cationic trypsinogen gene)
Gain of function mutation
Loss of function mutation in SPINK 1
Increased intra acinar trypsinogen
activation

8. 4.Hyperlipidemia
5.Hyperparathyroidism
6.Autoimmune pancreatitis
7.Tropical pancreatitis

9. 01
Fibrosis
02
Atrophy
03
04
Variable dilation of pancreatic
ducts / strictures
05
Parenchymal calcification
PATHOLOGY
Drop out of
acini

10. Alcoholic
pancreatitis
● Ductile dilatation
● Intraluminal protein plugs
● Calcifications
Autoimmune
pancreatitis
● Elevated IgG4
● Venulitis
● Inflammatory infiltrates

11. CLASSIFICATION
TIGAR-O (Based on risk factors and etiology)
AUTO IMMUNE
TOXIC METABOLIC IDIOPATHIC
RECURRENT AND
SEVERE ACUTE
PANCREATITIS
GENETIC
OBSTRUCTIVE

12. Classification based on etiological causes

13. Clinical features
● pain in the epigastric region
● Persistent and severe radiates to back
● It is mainly due to Irritation of retro pancreatic nerve ,due to ductile
dilatation and stasis or due to chronic inflammation itself
● Two patterns of pain
● TYPE A: short relapsing episodes, lasting for days to weeks ,pain free
intervals present
● TYPE B : prolonged ,severe , unrelenting pain
● There is often a gradual diminish in pain over years due to pancreatic
burn out by extensive calcification, exocrine and endocrine insufficiently

14. Endocrine
dysfunction
• DM ( Brittle due to concomitant glucagon
deficiency)
• Mild jaundice - due to narrowing of retro
pancreatic bile duct and cholangitis
Exocrine
dysfunction
• Diarrhea
• Asthenia
• Loss of weight and
appetite
• Steatorrhea
• Malabsorption

15. Differential diagnosis
Retroperitoneal tumour
Carcinoma of head of the
pancreas

16. Complications of chronic
pancreatitis
Pseudocyst of pancreas
Duodenal stenosis CBD stricture due to
oedema / inflammation
Pancreatic ascites
Carcinoma pancreas
Portal thrombosis -
segmental portal HT

17. Complications of chronic
pancreatitis
Pancreatic enteric fistula
Pancreatic pleural effusion
,Pancreatic ascites ,Pancreatic
fistula
Splenic vein thrombosis
Peptic ulcer

18. Investigations
● CT scan abdomen
1. Dilated pancreatic duct (68%)
2. Parenchymal atrophy 54%
3. Pancreatic calcification 50%)
4. Other findings – peri pancreatic fluid , focal pancreatic enlargement
,biliary duct dilation , irregular pancreatic parenchymal contour
5. It is also used to asses the complications

19. Investigations
● ERCP – gold standard
 Therapeutic modality
 Stricture , stones , pseudocyst , biliary stenosis
● MRCP + Secretin injection - to see ductal anatomy
 Intraductal strictures
 Pancreatic duct disruption
● Endosonography

20. Investigations
● Function tests
 Fecal elastase 1 level measurement :Normal >200ųg /g of feces
Mild to moderate; 100-200ųg /g feces Severe : <100ųg/g feces
 Fecal fat and weight estimation test ; Intake of 100g of fat per
day during 3 days If stool fat content exceeds 7 g /day -
diagnosis of steatorrhoea

21. Treatment
• Avoid alcohol
• Low fat ,high protein ,
high carbohydrate diet
• Pancreatic enzyme
supplements, vitamins
and minerals ,medium
chain fatty acids
• For pain analgesics,
splanchnic nerve or
coeliac plexus block
• Other drugs ;
antioxidants,
amitryptyline
,fluoxetine ,octreotid
• Control of diabetes by
oral hypoglycemic or
insulin
• Somatostatin and it's
analogues
• Repeated ascetic
taps for pancreatic
ascites
• Steatorrhea can be
controlled by PPI
Conservative

22. Endoscopic therapy
● INDICATIONS: pain relief ,ductal stones ,main duct stricture, pseudocyst
drainage ,Pancreatic ascites, effusion and fistula
● It is mainly used for main Pancreatic duct obstruction and pseudocyst ,less
useful for biliary stricture
● Pancreatic duct sphincterotomy

23. Pseudocyst
Transpapillary stenting
 If pseudocyst is communicating
 Cyst less than 6cm
 No Visible bulge in stomach
Transmural stenting
 Visible bulge
 Distance of cyst wall less than
1cm
 No major vessel at puncture site

24. Surgical
management

25. Indications for surgery
 Persisting pain
 Severe malabsorption
 Suspicion of malignant transformation
 Multiple relapses
 Complications like pseudocyst, segmental portal HT
 Biliary obstruction
 Pseudocyst
 Pancreatic ductal dilatation >7mm
 Pancreatic ascites/fistula
 Pancreatic ductal stenosis

26. Principles of surgery
 Pancreatic duct decompression ( drainage )
 Pancreatic resection ( total Pancreatectomy )

27. Surgeries
 Partington Rochelle operation
Longitudinal pancreatico jejunostomy is done using almost entire
laid open pancreatic duct . Spleen is retained in this procedure

28. Surgeries
 Puestow's operation
When the duct is dilated to more than 8mm , duct can easily be opened
longitudinally. After removing all the stones from the duct , it is
anastomosed to the jejunum as Roux en Y anastomosis Spleen is
removed in this procedure

29. Surgeries
 Longitudinal pancreaticojejunostomy
Frey's procedure - superficial part of the head of pancreas is
removed to achieve improved drainage and then it is anastomosed
with the Roux loop of jejunum

30. Surgeries
 Beger procedure
Duodenal preserving resection of head of pancreas in
front of portal vein with jejunal loop anastomosis to
transected neck of pancreas

31. Surgeries
 Total pancreatectomy :
Done when entire gland is diseased

32. Complications of surgery
Pancreatic leak / fistula
Infections
Bleeding
Recurrence
Brittle DM

33. POST OP CARE
Nutrition-TPN / Jejunostomy
feed
Fluid and electrolyte
management
Prevention/ control of
sepsis
Octreotide on table and
Postoperatively - regular
Intervals or slow infusions
- 5 days
01 02
03 04

34. Thank you !