Main culprits are heavy alcohol consumption and gallstones for chronic pancreatitis
CHRONIC PANCREATITIS
is a relapsing disorder which may arise insidiously or following repeated attacks of acute pancreatitis .The most commonest cause is chronic alcohol consumption and accompanied by a protien and fat rich diet .Other causes include cystic fibrosis ,hypercalcemia ,hyperlipidemiaand a rare familial pancreatitis .Pathological changes include parenchymal destruction ,fibrosis ,loss of acini ,calculi and duct stenosis with dilatation behind the stenosis.At operation the gland feels hard and irregular and may be mistaken for carcinoma .Calcification is often seen on plain abdominal X-ray.This is thought to be due to calcification of protien precipitates in ducts .
Pancreatic duct obstruction : due to Stricture e.g.after trauma or acute pancreatitis.Occlusion by pancreatic cancer.
Hyperparathyroidism ,cystic fibrosis ,Hereditory pancreatitis ,Infantile malnutrition ,Idiopathic ,Stenosis of ampulla of vater . In 12 % of adults ,etiology is unknown.
Initially pancreas may appear normal.Later pancreas enlarges and becomes hard due to sclerosis ,while the ducts become distorted and dilated with areas of ectasia .Calcified stones ,weighing from a few mg 200 g ,may form within ducts .Ducts become occluded with gelatinous protein-rich fluid and debris ,to form cysts.
Lesions affect a particular lobule producing ,Ductular metaplasia and hyperplasia ,Atrophy of acini ,Interlobular fibrosis .
In clinical features there is symptom of discompose in epigastrium ,which alter to left and correct hypochondrium and finished to back .boring discompose to biliary colic in character .duration about 3-4 days ,and exacerbated by beverage consumption.Vomiting ,anorexia ,Steatorrhea ,and Weight loss ( results from anorexia ,malabsorption steatorrhea and vomiting .It can cause some symptoms of diabetes mellitus ,these are late feature and includes polyuria ,polydipsia ,weight loss and imperfectness.
Signs of jaundice haw be present ( due to narrowing of retropancreatic bile duct ) A protective ,hard epigastric mass haw indicate formation of a sac . ( best way to palpate pancreas is to invoke the enduring to correct and hips and knees are flexed .Left costal margin is deeply palpated.This will evoke tendrness in accent and habitual pancreatitis ( Mallet-Guy's sign ).
DIAGNOSTIC INVESTIGATIONS
The identification of habitual pancreatitis is typically based on tests on pancreatic structure and function, as direct biopsy of the pancreas is thoughtful excessively risky. Serum amylase and lipase may well not be elevated in cases of advanced habitual pancreatitis, but are often utilised as markers for sleuthing pancreatic inflammation in acute pancreatitis. A secretin stimulation effort is thoughtful the gold standard functional effort for identification of habitual pancreatitis but not often utilised clinically. The observation that bi-carbonate production is impaired early in habitual pancreatitis has led to the rationale of ingest of this effort in early stages of disease (sensitivity of 95%). Other ordinary tests utilised to determine habitual pancreatitis are faecal elastase measurement in stool, serum trypsinogen, Computed tomography (CT) scans, ultrasounds, EUS, MRI's, ERCP and MRCP's. Pancreatic calcification crapper often be seen on plain abdominal X-rays, as well as CT scans.
There are other non-specific laboratory studies useful in identification of habitual pancreatitis. Serum bilirubin and alkaline phosphatase crapper be elevated, indicating stricturing of the ordinary bile funiculus cod to edema, fibrosis or cancer. When the habitual pancreatitis is cod to an autoimmune process, elevations in ESR, IgG4, rheumatoid factor, ANA and antismooth hooligan antibody may be seen. The ordinary symptom of habitual pancreatits, steatorrhea, crapper be diagnosed by two assorted studies: Sudden staining of feces or soiled fruitful organic over 24hr on a 100g fruitful diet. To check for pancreatic exocrine dysfunction, the most sensitive and specific effort is the measurement of soiled elastase, which crapper be done with a azygos crap sample, and a value of inferior than 200 ug/g indicates pancreatic insufficiency.
TREATMENT
MEDICAL TREATMENT
Aimed at controlling discompose and malabsorption .Intermittent attacks treated like accent pancreatitis.Alcohol and super fatty meals must be avoided .Narcotics for severe discompose ,but subsequent addiction is common ,Patients unable to maintain adequate hydration should be hospitalized ,while those with milder symptoms crapper be managed on an ambulatory basis. Surgery haw curb discompose if there is a ductal stricture .Subtotal pancreatectomy haw also curb discompose but at the outlay of exocrine insufficiency and diabetes .Malabsorption is managed with a low fat diet and pancreatic enzymes equal ( 8 customary tablets or 3 viscus glazed tablets with meals ).Because pancreatic enzymes are inactivated by Elvis ,agents that turn Elvis creation ( e.g . omeperazole or sodium bicarbonate ) haw improve their efficacy ( but should not be presented with viscus glazed preparation ) Insulin haw be needed to curb serum glucose .
SURGICAL TREATMENT
Traditional Surgery for Chronic Pancreatitis tends to be divided into two areas - resectional and drainage procedures.New and proven transplantation options preclude the patient from decent diabetic following the surgical removal (resection) of their pancreas. This is achieved by transplanting backwards in the patients own insulin-producing beta cells.
DISTAL PANCREATOMY it consist of distal pancreatic resection up to portal vein ,and it is performed if head of pancreas is relatively normal .
PANCREATODUDENECTOMY it is performed if head of pancreas is mainly involved .
LONGITUDINAL PANCREATOJEJUNOSTOMY it is performed if pancreatic duct is grossly dilated .
COMPLICATIONS
Vitamin B6 malabsorption in 40 % of alcohol induced and all cystic fibrosis cases.Impaired glucose tolerance .Nondiabetic retinopathy due to vitamin A and/ or zinc deficiency,Gastrointestinal bleeding ,icterus ,effusion ,subcutaneous fat necrosis and bone pain occasionally occur .Increased risk for pancreatic carcinoma .Narcotic addiction common.
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