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Chronic pancreatitis

lecture for students
by

Chang Min Cho

on 18 September 2014

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Transcript of Chronic pancreatitis

©2004 by American Physiological Society
Whitcomb D C Am J Physiol Gastrointest Liver Physiol 2004;287:G315-G319
Injury and repair in the pathway for normal pancreas to pancreatic cancer.
Whitcomb D C Am J Physiol Gastrointest Liver Physiol 2004;287:G315-G319
Injury and repair in the pathway for normal pancreas to pancreatic cancer
Kyungpook National University Medical Center
Department of Hepatobiliary Pancreatic cancer
Chronic Pancreatitis
Chang-Min Cho
irreversible damage to the pancreas
parenchymal and ductal change
presence of histologic abnormalities
chronic inflammation
fibrosis
progressive destruction of exocrine and endocrine tissue
clinical manifestation
abdominal pain
maldigestion, steatorrhea
diabetes
Chronic pancreatitis
uncommon disorder of presumed autoimmune causation
characteristic findings
laboratory: IgG4 elevation
histology:
morphology
associated with other autoimmune disorders
Sjogren's syn, mediastinal adenopahty
autoimmune thyroiditis, tubulointerstitial nephritis
retroperitoneal fibrosis
clinical manifestation
mild abdominal pain
attack of acute pancreatitis: unusual
obstructive jaundice
weight loss and new onset of diabetes
Treatment: glucocorticoids and azathioprine or 6-MP
Autoimmune pancreatitis
matrix metalloproteinase-mediated destruction
normal collagen in pancreatic parenchyma
pancreatic remodeling

activation of inflammatory response
proinflammatory cytokines, TNF-a, IL-1, IL-6
oxidant complex

induction of PSC activation
new collagen synthesis
TGF-b-mediated self-activating autocrine pathway
Sentinel acute pancreatitis event (SAPE) hypothesis
Structure

ERCP, EUS


CT scan
USG

Abdominal X-ray
Steatorrhea
enzyme replacement
enteric coated microsphere
80,000 - 100,000 units of lipase per meal

Pain
nonenteric coated enzyme preparation
high concentration of serine protease
no consistent benefit of enzyme therapy
antioxidant therapy
prokinetics in gastroparesis
endoscopic treatment
sphincterotomy, stenting, stone extraction
drainage of pseudocyst
surgery
Whipple procedure
total pancreatectomy with autologous islet cell transplantation
celiac plexus block
Chronic pancreatitis - treatment
Removal or bypass of any obstruction within pancreatic duct
PD sphincterotomy and/or stenting
dilation of stricture
removal of pancreatic calculi
drainage (pseudocyst, biliary obstruction)

Candidates
significant pancreatic ductal stricture in head with upstream dilation
few obstructing stones within head of PD

Complications
bleeding, cholangitis, stent migration, stent clogging, pancreatitis
Endoscopic treatment
independent, dose-dependent risk factor for
chronic pancreatitis
recurrent acute pancreatitis

increased susceptibility to panceatic self-digestion
predisposition to dysregulation of duct cell CFTR function
Etiology - smoking
Narcotic addiction
Impaired glucose tolerance
DKA and coma: uncommon
end-organ damage: uncommon
Nondiabetic retinopathy
vitamin A and/or zinc deficiency
Gastroparesis
GI bleeding
PU, gastritis, pseudocyst, ruptured varices
Jaundice, cholestasis, and biliary cirrhosis
Pancreatic cancer
Complications of chronic pancreatitis
abdominal pain
variable location, severity, and frequency
constant or intermittent with frequent pain-free intervals
exacerbated with eating
fear of eating with consequent weight loss
spectrum of abdominal pain
mild to quite severe
narcotic dependence

maldigestion
chronic diarrhea, steatorrhea, weight loss, fatigue
Clinical features
Diagnosis of chronic pancreatitis
Pathophysiology
intraductal plugging and obstruction
direct toxins and toxic metabolites
release of cytokines
stimulate pancreatic stellate cells
production of collagen
fibrosis
oxidative stress
necrosis-fibrosis
ischemia
autoimmune disorders
P: CCK releasing peptide
Negative feedback mechanism
CCK releasing peptide
Serine protease
Mechanism of pain
Serologic findings
Increased levels of serum gamma globulins especially IgG4
Other auto-antibodies: ANA, RA factor
Imaging findings
Diffuse swelling and enlargement of the pancreas
Diffuse irregular narrowing of the pancreatic duct in ERCP
Absence of pancreatic calcifications or cysts
Obstructive jaundice or a "mass" in the head
Histopathologic findings
Extensive fibrosis and lymphoplasmacytic infiltration
Sensitivity

most


less


least
Function

Secretin test
Fecal elastase

Serum trypsinogen
Fecal chymotrypsin

Fecal fat
Serum amylase/lipase
Full transcript