Chronic Pancreatitis

Chronic pancreatitis (CP) is a benign inflammatory process of the pancreas characterized by progressive and irreversible damage to the organ that eventually leads to pain and/ or exocrine and endocrine insufficiency as well as malnutrition.

Etiologic factors: TIGAR-O classification

  • Toxic-metabolic (alcohol/tobacco)
  • Idiopathic
  • Genetic (Trypsinogen gene mutations)
  • Autoimmune
  • Recurrent and severe acute pancreatitis
  • Obstructive (Divisum or Tumor)

Clinical signs and symptoms

According to the best chronic pancreatitis doctor in Kolkata, the following symptoms are usually observed:

  • Pain: Abdominal pain is most common and morbid symptom occurring in majority of patients (90%) and is the leading cause for most hospital admissions related to CP. The pain typically occurs in the epigastric area, often radiates to the back, dull or boring in quality and worsens after eating
  • Endocrine insufficiency (diabetes mellitus): This usually occurs at a later stage of the disease. It is reported to account for 20–30% of the Indians. It can be controlled with diet, insulin therapy, and OHAs.
  • Exocrine insufficiency: Pancreatic exocrine insufficiency may be mild, moderate or severe depending on stage of disease process, duration of disease and etiology. Clinically apparent steatorrhea (fatty diarrhoea) generally does not occur until 90% of pancreatic function has been lost.

Complications

Dr. Purnendu Bhowmik, an experienced pancreatic specialist doctor in Kolkata elucidates that different complications, including biliary or duodenal obstruction, pseudocysts, internal or external pancreatic fistulae, pancreatic malignancy, and left-sided portal hypertension.

How to diagnose chronic pancreatitis?   

  • Biochemical Measurements: People with chronic pancreatitis may have low or elevated levels of isoamylase, trypsin, lipase, and elastase. In cases with mild chronic pancreatitis, it is difficult to make a definitive diagnosis based on serum enzyme levels alone.
  • Radiological Testing
  • Plain Abdominal Film: An abdominal film is usually the first diagnostic test used to establish a diagnosis of chronic pancreatitis. Diffuse, speckled calcification of the gland may suffice as a positive finding
  • Transabdominal Ultrasound: This is a simple, noninvasive, and relatively inexpensive imaging technique. Findings of a dilated pancreatic duct (greater than 4 mm), calcification, and large cavities (greater than 1 cm) are associated with chronic pancreatitis (70% sensitivity and 90% specificity)
  • Computed Tomography (CT): More sensitive than transabdominal ultrasound, CT (computed tomography) scanning can demonstrate duct dilation, cystic lesions, and calcification. This technique is useful in discriminating chronic pancreatitis from pancreatic carcinoma
  • Magnetic Resonance Cholangiopancreatography (MRCP): It represents a major advance in the demonstration of pancreatic ductal anatomy. MRCP yields satisfactory pancreatograms in patients with chronic pancreatitis in whom a CT scan showed no abnormalities
  • Endoscopic Retrograde Cholangiopancreatography (ERCP): ERCP is an endoscopic technique for visualization of the bile and pancreatic ducts. This is a sensitive and specific diagnostic tool in chronic pancreatitis. ERCP shows details of the pancreatic ductal anatomy, including strictures, ductal rupture and pseudocysts
  • Endoscopic Ultrasonography (EUS): It is the most sensitive imaging tool for the diagnosis of chronic pancreatitis, and has been proven to be more accurate than the CT scan.

 Chronic Pancreatitis Treatment in Kolkata

The most important aspects of managing CP involve: (1) amelioration of pain; (2) maintain nutrition and control indigestion and (3) tackle complications.

  • Control of abdominal pain: The goal of therapy is to control pain to that level that it may not hamper patient’s life as complete relief of pain is not expected. The following modalities are used to control the pain.
  • Analgesics
  • Pancreatic Enzymes
  • Antioxidants
  • Pregabalin
  • Nerve Blocks: Celiac plexus blockade (CPB) and celiac plexus neurolysis (CPN) are the nerve block methods used to disrupt the signaling of the pancreatic pain afferents to the spinal cord.
  • Endoscopic Therapy: The aim of the endotherapy is to relieve pain by alleviating outflow obstruction of PD and decrease ductal hypertension. Endoscopic pancreatic sphincterotomy has been used to reduce pancreatic duct pressure and to facilitate other procedures such as pancreatic stent placement, tissue sampling, dilation of strictures, or stone removal
  • Surgical intervention: Surgical therapy is usually reserved for patients with pain not responding to both medical and endoscopic therapy or in whom endoscopic therapy is difficult like multiple and distal strictures, large, multiple and impacted stones.
  • The surgical intervention is aimed at reaching two goals; the removal of the space occupied lesions and the provision of the decompression of the pancreatic duct system; however, the type of surgical intervention has been a matter of debate.

Types of surgeries:(each procedure have their own indication, pros & cons)

  • Distal pancreatectomy
  • Duct Drainage Procedures
  • Puestow procedure
  • Duodenum-Preserving Pancreatic Head Resections:
    • Frey Procedure and
  • Beger Procedure
  • Whipple Procedure
  • Total Pancreatectomy (+/- islet autotransplantation)
  • Control of maldigestion due to excrine insufficiency: The maldigestion in CP is treated by oral enzyme supplementation.
  • Control of endocrine Insufficiency: Pancreatic endocrine insufficiency secondary to CP ranges in severity from mild form that is easily controlled with oral hypoglycemic agents to severe form requiring increasing doses of insulin for proper glycemic control

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