Chonic Pancreatitis

risk factors

• heavy (50-80g/day) alcohol consumption (70-80%)

• recurrent gallstone pancreatitis

• smoking (dose-dependent)

• autoimmune (associated w/PSC and Sjögren syndrome)

• hypercalcemia

• hereditary (66% PRSS1; others incl. CFTR and SPINK1)

• pancreas divisum

• tropical pancreatitis (associated w/SPINK1)

clinical

• episodic (then persistent) abdominal pain

• hx of ≥ 1 hospitalization

• weight loss

• malabsorption

• steatorrhea

• DM

diagnosis

• best initial

  1. CT-pancreas

     • pancreatic duct dilation > 4 mm

     • parenchymal cavities

     • parenchymal heterogeneity

     • calculi/pancreatic calcification

     • duct “chain of lakes” irregularities

  2. MRCP w/secretin stimulation

     • > 80 mEq/L bicarbonate secretion considered normal

• most accurate: EUS (Rosemont classification)

  1. major A criteria

     • hyperechoic foci w/shadowing

     • main pancreatic duct calculi

  2. major B criteria

     • lobularity w/honeycombing

  3. minor criteria

     • cysts

     • dilated ducts ≥ 3.5 mm

     • irregular pancreatic duct contour

     • dilated side branches ≥ 1 mm

     • hyperechoic duct wall

     • strands

     • non-shadowing hyperechoic foci

     • lobularity w/non-contiguous lobules

  4. interpretation

     • definitive

       1. 1 major A + ≥ 3 minor

       2. 1 major A + 1 major B

       3. 2 major A

     • suspected

       1. 1 major A + < 3 minor

       2. 1 major B + ≥ 3 minor

       3. ≥ 5 minor

     • possible

       1. 3-4 minor, no major

       2. major B +/- < 3 minor

     • normal: < 3 minor, no major

therapy

• medical

  1. analgesia (long-acting opioids)

  2. alcohol abstinence & low-fat meals

  3. PPI (prevent PO lipase from being inactivated)

  4. exocrine enzyme supplementation

  5. therapy for DM

  6. autoimmune: steroids

• surgical

  1. indications

     • refractory intractable pain (most common)

     • recurrent flares

     • fibrosis sequelae (duodenum/CBD/colon obstruction)

     • ductal rupture (eg pseudocyst, ascites)

     • suspected pancreatic cancer

• drainage procedures

  1. lateral pancreaticojejunostomy (Duval)

     • distal pancreatectomy w/splenectomy and retrograde drainage of distal duct via pancreaticojejunostomy

     • ideal for single duct strictures

     • partial to complete pain relief in up to 90% of patients

     • 25% will develop pancreatic diabetes

  2. longitudinal pancreaticojejunostomy (Peustow)

     • reserved for duct dilation ≥ 6 mm w/wo significant enlargement of the pancreatic head

• combined resection w/drainage

  1. Frey procedure

     • subtotal pancreatic head resection w/longitudinal resection decompression of duct in the body and tail

     • ideal for head-dominant disease w/wo duct dilation

  2. Beger procedure

     • duodenal-sparing pancreatic head resection w/2 pancreaticojejunostomies and a jejunojejunostomy

     • ideal for small duct head-dominant disease

     • offers symptomatic relief similar to Whipple or Frey

  3. Berne procedure

     • Beger w/out division of pancreas anterior to portal vein

     • no outcome differences between Beger and Berne

  4. pancreaticoduodectomy (Whipple procedure)

     • ideal for small duct, head-dominant disease w/multiple obstructions of pancreatic duct

  5. partial/total pancreatectomy

     • ideal for intractable pain or prior failed surgeries

     • often paired w/autologous islet cell transplant

  6. thoracoscopic splanchnicectomy

     • ideal for minimal change pancreatitis

complications

• pancreatic diabetes (up to 30%)

• malabsorption 2/2 exocrine insufficiency

• opioid use disorder

• pancreatic cancer