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Chronic Pancreatitis - Coggle Diagram
Chronic Pancreatitis
Complications
Pseudocysts
Fistulae
Duodenal / biliary obstruction
Pancreatic ascities
Ascities
Splenic vein thrombosis
Pseudoaneurysm
Pscyho social issues - substance abuse /depression
Biliary Strictures
Presentation: Obstructive jaundice
Tx: ERCP and biliary stent
Bypass surgery if stent dependent
Duodenal stricture
PResentation: Gastric outlet obstruction and vomiting
Tx; Endoscopy and removable stent
NJ feeding and wait for inflammation to settle
Bypass gastrojejunotomy for long term obstruction
Pancreatic Ascities
Rare
Path: Massive accumulation of pancreatic fluid in the fluid cavity
High fluid amylase
Tx: Percutaneous drainage
ERCP and pancreatic stent
False Aneurysm of Visceral VEssels
PResentation: Bleeding and haemorrhagic shock
Arteries: Gastroduodenal and splenic
Tx: Angiographic embolism
Pancreatic cancer
Increased lifetime risk
Relative risk 13.3
10-12 yr lag between incidence of pancreatitis and maliganncy
Aetiology
Toxic Metabolic
Alcohol
Smoking
Hypercalcaemia
Hyperlipidaemia
Idiopathic
LAte onset
Early onset
Genetic
PRSS1 Premature intra-acinar activation of trypsinogen
SPINK1 compromised intracellular inactivation of trypsin
Cystic fibrosis gene
Autoimmune
IgG4 related disease
Recurrent and severe acute pancreastitis
Obstructive
Tumour
Strictures
PAcnreas Divisu
TIGER-O
Natural History
Early phase
Pain
Acute pancreatitis
Hospitilisations
0-5 years
Intermediate phase
5-10 years
Reduced pain
PD stricture
Morphological changes
Increased pancreatic insufficiency
Late Phase
Over 10 year
Exocrine insufficiency
Endocrine insuficiency
Progressive fibrosis with time
Management
History
Pain and duration of symptoms
Steatorrhoea w/ weight loss / fatty meal intolerance
Hx new onset diabetes or worsening DM
Hx risk factors - Alcohol, smoking
Hx pnacreatitis + age
Examination
BMI
Evidence of malnutrition
Abdominal mass
Previous sacres
Investigation
Bloods
FBC
U&E
LFTs
FBS
HbA1C
Amylase /lipase
CRP
IgG4
Bedsides
Faecal elastase
Imaging
U/S
Findings
Intraductal parenchymal calcifications (echogenic foci)
Pancreatic duct dilation adn irregulatrities (beaded appearance)
Complications - pseudocysts, splenic vein thrombosis
CT 🥇
Can diagnose chronic and acute
R/o other causes
Calcifications
Ductal changes
DEtect complications
MRI
More sensitive
Can give parenchymal details esp if tumour suspected
Special
Endoscopic U/S
Can obtain tissue and fluid for chemical analysus
CAn detect smaller tumours
Treats pseudocyst
Treatment
Medical
Treat Cause
Treat addiction - alcohol and smoking cessation
Cholecystectomy
Correct hyperlipidaemia
Correct hypercalcaemia - parathyroidectomy
Initiate steroids for Autoimmune pancreatitis
Pain Management
WHO analgesic ladder
Consider engancing agents - Gabapentin
Should be titrated to achieve the pain relief with the lowest effective dose
Opiod addiction common
Endoscopic Coeliac Plexus block
Injection of local anaesthesia can be used
THose who respond to LA - destruction of plexu considered by injection of alcohol
Exocrine Insufficiency
Endocrine Insuf
Goals
Pain management
REmoval of causitive agents (alcohol, smoking)
Mx of endocrine / exocrine insufficiency and nutrition
Mx of complications
Endoscopic
Indications
PT with dilated MPD without heas mass
Pancatic duct sphincteroomy
REmove intrecuctal stones
Leave stent for prolonged drainage
Pancreatic ductal stones might represent parenchymal calcification with intraductal projections
Larger stones on CT might need ESWL
Surgery
Indications
Symptomatic local complications
Common bile duct obstruction
Duodenal or colonic obstruction
Pancreatic psuedocyst
Pancreatic ascites
Unsuccessful endoscopic mx
Suscpicion of malignant
Intractable pain
Types
Drainage
Resection
Neuroablative
Optimal Surgical Procedure - Sugery for Pain
Manage / control pain
Preserve endocrine / exocrine fx
Improve QoL
Surgical Options
Partington-Rochell proceduer
Kausch-WHipple / PPD
BEger procedure DPPHR
Frey procedure
Berne procedure
Izbiki procedure
Total pancreatectomy +/- islet cell transplantation
Pathogenesis of Pain in CP
Pancreatic
Inflammation of gland
Obstruction of main prancreatic duct
Extrapancreatic
Abnormal neural pathway
Aberrent CNS preception of apin
Increased number and diameter of non-myelinated type C pain fibres
Extrapancreatic factorss might account for ttt failure of pancreas directed ??? procedures
Pathology
Destruction of acinar and islet cells, scar tissue -> Gradual deteriorationin exocrine and endocrine
Progressive exocrine atrophy with replacemntof normal pancreatic t
Pathophysiology
Two hit hypothesis
Toxic metabolite (alcohol)
Ductal blockage (alcohol)
Chronic inflammation - fibrosis
Loss of acinar cells - exocrine failure
Islet cell famage - DM Type 3c
Neural involement - chronic pain
Presentation
Acute attack on Chronic Pancreatitis - treat acute
Obstructive jaundice
Incidental finding
The Pancreas
Structure
From C duodenum and spleen
Key organ in digestion and metabolism
Soft lobulated, yellow gland
Many associated vascular structure
Retorperitoneal orgna
Function
Endocrine
Pale staining islet embedded within the parenchyma
Make up 1-2% of total weight of pancreas
Recieve 20% of blood supply
Exocrine
Lobules of serous acini connected to pancreatic duct by ductules lined by columnar epithelium
Secrete bicarbonate rish fluid
Produced 2.5L fluid exocrine fluid a day
Nutrients in intestines stimulated exocrine fx
Resection Vs Duodenal Preservation
Resection
Adantages
REmoved inflammatory mass
Separates gland from splanchnic nerves
Established procedure
Disadvantages
Long term morbidity
REcurrent cholangitis
Intestinal ulceration
Disordered digestive functino
Duodenal Preservation (Beger / Frey / Izbicki)
Advantages
Preserves duodenum
Aloows for normal enteric passage
Normal interaction of duodenal hormones with insulin secretion
Improved pain control, endocrine fx, weight gain (short term)
Disadvantages
Complex procedures
? Increased recurrence
Need for re-operation (biliary obstruction
Definition
A chronic Inflammatory Disease characterised by irreversible morphological change and typically causing painand / or permanent loss of function
Epidemiology
IRE prevalence 11.6-13per 100,000