Pancreas—Chronic Pancreatitis
Concept
Etiology: alcohol abuse, hyperparathyroidism, cystic fibrosis, pancreatic divisum, trauma. Alcohol related most common in developed countries. Variety of suggested mechanisms:
hypersecretion of protein from acinar cells, plugging of pan- creatic ducts with protein precipitates, and pancreatic ductal hypertension. Pathology: acinar loss, glandular shrinkage, proliferative fibrosis, calcification, ductal stricturing
Way Question May Be Asked?
“45 y/o alcoholic with a history of several episodes of pan- creatitis presents now with worsening abdominal pain and is taking narcotics around the clock. What do you want to do?” Could be presented with any of the complications of chronic pancreatitis. Be careful to rule out other complica- tions of pancreatitis (ascites, pseudocyst, acute pancreati- tis) before diving into discussion of the management of chronic pancreatitis.
How To Answer?
History
Abdominal pain, epigastric, radiation to back, continu- ous or relapsing,
Anorexia Weight loss IDDM in 1/3 pt Steatorrhea in 1/4 pt.
Classic Tetrad: abd pain, wt loss, DM, steatorrhea Narcotic use
Flares of pancreatitis Etiology of pancreatitis
Physical Exam
Palpable mass (pseudocyst)
Stigmata of alcoholic liver disease
Abdominal exam (ascites, epigastric tenderness c/w acute pancreatitis)
Diagnostic Studies
Lab tests (only for completeness—IV secretin and CCK stimulation with collection of pancreatic effluent, 72 h fecal fat, glucose tolerance testing to measure endocrine function)
AXR: pancreatic calcifications 95% specific if seen CT: evaluate parenchymal disease, pseudocyst, ductal
dilatation
ERCP: ductal dilatation, strictures, calculi, chain of lakes pancreatogram
Surgical Treatment
(1) Nonoperative therapy
(a) Control abd pain: abstinence from alcohol, dietary manipulation (low fat, small volume meals, non-narcotic analgesics 1st . . . . often failure of this is indication for surgery
(b) Tx for endocrine insufficiency: exogenous insulin carefully,’ (hypoglycemia can arise as result of poor nutrient absorption)
(c) Tx for exocrine insufficiency: low fat diet, exogenous pancreatic enzymes,
If medical therapy fails (which of course it always will on the Oral Exam!):
(2) What is size of pancreatic duct (a) large →Peustow procedure
Peustow/Gillesby 1958—side to side pancreatico- jejunostomy, success rates 60–90%, decom- presses entire duct, need duct greater than 7 mm in diameter, pancreatic calcifications, pan- creatic-jejunal anastomosis longer than 6 cm, does not affect endocrine/exocrine insuffi- ciency
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Chevron incision, divide gastrocolic ligament to enter lesser sac, expose entire anterior surface of pancreas, create Roux-en-Y and anastomose to entire pancreatic duct
(b) small → pancreatic resection
Pylorus—preserving pancreaticoduodenectomy for pt with chronic pancreatitis, no ductal dilatation, and disease primarily in head of gland, preserves endocrine function in body/tail
(3) Ampullary stenosis →
(a) ampullary procedures: transduodenal sphinc- teroplasty helpful if focal obstruction at ampullary orifice, in pt with pancreatic divi- sum and stenosis of minor pancreatic duct papilla (these procedures have generally fallen out of favor)
(4) Celiac block considered for pts who fail operative interventions
Common Curveballs
Pt will present with complication of chronic pancreatitis:
Pain
Pseudoaneurysm Splenic vein thrombosis
Obstruction (GI or biliary tract) Exocrine/endocrine deficiency Pseudocyst
Anastomotic leak after Peustow procedure Asked to describe Peustow procedure
Pancreatic duct will be “large” initially, then asked to comment on surgery for “small” duct
Pt will develop hepatic failure post-op (alcoholic liver disease)
Pt will have DTs post-op
Strikeouts
Not getting ERCP/CT scan
Not knowing what operation to offer for “large/small”
pancreatic duct
Not knowing complications of chronic pancreatitis Not being able to describe the Peustow procedure Offering pt total pancreatectomy or 95% pancreatec-
tomy in favor of the more standard options
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