Chronic pancreatitis

Unlike acute pancreatitis, in chronic pancreatitis destruction of the pancreas persists sometimes even when the underlying causes are removed.

Alcohol abuse is the most common cause.

Clinical suspicion

Pancreatic pain (severe agonizing epigastric pain which may radiate to the back accompanied by nausea and vomiting) accompanied by steatorrhoea and loss of weight.

Diagnosis

Elevations of serum amylase and lipase are found only during acute attacks of pancreatitis, usually early in the course of the disease. In the later stages of chronic pancreatitis, atrophy of the pancreatic parenchyma can result in serum enzyme levels within the reference range, even during acute attacks of pain.

Abdominal x-ray: Pancreatic calcifications, often considered pathognomonic of chronic pancreatitis, are observed in approximately 30% of cases.

Calcified shrunken pancreas can be detected by abdominal CT scan in advanced cases. CT is less sensitive in early or moderate cases.

ERCP is the diagnostic procedure of choice. It allows the most accurate visualization of the pancreatic ductal system and has been regarded as the criterion standard for diagnosing chronic pancreatitis. One limitation of ERCP is that it cannot be used to evaluate the pancreatic parenchyma, and histologically proven chronic pancreatitis has been documented in the setting of normal findings on pancreatogram.

Endoscopic ultrasonography and Magnetic resonance cholangiopandreatography (MRCP) are being reviewed and improved as methods of diagnosis.

Treatment

Conservative measures as acute pancreatitis. Antioxidant vitamin and micronutrient supplementation may have a role in facilitating pancreatic healing. Pain control involves pethidine or may require celiac ganglion blockade.

Surgery is indicated in cases accompanied by biliary obstruction and complications as pseudocysts. Pancreatic resection: may be an option If the disease is limited to the head of the pancreas. However, pancreatic function and quality of life are impaired after these procedures, and the operative mortality rate of total pancreatectomy is about 10%. Total pancreatectomy and islet autotransplantation is used in selected patients to avoid the morbidity of diabetes following pancreatectomy.