Makindo Medical Notes

Related Subjects:Acute Cholecystitis |Acute Appendicitis |Chronic Peritonitis |Abdominal Aortic Aneurysm |Ectopic Pregnancy |Acute Cholangitis |Acute Abdominal Pain/Peritonitis |Assessing Abdominal Pain |Penetrating Abdominal Trauma |Acute Pancreatitis |Acute Diverticulitis

⚠️ In chronic pancreatitis with secondary diabetes, hypoglycaemic episodes are more serious because patients lack both insulin and glucagon – the pancreatic hormone that normally raises blood glucose.

📌 About

• Chronic pancreatitis is a progressive, irreversible inflammatory disease of the pancreas.
• Characterised by fibrosis, scarring and loss of both exocrine and endocrine function.
• Can mimic acute pancreatitis, and may be difficult to distinguish from pancreatic cancer.

🧾 Aetiology

• 🍷 Alcohol misuse → ~70% of cases, onset typically ~40 yrs.
• Idiopathic (~20%).
• Recurrent acute pancreatitis episodes.
• Metabolic: hyperparathyroidism, hypertriglyceridaemia.
• Genetic/anatomical: pancreas divisum, cystic fibrosis (children), hereditary pancreatitis (AD).
• Autoimmune (IgG4-related), tropical pancreatitis, post-renal transplant.

🧬 Pathophysiology

• Progressive fibrosis → ductal strictures, calcification, and loss of islet cells.
• Endocrine failure → diabetes mellitus, with high risk of hypoglycaemia (loss of glucagon).
• Exocrine failure → malabsorption, steatorrhoea, fat-soluble vitamin deficiency, metabolic bone disease.
• Increased risk of pancreatic ductal adenocarcinoma.

🔎 Types

• Chronic calcifying pancreatitis – protein plugs → calcification, fibrosis, secondary diabetes. Abstinence from alcohol may not halt progression.
• Chronic obstructive pancreatitis – due to stones/strictures; surgical relief may improve outcome.

🤒 Clinical Features

• Recurrent, severe epigastric pain radiating to the back, relieved by sitting forward.
• 💩 Malabsorption → steatorrhoea, bloating, weight loss, malnutrition.
• Cachexia in advanced cases.

⚠️ Complications

• Secondary diabetes mellitus (loss of insulin + glucagon).
• Malabsorption → fat-soluble vitamin deficiencies (A, D, E, K).
• Chronic abdominal pain → opiate dependence.
• Pancreatic pseudocysts and strictures.
• Pancreatic duct calcification (visible on AXR/CT).
• ↑ Risk of pancreatic cancer.

🧪 Investigations

• Bloods: FBC (anaemia/infection), glucose (diabetes), IgG4 (autoimmune).
• Amylase/lipase: Often normal in chronic disease.
• AXR: Pancreatic calcification in ~30% cases.
• CT: Detects pseudocysts, calcifications, ductal changes.
• MRCP/ERCP: Defines ductal strictures, stones; MRCP preferred (non-invasive).
• Faecal elastase-1: Low in exocrine insufficiency.

💊 Management

• 🏥 Acute admissions: pain control (opiates often required), IV fluids, NBM initially.
• 🚭 Lifestyle: Abstain from alcohol & smoking – slows progression.
• 🍽️ Enzyme replacement: Pancreatic enzyme supplements (e.g., Creon) + PPI for better efficacy.
• 💉 Diabetes management: Insulin therapy with close monitoring (loss of glucagon → hypoglycaemia risk).
• 🩺 Pain management: Analgesics, coeliac plexus block in refractory cases.
• 🔧 Interventions: ERCP for stone removal/stenting; surgery (e.g., longitudinal pancreaticojejunostomy) in selected cases.
• 🥗 Nutritional support: Dietician input, vitamin supplementation (esp. fat-soluble vitamins).

📚 References

• Complications of Chronic Pancreatitis – PubMed

Cases — Chronic Pancreatitis

• Case 1 (Alcohol-related): A 47-year-old man with a 20-year history of heavy alcohol use presents with recurrent episodes of epigastric pain radiating to the back, steatorrhoea, and weight loss. CT abdomen shows pancreatic calcifications and ductal dilatation. Faecal elastase is low, confirming exocrine insufficiency. Management: Alcohol cessation support, pancreatic enzyme replacement (Creon), fat-soluble vitamin supplementation, and oral analgesia. Referred to a pain management service. Outcome: Symptoms improve with enzyme therapy, though pain persists intermittently. Abstinence from alcohol reduces frequency of exacerbations.
• Case 2 (Idiopathic/hereditary): A 28-year-old woman presents with chronic upper abdominal pain and intermittent vomiting. She has a strong family history of pancreatitis. MRCP shows irregular pancreatic ducts and strictures, with reduced gland size. Endocrine tests reveal impaired glucose tolerance.
  Management: Pancreatic enzyme replacement therapy, low-fat diet, insulin started for secondary diabetes, and endoscopic therapy for ductal strictures. Genetic counselling offered. Outcome: Symptom control achieved with enzymes and diet. Glycaemic control stabilised on insulin. Remains under surveillance for long-term risk of pancreatic cancer.

Teaching Commentary 🧑‍⚕️

Chronic pancreatitis is a progressive fibro-inflammatory process leading to irreversible pancreatic damage. Common causes are chronic alcohol misuse, smoking, hereditary mutations (PRSS1, SPINK1, CFTR), and idiopathic disease. Clinical hallmarks: chronic pain, malabsorption (steatorrhoea), and diabetes mellitus. Imaging may show calcifications and ductal irregularity. Management is largely supportive: alcohol/tobacco cessation, enzyme supplementation, analgesia, endoscopic or surgical drainage for strictures, and treatment of diabetes. Long-term, patients are at increased risk of pancreatic cancer, warranting careful follow-up in specialist centres.