ССhronic hronic pancreatitispancreatitis

Lykhatska G.V.Lykhatska G.V.

Pancreatic structure and Pancreatic structure and functionfunction

Pancreatic enzymesPancreatic enzymes

EnzymeEnzyme SubstrateSubstrate ProductProduct

AmylaseAmylase Starch and Starch and glycogenglycogen

Limit dextransLimit dextrans

MaltoseMaltose

MaltrioseMaltriose

LipaseLipase

ColipaseColipase

TriglyceridesTriglycerides Monoglycerides and Monoglycerides and free fatty acidisfree fatty acidis

Proteolytic enzymesProteolytic enzymes

TrypsinogenTrypsinogen

ChymotripsinogenChymotripsinogen

ProelastaseProelastase

ProcarboxypeptidasesProcarboxypeptidases

Proteins and Proteins and polypeptidespolypeptides

Shot polypeptidesShot polypeptides

•Pancreatitis Pancreatitis is a chronic inflammatory is a chronic inflammatory disease which is more than 6 months and disease which is more than 6 months and characterized by fibrosis and destruction of characterized by fibrosis and destruction of exocrine pancreatic tissue. exocrine pancreatic tissue.

Etiology of chronic Etiology of chronic pancreatitispancreatitis

Primary pancreatitis:Primary pancreatitis:•Alcohol abuse (70-80% of all diagnostic cases)Alcohol abuse (70-80% of all diagnostic cases)•Regular eating of fatty foodsRegular eating of fatty foods•Medicamentous (estrogen, azathioprine, Medicamentous (estrogen, azathioprine,

tetracycline, oral hypoglycemics, furosemide/ tetracycline, oral hypoglycemics, furosemide/ thiazide diuretics)thiazide diuretics)

•Protein insufficiencyProtein insufficiency•HereditaryHereditary•Ischemic (affection of vesels of pancreas)Ischemic (affection of vesels of pancreas)•IdiopathicIdiopathic

Causes of chronic pancreatitisCauses of chronic pancreatitis

Secondary pancreatitis: diseases of billiary tract (in 30-40 %)        diseases of duodenum       diseases of liver        diseases of intestine        inflectional diseases (parotitits)        allergy        hyperlipidemia        hyperparathyroidism traumas of pancreas

Pathogenesis of chronic Pathogenesis of chronic pancreatitispancreatitis

• The main pathogenetic mechanisms of chronic pancreatitis is destructive affection of acinus caused by activation of intracellular enzymes of pancreas.

• Changers of getting out of juice of pancreas.• Progressive fibrosis gradually leads to changers

of physiological functions of pancreas. • Development of areas of necrosis and aseptic

inflammation.

Pathophysiology of chronic Pathophysiology of chronic pancreatitispancreatitis

International Classification of the diseasesInternational Classification of the diseases• 1.     Chronic alcoholic pancreatitis (code K 86.0)1.     Chronic alcoholic pancreatitis (code K 86.0)• 2.     Other types of chronic pancreatitis (code K 86.1) 2.     Other types of chronic pancreatitis (code K 86.1)

(chronic pancreatitis with unknown etiology, infection (chronic pancreatitis with unknown etiology, infection pancreatitis) pancreatitis)

Marseilles and Rome ClassificationMarseilles and Rome Classification• 1. Chronic calcareous pancreatitis.1. Chronic calcareous pancreatitis.• 2. Chronic obstructive pancreatitis.2. Chronic obstructive pancreatitis.• 3. Chronic fibrous and indurated (inflammatory or 3. Chronic fibrous and indurated (inflammatory or

parenchymatous pancreatitis).parenchymatous pancreatitis).• 4. Chronic cysts and pseudocysts of the pancreas.4. Chronic cysts and pseudocysts of the pancreas.

Clinical classificationClinical classification

• Chronic reccurent pancreatitis

• Chronic pancreatitis with pain syndrome

• Latent pancreatitis (without pain, changers of exocrine function of pancreas)

• Pseudotumorous chronic pancreatitis

Clinical classificationClinical classification

According to the running of the disease

• Mild form of pancreatitis

• Moderate form of pancreatitis (changers of exocrine or endocrine functions of pancreas)

• Severe form of pancreatitis (terminal stage)

Clinical classificationClinical classification

• With exocrine disfunction

• With endocrine disfunctio

Phase of disease

• Execerbation

• Remission

Complications

Clinical presentationClinical presentation

• 1.     Pain syndrome 1.     Pain syndrome – epigastric abdominal pain.– epigastric abdominal pain.• 2.     Dyspeptic syndrome 2.     Dyspeptic syndrome - loss of appetite, sialorrhea, - loss of appetite, sialorrhea,

nausea, vomiting, meteorism, diarrhea, steatorrea.nausea, vomiting, meteorism, diarrhea, steatorrea.• 3.    Exocrine insufficiency with malabsorption and 3.    Exocrine insufficiency with malabsorption and

maldigestion syndromes maldigestion syndromes – weight loss, pale and dry – weight loss, pale and dry skin, hypovitaminosis.skin, hypovitaminosis.

• 4.     Incretion insufficiency 4.     Incretion insufficiency – secondary diabetes – secondary diabetes mellitus.mellitus.

• 5. 5. Asteno-vegetative syndromeAsteno-vegetative syndrome – general weakness, – general weakness, bad sleeping, bad sleeping,

• Pain syndromePain syndrome

Physical examination data.Physical examination data.

1.1. Shofar’s zoneShofar’s zone

2.2. Hubergrits-Hubergrits-Skulskyy zoneSkulskyy zone

3.3. Mayo-Robson Mayo-Robson pointpoint

4.4. D’Egarden’s D’Egarden’s pointpoint

11

33

22

44

D’Egarden’s pointD’Egarden’s point

Shofar’s zoneShofar’s zone

Mayo-Robson pointMayo-Robson point

Dyspeptic syndrome Dyspeptic syndrome - loss of appetite, sialorrhea, nausea, - loss of appetite, sialorrhea, nausea, vomiting, meteorism, diarrhea, steatorrea.vomiting, meteorism, diarrhea, steatorrea.

Symptom of red drops Symptom of red drops (microanevrismus)(microanevrismus)

Clinical symptomsClinical symptoms

• Catch symptom - hyperesthesia of the skin in the innervations zone of the 8-th thoracic vertebra.

• Grot symptom – subcutaneous cellular tissue atrophy near the pancreas

• Zakcharin symptom – tenderness in the right hypogastria.

Clinical course of diseaseClinical course of disease

• Chronic recurrent pancreatitis - the most frequent form, which is characterised by attack of pain, combined with increased levels of pancreatic enzymes in blood and urine, sometimes with jaundice. In the phase of remission can be with dyspeptic syndrome.

Pain-form is characterized by a constant dull pain in the left hypochondrium and laboratory data that confirm the diagnosis of pancreatitis, in anamnesis there are data about pancreonecrosis.

Latent form - characterized by asymptomatic course. The main is dyspeptic syndrome and syndrome of exocrine insuficiency.

Pseudotumorous form - characterized by a combination of jaundice with exocrine and endocrine insuficiency.

Investigations in chronic Investigations in chronic pancreatitispancreatitis

•LeukocytosisLeukocytosis•Elevated amylase and lipase: Elevated amylase and lipase: •Amylase: 3X normal; peak 2-3 days;Amylase: 3X normal; peak 2-3 days;•Lipase: 3X normal; peak 7-14 days.Lipase: 3X normal; peak 7-14 days.•Collection of pure pancreatic juice after secretin Collection of pure pancreatic juice after secretin injection (gold standard but invasive and seldom injection (gold standard but invasive and seldom used)used)•Pancreolauryl or PABA testPancreolauryl or PABA test•Faecal pancreatic chymotrypsin or elastaseFaecal pancreatic chymotrypsin or elastase•Oral glucose tolerance testOral glucose tolerance test

Tests of exocrine pancreatic Tests of exocrine pancreatic ffunctionunction

Tests to establish the Tests to establish the diagnosisdiagnosis

• UltrasoundUltrasound• CT (may show atrophy, calcification or ductal CT (may show atrophy, calcification or ductal

dilatation)dilatation)• Abdominal radiograph (may show calcification)Abdominal radiograph (may show calcification)• ERCP only if non-invasive tests are negative or ERCP only if non-invasive tests are negative or

equivocalequivocal• MRCPMRCP• Endoscopic ultrasoundEndoscopic ultrasound

Ultrasound investigationUltrasound investigation. . Normal Normal pancreaspancreas

Ultrasound investigationUltrasound investigation.. Chronic Chronic pancreatitispancreatitis

а) а) calcificates in the head of calcificates in the head of pancreaspancreas;; б) б) VirsungovVirsungov’’s ducts duct; ; в) в) pseudocyst of pancreaspseudocyst of pancreas; ; г) г) increase of the head of increase of the head of pancreaspancreas;; д) д) spleen veinspleen vein

Ultrasound investigationUltrasound investigation. . CChronic calcified hronic calcified pancreatitis pancreatitis а)а) virsungolithiasis virsungolithiasis б) б) dilated dilated

VirsungovVirsungov’’s duct.s duct.

CT scan with central CT scan with central pseudocystpseudocyst

ERCP of chronic pancreatitis with distortion ERCP of chronic pancreatitis with distortion of the pancreatic ductof the pancreatic duct

An endoscopic retrograde An endoscopic retrograde cholangiopancreatography image cholangiopancreatography image

demonstrating massive pancreatic duct demonstrating massive pancreatic duct dilatation in a patient with bigduct chronic dilatation in a patient with bigduct chronic

pancreatitis.pancreatitis.

An endoscopic retrograde cholangiopancreatography An endoscopic retrograde cholangiopancreatography image demonstrating minimal pancreatic duct image demonstrating minimal pancreatic duct

abnormalities in a patient with painful small-duct abnormalities in a patient with painful small-duct chronic pancreatitis.chronic pancreatitis.

An endoscopic ultrasound image An endoscopic ultrasound image demonstrating a dilated pancreatic duct demonstrating a dilated pancreatic duct

(markers) in a patient with advanced chronic (markers) in a patient with advanced chronic pancreatitispancreatitis

Plain X-ray of abdomenPlain X-ray of abdomen showing showing calcific calcific pancreatitispancreatitis

Complications of chronic Complications of chronic pancreatitispancreatitis

• PseudocystsPseudocysts are the collection of tissue, fluid, disintegration are the collection of tissue, fluid, disintegration products, ferments and blood, have not epitelial lining, appear products, ferments and blood, have not epitelial lining, appear during expressive severity of chronic pancreatitisduring expressive severity of chronic pancreatitis

• Diabetes mellitusDiabetes mellitus• AbscessAbscess of pancreatic gland appears during the combination of of pancreatic gland appears during the combination of

infection process with presence of pseudocyst.infection process with presence of pseudocyst.• Mechanical jaundiceMechanical jaundice appears as a result of choledoch obstruction, appears as a result of choledoch obstruction,

pressing its by increased bulb of pancreas.pressing its by increased bulb of pancreas.• Duodenal stenosisDuodenal stenosis• Portal or spleenPortal or spleen vein thrombosis leading to segmental portal vein thrombosis leading to segmental portal

hypertension and gastric varicosehypertension and gastric varicose• Infection complicationsInfection complications (inflammatory infiltrate, cholangitis, (inflammatory infiltrate, cholangitis,

peritonitis, septic states).peritonitis, septic states).

ComplicationsComplications

• Pancreatic necrosis

• Pancreatic ascites

• Erosive gastritis

• Gastrointestinal bleeding

• Abdominal ischemic syndrome

• Exudative pleuritis

• Cancer of pancreas

Differential diagnosticDifferential diagnostic

• Chronic cholecystitis• Chronic gastroduodenitis• Ulcer disease• Chronic hepatitis• Gallstone disease• Cancer of pancreas• Aneurisms of aorta• Kidney colic• Angina pectoris

ManagementManagement

• 1. A low-fat diet.1. A low-fat diet.• 2. Pain relief: not narcotic analgesics, miotropic 2. Pain relief: not narcotic analgesics, miotropic

spasmolitics, M – holinoliticsspasmolitics, M – holinolitics• 3. Antisecretion preparations: H3. Antisecretion preparations: H2 2 – blockers (Kvamatel), – blockers (Kvamatel),

proton pump inhibitors (Omeprazol).proton pump inhibitors (Omeprazol).• 4. Pancreatic enzymes replacement (Kreon, Festal).4. Pancreatic enzymes replacement (Kreon, Festal).• 5. Antibiotics5. Antibiotics• 6. Cytoprotection6. Cytoprotection• 7. Antioxydation therapy (Thiotriazolin, vst. E) 7. Antioxydation therapy (Thiotriazolin, vst. E) • 8. Immunomodulation (Imunal, Timalin)8. Immunomodulation (Imunal, Timalin)• 9. Vitamin supplements9. Vitamin supplements• 10. Oral hypoglycemics for diabetics10. Oral hypoglycemics for diabetics

CHRONIC PANCREATITISCHRONIC PANCREATITISSUMMARYSUMMARY