Back to Topics<<<<

CHRONIC AND CHRONIC RELAPSING PANCREATITIS

Pathology:
The pancreas undergoes gradual but progressive and permanent loss of structure and function. The acini and/or the islet cell undergo progressive destruction. The destroyed areas are replaced by the fibrous tissue, in which there are multiple foci of calcification. The calcification, however, is almost always intraductal and interstitial i.e. presenting as pancreatic stones. The duct system shows irregular segment of constriction, with proximal dilation.

Etiology:
There are three major causes for the chronic pancreatitis and they are:
  • Gall stones, particularly those impacted in the common bile duct
  • Chronic alcoholism
  • As a sequaelae from the acute pancreatitis
The first two conditions are associated with depressed liver function.

Presenting Features:
The patient may present with different features, which may be grouped as follows:
  • Pain, characteristically pancreatic – Localized centrally in the epigastrium, often radiating to the neck
  • Gastrointestinal upsets – Anorexia, nausea, vomiting etc
  • Obstructive jaundice
  • Malabsorption syndromes e.g. Steatorrhoea, loss of weight. These are due to the failure of external secretions.
  • Diabetes – due to the failure of internal secretions
  • X-ray – Pancreatic calcification (pancreatic calculi)
  • E.R.C.P. – Strictures (usually multiple) with proximal dilations (sacculations) and stones may be demonstrated. There may be a “chain of lakes” appearance due to alternating strictures and sacculation along the duct
  • Open pancreatography – If an E.RC.P. has not been done, 60% Hypaque solution is injected into the pancreatic duct through the duodenum during the operation and X-ray is taken. The state of the duct system demonstrated
  • At laparatomy – The pancreas feels indurated, with nodularity and restricted mobility (that is the feel of the “banting pancreas” that develops in the laboratory animals when the pancreatic duct is ligated). This condition may be difficult to be diagnosed from the carcinoma
The difference between chronic and chronic relapsing pancreatitis is mainly clinical. The chronic variety presents as persistant abdominal pain, while the relapsing type manifests itself by recurrent acute upper abdominal pain with minor residual symptoms in between the acute attacks.

Treatment:
  • Conservative:
    Unless the symptoms are intolerable, the only treatment advisable is conservative (medical) treatment, which is as follows:
    • Low fat, high protein, high calorie and high vitamin diet is prescribed. Iron should be supplemented if there is anaemia
    • Absolute stoppage of alcohol consumption
    • Pancreatic enzymes e.g. pancreatin, 5mg with each meal
    • Control of diabetes
  • Surgery:
    • Gall bladder stones:
      If there is evidence of gall bladder stones or cholecystitis, the patient must undergo an operation – cholecystectomy with choledochostomy. Some surgeons advocate simultaneous sphinterotomy.
    • For the pancreas:
      • Sphincterotomy: To give a free drainage to both the common bile duct and the pancreatic duct. The results are not satisfactory
      • Pancreato-jejunostomy: The pancreatic duct is opened with a longitudinal incision and to this the first loop of jejunum is anstomosed side to side. All stones, encountered in the duct are removed prior to anastomosis.
      • Partial amputation of the pancreas (distal pancreatectomy): the portion of the pancreas towards the tail is amputated when the disease is more manifested in this part of the gland. The cut end may either be closed with non-absorbable sutures or a loop of jejunum may be anastomosed to it i.e. retropancreatojejunostomy. With simple closure of the stump there is a high risk of pancreatic fistula.
        • Pancreato-duodenectomy: excision of the head of the pancreas and the duodenum (as done for the carcinoma of the pancreas) may be done when the disease is manifested at its maximum at the head of the gland.
      • For intractable pain: splanchnicectomy i.e. resection of a part of the right greater splanchnic nerve


Back to Topics<<<<                            Top of this page^^^^
This article has been written by Dr. M. Javed Abbas.
If you have any comments please do not hesitate to sign my Guest Book.
18:18 09/02/2003