پانكراتيت مزمن Dr. Mousavi Abadan-Khordad-1397
Chronic Pancreatitis Pain Calcification Pancreatic insufficiency Slide 286 Features of chronic pancreatitis The cardinal clinical features of chronic pancreatitis are pain, calcification and pancreatic insufficiency. Pain is the most common presenting symptom. Pancreatic calcification is intraductal. Pancreatic insufficiency involves the endocrine and exocrine pancreas and results in malabsorption and diabetes mellitus.
The essential difference between acute and chronic pancreatitis is the presence of permanent and progressive morphologic or functional damage in the latter
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Recommending a Strategy Ideas for Today and Tomorrow 1 19/03/1440
Clinical presentation Abdominal pain Weight Loss Malabsorption Pancreatic Diabetes Other Clinical Features : jaundice, ascites or pleural effusion, polyarthritis painful nodules
Vision Statement State the vision and long term direction 2 19/03/1440
3 Goal and Objective State the desired goal State the desired objective Use multiple points if necessary 3 19/03/1440
Mechanisms of pain Inflammation of the pancreas Increased intrapancreatic pressure Neural inflammation Extrapancreatic causes, such as common bile duct stenosis and duodenal stenosis
4 Today’s Situation Summary of the current situation Use brief bullets, discuss details verbally 4 19/03/1440
5 How Did We Get Here? Any relevant historical information Original assumptions that are no longer valid 5 19/03/1440
Routine Laboratory Findings Leukocytosis may be observed during acute exacerbations. Anemia Fat-soluble vitamin deficiency states Varying degree of cholestasis 19/03/1440
Imaging tests used for diagnosing chronic pancreatitis Abdominal x-ray Ultrasound CT EUS MRCP ERCP PET Slide 308 Imaging tests used for diagnosing chronic pancreatitis In chronic pancreatitis, a number of imaging tests may be used. Although insensitive, abdominal x-rays can detect pancreatic calcification. Ultrasonography can detect pancreatic calcification and duct dilatation with good sensitivity. CT is a sensitive method for revealing pancreatic calcification and duct dilation. ERCP demonstrates changes in the main pancreatic duct, pancreatic ductules, and pancreatic duct stones. The sensitivity of ERCP increasing with more advanced disease. Endoscopic ultrasonography demonstrates pancreatic duct abnormalities, duct dilation, and parenchymal changes and may be the most sensitive technique for diagnosing chronic disease. MRCP is useful for demonstrating duct dilation, but does not detect pancreatic duct stones. PET scanning for glucose metabolism has been used to distinguish chronic pancreatitis from pancreatic cancer.
6 Available Options State the alternative strategies List advantages & disadvantages of each State cost of each option 6 19/03/1440
I. Measurement of pancreatic products in blood (Enzymes) II. Measurement of pancreatic exocrine secretions: A. Direct measurement 1. Enzymes 2. Bicarbonates B. Indirect measurement: Bentiromide test , Dual Schilling test III. Imaging techniques: Plain film radiography of abdomen, . Ultrasonography, Endoscopic ultrasonography ERCP 19/03/1440
7 Recommendation Recommend one or more of the strategies Summarize the results if things go as proposed What to do next Identify Action Items 7 19/03/1440
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Pancreatic calcifications detected using standard radiographs Slide 312 Pancreatic calcifications detected using standard radiographs Observing pancreatic calculi on plain films of the abdomen provides rapid and inexpensive confirmation of the diagnosis of chronic pancreatitis. The calcifications are intraductal and best seen in the pancreatic head or tail because the spinal column obscures their detection in the body. In alcoholic pancreatitis, calcification is observed in 20-50% of patients. Calcification is particularly frequent in hereditary and tropical pancreatitis. There are some reports of calcification reversing in patients with abstinence from alcohol. The radiograph demonstrates irregular calcifications in the region of pancreatic tail (arrow).
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Demonstration of some EUS findings in chronic pancreatitis Dilated main duct Echogenic strands Hyperechogenic duct wall Slide 321 Demonstration of some EUS findings in chronic pancreatitis This slide shows some of the endoscopic ultrasonographic (EUS) findings in chronic pancreatitis. The left panel demonstrates dilation of the main pancreatic duct with a stricture. The center panel shows a highly echogenic pancreatic duct. The right panel shows echogenic stranding suggesting fibrosis and dilation of secondary ducts.
EUS findings in chronic pancreatitis Parenchymal Echogenic strands Hyperechoic foci Calcifications Lobular contour Cysts Ductal Wall echogenicity Irregular duct wall Visible side branches Strictures Stones Slide 322 EUS findings in chronic pancreatitis EUS findings in chronic pancreatitis are divided into those involving the parenchyma or the duct. As in observed with ERCP, the findings of chronic pancreatitis by EUS criteria agree best with tests that measure exocrine insufficiency when there is moderate or severe disease. Hollerbach S, Klamann A, Topalidis T, Schmiegel WH. Endoscopy 2001; 33:824-31
ERCP showing severe chronic pancreatitis Markedly dilated branches Markedly dilated main pancreatic duct Slide 319 ERCP showing severe chronic pancreatitis ERCP demonstrating severe pancreatitis. There is marked dilation of the main pancreatic duct the tail and clubbing of most secondary ducts. Short strictures of the main pancreatic duct, particularly toward the tail, are seen. (Courtesy of A. Shah, Rochester, NY)
Management: Control of Pain Management of Pancreatic Insufficiency 19/03/1440
Control of Pain Avoidance of Alcohol Analgesics Celiac Plexus Block Enzyme Therapy Treatment With Octreotide Endoscopic Therapy Surgical Treatment 19/03/1440
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Computed tomography in splenic veins thrombosis Fluid collections Splenic vein Thrombosis Slide 352 Computed tomography in splenic veins thrombosis This CT shows a thrombus in the splenic vein in a patient with chronic pancreatitis. Several fluid collections are present. If ultrasonography is used to diagnose splenic vein thrombosis, large collaterals are sometimes misdiagnosed as an intact splenic vein. Image courtesy of A. Nagar and C. Taylor, West Haven, CT.
Pancreatic Cancer Risk 10 6 5 4 3 2 1 15 20 Years after diagnosis of chronic pancreatitis % Cumulative incidence 1160 599 244 64 3-15 fold increase Normal Cancer Slide 353 Pancreatic cancer risks in chronic pancreatitis Many chronic inflammatory conditions are associated with an increased risk of developing malignancy (ulcerative colitis, esophagitis – especially with Barrett’s mucosa, atrophic gastritis, etc). The CT shows a pancreatic cancer in chronic pancreatitis with calcification. The graph shown at the right is the cumulative incidence of pancreatic cancer in patients with chronic pancreatitis. The bars represent 95% confidence limits. Compared to controls without chronic pancreatitis (not shown), chronic pancreatitis increases the risk of pancreatic cancer 3- to 15-fold. Lowenfels AB, Maisonneuve P, Cavallini G, Ammann RW, Lankisch PG, Andersen JR, DiMagno EP, Andren-Sandberg A, Domellof L. New Eng.J .of Med. 1993;328:1433-7 Lowenfels, et al., N Engl J Med 1993; 328:1433
EUS guided biopsy of pancreatic cancer Biopsy needle Pancreatic mass Slide 354 EUS guided biopsy of pancreatic cancer This slide demonstrates a needle biopsy of a pancreatic mass performed using EUS guidance. The biopsy shown on the right demonstrates cells with enlarged hyperchromatic nuclei and visible nucleoli that are consistent with pancreatic cancer.
Symptoms Suggesting Cancer Development Changing pain pattern Weight loss unresponsive to enzyme replacements Development of biliary and/or gastric outlet obstruction New onset of depression Migratory thrombosis Slide 355 Clues to the development of pancreatic cancer in patients with chronic pancreatitis Clues to the development of pancreatic cancer in chronic pancreatitis are provided by the appearance of distinct signs and symptoms.