2. پانكراتيت مزمن
Dr. Mousavi
Abadan-Khordad-1397

3. 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.

4. The essential difference between acute and chronic pancreatitis is the presence of permanent and progressive morphologic or functional damage in the latter

5. Title goes here
MSFF
4 minutes
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6. Recommending a Strategy
Ideas for Today and Tomorrow 1
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7. Clinical presentation
Abdominal pain
Weight Loss
Malabsorption
Pancreatic Diabetes
Other Clinical Features : jaundice, ascites or pleural effusion, polyarthritis painful nodules

8. Vision Statement
State the vision and long term direction 2
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9. 3 Goal and Objective State the desired goal
State the desired objective
Use multiple points if necessary 3
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10. Mechanisms of pain Inflammation of the pancreas
Increased intrapancreatic pressure
Neural inflammation
Extrapancreatic causes, such as common bile duct stenosis and duodenal stenosis

11. 4 Today’s Situation Summary of the current situation
Use brief bullets, discuss details verbally 4
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12. 5 How Did We Get Here? Any relevant historical information
Original assumptions that are no longer valid 5
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13. Routine Laboratory Findings
Leukocytosis may be observed during acute exacerbations.
Anemia
Fat-soluble vitamin deficiency states
Varying degree of cholestasis
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14. 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.

15. 6 Available Options State the alternative strategies
List advantages & disadvantages of each
State cost of each option 6
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16. 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
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17. 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
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26. 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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29. 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.

30. 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

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)

32. Management: Control of Pain Management of Pancreatic Insufficiency
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33. Control of Pain Avoidance of Alcohol Analgesics Celiac Plexus Block
Enzyme Therapy
Treatment With Octreotide
Endoscopic Therapy
Surgical Treatment
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46. 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.

47. Pancreatic Cancer Risk10 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

48. 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.

49. 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.