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CHRONIC PANCREATITIS.pptx

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CHRONIC PANCREATITIS.pptx

  1. 1. CHRONIC PANCREATITIS PRESENTOR : Adithya S MBBS, Govt Thiruvarur Medical College
  2. 2. Definition ● Chronic pancreatitis is a progressive inflammatory disease in which there is irreversible destruction of pancreatic tissue occurs . ● It is more common in males (4:1) ● Mean age of Onset is about 40 years
  3. 3. Etiology 1.High Alcohol consumption (60 -70% cases)  Increased total protein concentration in pancreatic juice  Increased glycoprotein 2  Protein plug formation  Stones (inside pancreatic duct)  Decreased pancreatic secretion  Auto digestion
  4. 4. Fatty acid ethyl esters , ROS Fragility of intra acinar organelles ( zymogen granules and lysosomes) Abnormal pancreatic enzyme activation inside the acinar cells Acetaldehyde direct acinar injury
  5. 5. chronic inflammation Rrelease of inflammatory mediator ( PDGF , TGE β , TNF α , IL-1 ,IL-6) Pancreatic stellate cells Collagen deposition fibrosis
  6. 6. 2.PANCREATIC DUCT OBSTRUCTION ● Stricture formation after trauma ● Acute pancreatitis ● Pancreatic carcinoma ● Pancreas divisum and annular pancreas
  7. 7. 3.HEREDITARY PANCREATITIS ● Gain of function mutation in PRSS1 on chromosome 7 ● Loss of function mutation in SPINK 1 ● CFTR gene mutation PRSS 1 – (cationic trypsinogen gene) Gain of function mutation Loss of function mutation in SPINK 1 Increased intra acinar trypsinogen activation
  8. 8. 4.Hyperlipidemia 5.Hyperparathyroidism 6.Autoimmune pancreatitis 7.Tropical pancreatitis
  9. 9. 01 Fibrosis 02 Atrophy 03 04 Variable dilation of pancreatic ducts / strictures 05 Parenchymal calcification PATHOLOGY Drop out of acini
  10. 10. Alcoholic pancreatitis ● Ductile dilatation ● Intraluminal protein plugs ● Calcifications Autoimmune pancreatitis ● Elevated IgG4 ● Venulitis ● Inflammatory infiltrates
  11. 11. CLASSIFICATION TIGAR-O (Based on risk factors and etiology) AUTO IMMUNE TOXIC METABOLIC IDIOPATHIC RECURRENT AND SEVERE ACUTE PANCREATITIS GENETIC OBSTRUCTIVE
  12. 12. Classification based on etiological causes
  13. 13. Clinical features ● pain in the epigastric region ● Persistent and severe radiates to back ● It is mainly due to Irritation of retro pancreatic nerve ,due to ductile dilatation and stasis or due to chronic inflammation itself ● Two patterns of pain ● TYPE A: short relapsing episodes, lasting for days to weeks ,pain free intervals present ● TYPE B : prolonged ,severe , unrelenting pain ● There is often a gradual diminish in pain over years due to pancreatic burn out by extensive calcification, exocrine and endocrine insufficiently
  14. 14. Endocrine dysfunction • DM ( Brittle due to concomitant glucagon deficiency) • Mild jaundice - due to narrowing of retro pancreatic bile duct and cholangitis Exocrine dysfunction • Diarrhea • Asthenia • Loss of weight and appetite • Steatorrhea • Malabsorption
  15. 15. Differential diagnosis Retroperitoneal tumour Carcinoma of head of the pancreas
  16. 16. Complications of chronic pancreatitis Pseudocyst of pancreas Duodenal stenosis CBD stricture due to oedema / inflammation Pancreatic ascites Carcinoma pancreas Portal thrombosis - segmental portal HT
  17. 17. Complications of chronic pancreatitis Pancreatic enteric fistula Pancreatic pleural effusion ,Pancreatic ascites ,Pancreatic fistula Splenic vein thrombosis Peptic ulcer
  18. 18. Investigations ● CT scan abdomen 1. Dilated pancreatic duct (68%) 2. Parenchymal atrophy 54% 3. Pancreatic calcification 50%) 4. Other findings – peri pancreatic fluid , focal pancreatic enlargement ,biliary duct dilation , irregular pancreatic parenchymal contour 5. It is also used to asses the complications
  19. 19. Investigations ● ERCP – gold standard  Therapeutic modality  Stricture , stones , pseudocyst , biliary stenosis ● MRCP + Secretin injection - to see ductal anatomy  Intraductal strictures  Pancreatic duct disruption ● Endosonography
  20. 20. Investigations ● Function tests  Fecal elastase 1 level measurement :Normal >200ųg /g of feces Mild to moderate; 100-200ųg /g feces Severe : <100ųg/g feces  Fecal fat and weight estimation test ; Intake of 100g of fat per day during 3 days If stool fat content exceeds 7 g /day - diagnosis of steatorrhoea
  21. 21. Treatment • Avoid alcohol • Low fat ,high protein , high carbohydrate diet • Pancreatic enzyme supplements, vitamins and minerals ,medium chain fatty acids • For pain analgesics, splanchnic nerve or coeliac plexus block • Other drugs ; antioxidants, amitryptyline ,fluoxetine ,octreotid • Control of diabetes by oral hypoglycemic or insulin • Somatostatin and it's analogues • Repeated ascetic taps for pancreatic ascites • Steatorrhea can be controlled by PPI Conservative
  22. 22. Endoscopic therapy ● INDICATIONS: pain relief ,ductal stones ,main duct stricture, pseudocyst drainage ,Pancreatic ascites, effusion and fistula ● It is mainly used for main Pancreatic duct obstruction and pseudocyst ,less useful for biliary stricture ● Pancreatic duct sphincterotomy
  23. 23. Pseudocyst Transpapillary stenting  If pseudocyst is communicating  Cyst less than 6cm  No Visible bulge in stomach Transmural stenting  Visible bulge  Distance of cyst wall less than 1cm  No major vessel at puncture site
  24. 24. Surgical management
  25. 25. Indications for surgery  Persisting pain  Severe malabsorption  Suspicion of malignant transformation  Multiple relapses  Complications like pseudocyst, segmental portal HT  Biliary obstruction  Pseudocyst  Pancreatic ductal dilatation >7mm  Pancreatic ascites/fistula  Pancreatic ductal stenosis
  26. 26. Principles of surgery  Pancreatic duct decompression ( drainage )  Pancreatic resection ( total Pancreatectomy )
  27. 27. Surgeries  Partington Rochelle operation Longitudinal pancreatico jejunostomy is done using almost entire laid open pancreatic duct . Spleen is retained in this procedure
  28. 28. Surgeries  Puestow's operation When the duct is dilated to more than 8mm , duct can easily be opened longitudinally. After removing all the stones from the duct , it is anastomosed to the jejunum as Roux en Y anastomosis Spleen is removed in this procedure
  29. 29. Surgeries  Longitudinal pancreaticojejunostomy Frey's procedure - superficial part of the head of pancreas is removed to achieve improved drainage and then it is anastomosed with the Roux loop of jejunum
  30. 30. Surgeries  Beger procedure Duodenal preserving resection of head of pancreas in front of portal vein with jejunal loop anastomosis to transected neck of pancreas
  31. 31. Surgeries  Total pancreatectomy : Done when entire gland is diseased
  32. 32. Complications of surgery Pancreatic leak / fistula Infections Bleeding Recurrence Brittle DM
  33. 33. POST OP CARE Nutrition-TPN / Jejunostomy feed Fluid and electrolyte management Prevention/ control of sepsis Octreotide on table and Postoperatively - regular Intervals or slow infusions - 5 days 01 02 03 04
  34. 34. Thank you !

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