Chronic pancreatitis refers to an ongoing inflammatory and fibrosing disorder of the pancreas characterized by irreversible morphological changes and the progressive loss of exocrine and endocrine function. It involves fibrosis, reduced acinar cells and islets of Langerhans, development of strictures, dilation of pancreatic ducts, and calcium calculi. Risk factors include heavy alcohol use, smoking, genetics, and other causes. Diagnosis involves blood tests, stool tests, CT, MRI, ERCP, and EUS to detect changes. Treatment includes lifestyle changes, pain management, pancreatic enzyme supplements, endoscopic procedures to manage complications, and surgery for intractable pain or complications.

1. Chronic
Pancreatitis
Paithankar Adwait
7610 m2a

2. Chronic pancreatitis generally refers to
 an ongoing inflammatory and fibrosing disorder
 characterized by irreversible morphologic changes,
progressive and permanent loss of exocrine and
endocrine function,
 and a clinical pattern of recurrent acute exacerbation
or persistent pain.
Definition


3.  Fibrosis, a reduced number of acinar
cells and islets of Langerhans
Development of strictures
Dilation of pancreatic ducts
 Calcium calculi (pancreatic duct
stones)
The histopathologic
changes

4. 
 Necrosis-Fibrosis Hypothesis- consequence of several
distinct episodes of acute pancreatitis at different times,
which then lead to necrosis and fibrosis
 Protein-Plug (Stone/Ductal Obstruction) Hypothesis
-increased lithogenicity of pancreatic fluid leads to the
formation of eosinophilic proteinaceous aggregates that
precipitate and obstruct the pancreatic ductules
 Toxic-Metabolic Theory-toxic metabolites cause
accumulation of intracellular lipids and fatty acid ethyl
esters, which damage the acinar cell.
Pathogenesis

5. Risk Factors


6. Risk Factors


7.  MC- Abdominal pain 90%
Early phase- pain may be minor feature and is
episodic and minimal
Late phase- pain may disappear “burnout”
 Weight loss and malnutrition
 bloating, flatulence, or steatorrhea
Clinical Manifestations


8.  There are no perfect tests for chronic pancreatitis,
particularly in its earliest stages.
Serum amylase and lipase, fasting serum glucose and
glycosylated hemoglobin (HbA1c) may be helpful.
 Stool is collected for a 72-hour period and fat content
greater than 7 g per day is abnormal.
 fecal elastase levels may be insensitive
 A C-mixed triglyceride breath test is also in
development for the diagnosis
Diagnosis


9.  Sensitivity – 56- 95 % , Specificity – 85 -100%
 Dilated pancreatic duct (68%)
 Parenchymal atrophy (54%)
 Pancreatic Calcification (50%)
 CT is particularly useful to assess complication such
as pancreatic duct disruption , pseudocyst, portal
and splenic vein thrombosis and pseudoaneurysm of
splenic and pancreaticoduodenal artery.
CT Findings


10. 

11. 
 Before the widespread use of magnetic resonance
imaging, ERCP was the gold standard for diagnosis
ERCP

12.  MRCP with intravenous secretin administration may
augment visualization of pancreatic side ducts.
 Specifically, intravenous (IV) secretin should lead to
an increase in the pancreatic duct diameter of more
than 1 mm, with recovery of its size after 10 minutes
MRCP


13. 
 A few studies have demonstrated that endoscopic
ultrasound (EUS) may detect early changes/features
characteristic
EUS

14.  Treatment begins with lifestyle changes.
 Oral pancreatic enzyme supplementation with meals
 Analgesic selection is cornorstone of treatment
 NSAIDs can be used in early phase --- moderate to
severe pain may require tramadol -----long term
narcotics--- TCA can also be useful
 who are not candidates for endoscopic or surgical
options, a celiac plexus nerve block may be
performed percutaneously or endoscopically.
 Alternatively, thoracoscopic denervation of
splanchnic nerves has been reported to achieve
short-term pain relief
Medical Treatment


15. 
 Pancreatic sphincterotomy permits the introduction of
endoscopic equipment to dilate pancreatic duct strictures by
balloon dilation or coiled wire stent removal device.
 Ductal stents are routinely removed after a period of time (2
to 4 months)
 Intraductal stones can be removed with Dormia-type
baskets. Stones larger than the pancreatic duct orifice can be
broken into smaller pieces by ESWL
 Symptomatic pseudocysts can be drained transgastrically or
transduodenally in appropriately selected patients to achieve
relief of pain.
Endoscopic Management

16. 
 Intractable abdominal pain
 Secondary complications of chronic pancreatitis
- biliary stricture
- duodenal stenosis
- pseudocyst
- suspected pancreatic neoplasm.
Indications
for Surgery

17.  For patients with focal disease largely confined to the
head of the pancreas without duct dilation.
 The reconstruction includes a two-layered end-to-
side pancreaticojejunostomy, an end-to-side
hepaticojejunostomy, and a gastrojejunostomy.
 Mortality associated with the procedure is generally
less than 5%, although the overall rate of
postoperative complications is typically reported
between 30% and 40%
Kausch-Whipple
procedure
(pancreaticoduodenectomy [PD]

18. 

19. 

20.  Traverso and Longmire introduced a pylorus-
preserving pancreaticoduodenectomy (PPPD), an
operation that was intended to improve functional
digestive outcomes and quality of life by preserving
the physiologic gastric emptying mechanism.
 Beger introduced duodenum-preserving pancreatic
head resection (DPPHR) as an alternative to PD or
PPPD
PPPD and DPPHR


21. 
The pancreatic head and duodenum are removed. The
reconstruction is performed by a pancreaticojejunostomy,
hepaticojejunostomy, and a duodenojejunostomy
PPPD

22. 
 The duodenum-preserving pancreatic head resection
introduced by Beger. (A) The procedure includes division of
the neck of the pancreas, leaving a small rim of pancreatic
tissues along the duodenum. (B) The procedure is completed
with end-to-end and side-to-side Roux-en-Y
pancreaticojejunostomy

23. DPPHR: Bern
modification

24.  Duval described drainage of the tail of the pancreas
with a Roux-en-Y limb of jejunum as a procedure for
chronic pancreatitis
 Puestow and Gillesby introduced a modified
procedure to drain the entire pancreatic duct along
the body and tail of the pancreas laterally into a
Roux-en-Y limb of jejunum, which was initially
described in conjunction with splenectomy and
distal pancreatectomy.
DECOMPRESSION


25.  An illustration of a retrocolic side-to-side Roux-en-Y
 pancreaticojejunostomy.
Puestow procedure


26. 
 Frey introduced a procedure that combines
duodenum-sparing resection of the pancreatic head,
without formal division of the neck of the pancreas,
combined with longitudinal pancreaticojejunostomy
of the dorsal duct.
 Izbicki introduced a procedure that combines
excavation of the pancreatic head with a V-shaped
longitudinal wedge resection, followed by lateral
decompressive pancreaticojejunostomy of the
pancreatic body and tail.
The Frey and Izbicki
procedure

27. Frey Procedure


28.  Shackelford’s Surgery of the ailementary tract(8th
Edition)
 Blumgart’s Surgery of Liver, Biliary tract and
Pancreas.( 6th Edition)
 Sabiston textbook of Surgery ( 20th Edition)
Reference


29. 
THE END