CHRONIC PANCREATITIS

Definition:
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 either recurrent acute exacerbation or persistent pain.

Etiology:

Etiologic Risk Factors Associated With Chronic Pancreatitis: TIGAR-O

Toxic-metabolic Alcoholic, tobacco smoking, hypercalcemia (hyperparathyroidism),
Hyperlipidemia,
Chronic renal failure
Medications, toxins
Idiopathic Tropical

Genetic Cationic trypsinogen

CFTR, SPINK1
Autoimmune Isolated or associated with autoimmune disorders

Recurrent acute and severe Postnecrotic (severe acute pancreatitis)

Recurrent acute pancreatitis
Vascular disease/ischemic
Postirradiation

Obstructive Pancreatic divisum

Sphincter of Oddi disorders
Duct obstruction (tumor)
Posttraumatic pancreatic duct scars
Preampullary duodenal wall cysts

Pathogenesis:

One hypothesis envisions the activation of pancreatic stellate cells, which induce desmoplasia, as the
key pathogenetic “switch” that leads to the transition to chronic pancreatitis.

Clinical Feature:
Pain-episodic and gradually become more constant, in late phases pain may disappear (“burnout”),
pain is localised to epigastrium and radiates to the back, associated to the nausea and vomiting,
exacerbated by eating.

Exocrine insufficiency: bloating, flatulence or steatorrhea (foul smelling, oily, and loose stool)
Deficiency of fat soluble vitamin(Vit A,D,E)
Endocrine insufficiency: Diabetes mellitus

Histologic Features:

The histopathologic changes of chronic pancreatitis comprise fibrosis, a reduced number of acinar
cells and islets of Langerhans, and development of strictures and dilation of pancreatic ducts as well
as calcium calculi (pancreatic duct stones).
Management
Pancreatic duct dilation secondary to duct stones or stricture-Pancreatic duct dilation is defined as
a main pancreatic duct measuring at least 7 mm in diameter,

Duval described drainage of the tail of the pancreas with a Roux-en-Y limb of jejunum(Resection of
tail of pancreas with retrograde pancreatico-jejunostomy) as a procedure for chronic
pancreatitis(Roux-en-Y pancreaticojejunostomy). This operation often failed because it did not
address disease in the proximal pancreas.

Duval’s caudal pancreaticojejunostomy

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 the distal pancreatectomy. Puestow procedure consisted of a
longitudinal unroofing of the dilated pancreatic duct in the body and neck of the gland, and also
involved resection of the pancreatic tail. A long segment longitudinal pancreaticojejunstomy was
then constructed to establish enteric drainage.
Puestow and Gillesby’s longitudinal pancreaticojejunostomy.

Partington and Rochelle simplified the Puestow technique by eliminating splenectomy and
pancreatic resection . Longitudinal, or side-to-side Roux-en-Y pancreaticojejunostomy that became
universally known as the modified Puestow procedure or lateral pancreaticojejunostomy.

Pancreatic duct dilation secondary to a single stricture or stone.- a pancreaticoduodenectomy can

be performed to relieve the obstruction

Focal inflammatory mass without significant dilation of the pancreatic duct.- resection of the
pancreatic head may be done with either of two operations: pancreaticoduodenectomy or
duodenum preserving pancreatic head resection, otherwise known as the Beger procedure. Once
the pancreatic head is removed, a Roux-en-Y is created and anastomosed to the rim of pancreas or
duodenum, pancreatic duct, and body and perhaps the bile duct if it was entered.

For patients with focal disease largely confined to the head of the pancreas without duct dilation, a
Whipple procedure (pancreaticoduodenectomy [PD]) is generally the preferred option

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

Diffuse glandular involvement without dilation of the pancreatic duct- The most effective
treatment to eliminate pain is total pancreatectomy. As several other centers have established islet
autotransplantation programs.

Hybrid Procedure-Some patients present with not only large duct disease but also significant
inflammatory disease within the head of the pancreas. 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.
For patients with an inflammatory head mass but small duct disease, 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.

Patients with small duct disease and diffuse parenchymal inflammation or minimal change disease,
hereditary syndromes, and failures of prior pancreatic operations present a particular challenge for
treatment. Options include near total or total pancreatectomy for end-stage or refractory disease.

Complication:
1. Pseudo cyst of pancreas
2. Biliary stricture
3. Splenic venous thrombosis and left sided portal hypertension
4. Splenic arterial aneurysm
5. Ascites
6. Carcinoma
7. Duodenal obstruction
8. Transverse colon obstruction