Сhronic

pancreatitis

Lykhatska G.V.
Pancreatic structure and
function
 Pancreatic enzymes
Enzyme Substrate Product

Amylase Starch and Limit dextrans

glycogen Maltose
Maltriose
Lipase Triglycerides Monoglycerides and
Colipase free fatty acidis
Proteolytic enzymes Proteins and Shot polypeptides
Trypsinogen polypeptides
Chymotripsinogen
Proelastase
Procarboxypeptidases
• Pancreatitis is a chronic inflammatory
disease which is more than 6 months and
characterized by fibrosis and destruction of
exocrine pancreatic tissue.
 Etiology of chronic
pancreatitis
Primary pancreatitis:
• Alcohol abuse (70-80% of all diagnostic cases)
• Regular eating of fatty foods
• Medicamentous (estrogen, azathioprine,
tetracycline, oral hypoglycemics, furosemide/
thiazide diuretics)
• Protein insufficiency
• Hereditary
• Ischemic (affection of vesels of pancreas)
• Idiopathic
 Causes of chronic pancreatitis
Secondary pancreatitis:
 diseases of billiary tract (in 30-40 %)
 diseases of duodenum
 diseases of liver
 diseases of intestine
 inflectional diseases (parotitits)
 allergy
 hyperlipidemia
 hyperparathyroidism
 traumas of pancreas
 Pathogenesis of chronic
pancreatitis
• The main pathogenetic mechanisms of chronic
pancreatitis is destructive affection of acinus
caused by activation of intracellular enzymes of
pancreas.
• Changers of getting out of juice of pancreas.
• Progressive fibrosis gradually leads to changers
of physiological functions of pancreas.
• Development of areas of necrosis and aseptic
inflammation.
Pathophysiology of chronic
pancreatitis
International Classification of the diseases
• 1. Chronic alcoholic pancreatitis (code K 86.0)
• 2. Other types of chronic pancreatitis (code K 86.1)
(chronic pancreatitis with unknown etiology, infection
pancreatitis)
Marseilles and Rome Classification
• 1. Chronic calcareous pancreatitis.
• 2. Chronic obstructive pancreatitis.
• 3. Chronic fibrous and indurated (inflammatory or
parenchymatous pancreatitis).
• 4. Chronic cysts and pseudocysts of the pancreas.
 Clinical classification
• Chronic reccurent pancreatitis
• Chronic pancreatitis with pain syndrome
• Latent pancreatitis (without pain, changers
of exocrine function of pancreas)
• Pseudotumorous chronic pancreatitis
 Clinical classification
According to the running of the disease
• Mild form of pancreatitis
• Moderate form of pancreatitis (changers of
exocrine or endocrine functions of
pancreas)
• Severe form of pancreatitis (terminal
stage)
 Clinical classification
• With exocrine disfunction
• With endocrine disfunctio
Phase of disease
• Execerbation
• Remission
Complications
 Clinical presentation

• 1. Pain syndrome – epigastric abdominal pain.

• 2. Dyspeptic syndrome - loss of appetite, sialorrhea,
nausea, vomiting, meteorism, diarrhea, steatorrea.
• 3. Exocrine insufficiency with malabsorption and
maldigestion syndromes – weight loss, pale and dry
skin, hypovitaminosis.
• 4. Incretion insufficiency – secondary diabetes
mellitus.
• 5. Asteno-vegetative syndrome – general weakness,
bad sleeping,
• Pain syndrome
Physical examination data.
1. Shofar’s zone
2. Hubergrits-
1 2 Skulskyy zone
3. Mayo-Robson
point
4 3
4. D’Egarden’s
point
D’Egarden’s point
Shofar’s zone
Mayo-Robson point
Dyspeptic syndrome - loss of appetite, sialorrhea, nausea,
vomiting, meteorism, diarrhea, steatorrea.
Symptom of red drops
(microanevrismus)
 Clinical symptoms
• Catch symptom - hyperesthesia of the
skin in the innervations zone of the 8-th
thoracic vertebra.
• Grot symptom – subcutaneous cellular
tissue atrophy near the pancreas
• Zakcharin symptom – tenderness in the
right hypogastria.
 Clinical course of disease
• Chronic recurrent pancreatitis - the most frequent form, which is
characterised by attack of pain, combined with increased levels of
pancreatic enzymes in blood and urine, sometimes with jaundice. In
the phase of remission can be with dyspeptic syndrome.
Pain-form is characterized by a constant dull pain in the left
hypochondrium and laboratory data that confirm the diagnosis of
pancreatitis, in anamnesis there are data about pancreonecrosis.
Latent form - characterized by asymptomatic course. The main is
dyspeptic syndrome and syndrome of exocrine insuficiency.
Pseudotumorous form - characterized by a combination of
jaundice with exocrine and endocrine insuficiency.
 Investigations in chronic
pancreatitis
•Leukocytosis
•Elevated amylase and lipase:
•Amylase: 3X normal; peak 2-3 days;
•Lipase: 3X normal; peak 7-14 days.
•Collection of pure pancreatic juice after secretin
injection (gold standard but invasive and seldom
used)
•Pancreolauryl or PABA test
•Faecal pancreatic chymotrypsin or elastase
•Oral glucose tolerance test
Tests of exocrine pancreatic
function
 Tests to establish the
diagnosis
• Ultrasound
• CT (may show atrophy, calcification or ductal
dilatation)
• Abdominal radiograph (may show calcification)
• ERCP only if non-invasive tests are negative or
equivocal
• MRCP
• Endoscopic ultrasound
Ultrasound investigation. Normal
pancreas
 Ultrasound investigation. Chronic
pancreatitis

а) calcificates in the head of

pancreas;
б) Virsungov’s duct;
в) pseudocyst of pancreas;
г) increase of the head of
pancreas;
д) spleen vein
 Ultrasound investigation. Chronic calcified
pancreatitis а) virsungolithiasis б) dilated
Virsungov’s duct.
CT scan with central
pseudocyst
ERCP of chronic pancreatitis with distortion
of the pancreatic duct
 An endoscopic retrograde
cholangiopancreatography image
demonstrating massive pancreatic duct
dilatation in a patient with bigduct chronic
pancreatitis.
An endoscopic retrograde cholangiopancreatography
image demonstrating minimal pancreatic duct
abnormalities in a patient with painful small-duct
chronic pancreatitis.
 An endoscopic ultrasound image
demonstrating a dilated pancreatic duct
(markers) in a patient with advanced chronic
pancreatitis
Plain X-ray of abdomen
showing
calcific
pancreatitis
 Complications of chronic
pancreatitis
• Pseudocysts are the collection of tissue, fluid, disintegration
products, ferments and blood, have not epitelial lining, appear during
expressive severity of chronic pancreatitis
• Diabetes mellitus
• Abscess of pancreatic gland appears during the combination of
infection process with presence of pseudocyst.
• Mechanical jaundice appears as a result of choledoch obstruction,
pressing its by increased bulb of pancreas.
• Duodenal stenosis
• Portal or spleen vein thrombosis leading to segmental portal
hypertension and gastric varicose
• Infection complications (inflammatory infiltrate, cholangitis,
peritonitis, septic states).
 Complications
• Pancreatic necrosis
• Pancreatic ascites
• Erosive gastritis
• Gastrointestinal bleeding
• Abdominal ischemic syndrome
• Exudative pleuritis
• Cancer of pancreas
 Differential diagnostic
• Chronic cholecystitis
• Chronic gastroduodenitis
• Ulcer disease
• Chronic hepatitis
• Gallstone disease
• Cancer of pancreas
• Aneurisms of aorta
• Kidney colic
• Angina pectoris
 Management
• 1. A low-fat diet.
• 2. Pain relief: not narcotic analgesics, miotropic
spasmolitics, M – holinolitics
• 3. Antisecretion preparations: H2 – blockers (Kvamatel),
proton pump inhibitors (Omeprazol).
• 4. Pancreatic enzymes replacement (Kreon, Festal).
• 5. Antibiotics
• 6. Cytoprotection
• 7. Antioxydation therapy (Thiotriazolin, vst. E)
• 8. Immunomodulation (Imunal, Timalin)
• 9. Vitamin supplements
• 10. Oral hypoglycemics for diabetics
CHRONIC PANCREATITIS
SUMMARY