С hronic pancreatitis

1. Сhronic pancreatitis Lykhatska G.V.

2. Pancreatic structure and function

3. Pancreatic enzymes

4. Pancreatitis is a chronic inflammatory disease which is more than 6 months and characterized by fibrosis and destruction of exocrine pancreatic tissue.

7. 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

8. 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

9. 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 necrosisand aseptic inflammation.

10. Pathophysiology of chronic pancreatitis

11. 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.

12. Clinical classification Chronic reccurent pancreatitis Chronic pancreatitis with pain syndrome Latent pancreatitis (without pain, changers of exocrine function of pancreas) Pseudotumorous chronic pancreatitis

13. 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)

14. Clinical classification With exocrine disfunction With endocrine disfunctio Phase of disease Execerbation Remission Complications

15. 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,

16. Pain syndrome

17. Physical examination data. Shofar’s zone Hubergrits-Skulskyy zone Mayo-Robson point D’Egarden’s point 1 2 4 3

18. D’Egarden’s point

19. Shofar’s zone

20. Mayo-Robson point

21. Dyspeptic syndrome - loss of appetite, sialorrhea, nausea, vomiting, meteorism, diarrhea, steatorrea.

22. Symptom of red drops (microanevrismus)

23. 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.

24. 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.

25. 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

26. Tests of exocrine pancreatic function

27. 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

28. Ultrasound investigation. Normal pancreas

29. 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

30. Ultrasound investigation. Chronic calcified pancreatitis а) virsungolithiasis б) dilated Virsungov’s duct.

31. CT scan with central pseudocyst

32. ERCP of chronic pancreatitis with distortion of the pancreatic duct

33. An endoscopic retrograde cholangiopancreatography image demonstrating massive pancreatic duct dilatation in a patient with bigduct chronic pancreatitis.

34. An endoscopic retrograde cholangiopancreatography image demonstrating minimal pancreatic duct abnormalities in a patient with painful small-duct chronic pancreatitis.

35. An endoscopic ultrasound image demonstrating a dilated pancreatic duct (markers) in a patient with advanced chronic pancreatitis

36. Plain X-ray of abdomen showing calcific pancreatitis

37. 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).

38. Complications Pancreatic necrosis Pancreatic ascites Erosive gastritis Gastrointestinal bleeding Abdominal ischemic syndrome Exudative pleuritis Cancer of pancreas

39. Differential diagnostic Chronic cholecystitis Chronic gastroduodenitis Ulcer disease Chronic hepatitis Gallstone disease Cancer of pancreas Aneurisms of aorta Kidney colic Angina pectoris

40. 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

41. CHRONIC PANCREATITISSUMMARY

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