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ChronicPancreatitis

AraSahakian,M.D.AssistantProfessorofMedicine

USCcorelecture

WhatisChronicPancreatitis

•  Progressiveinflammatorydisease•  Pancreaticparenchymareplacedw/fibroustissue

•  Destructionofacinarandisletcells.•  Painandlossoffunction(exoandendo)•  Diseaseofmorbidity(notmortality)

Pathogenesis

•  Usuallyhistoryofacutepancreatitis•  Riskofprogressiongreatestwithsmoking/etoh•  Mostwithacutepancdon’tdevelopchronicpanc

•  2-hithypothesis– Acutepancingeneticallysusceptiblept,enhancedbyenvironmentalfactors•  PRSS1,SPINK1,CFTR•  ETOHandsmoking

Presentation

•  Chronicupperabdominalpain– Worsewitheating

•  Crosssectionalimagingcanbenormal(early)•  Endocrine/exocrineinsufficiencyandchangesinimaging(late)

•  Phenotypesofchronicpanc– Cysticfibrosis:exocrineinsuffw/opain– Chroniccalcificpancinptw/ETOH

Diagnosis

•  Histology:Goldstandard,Limitations– Patchydisease– Falsepositivesinelderly,smokers,etoh– Riskofpancreatitiswithbx– Notfrequentlyused

Diagnosis

•  Functionaltests– Secretinstimulation(HCO3)– Fecalelastase– Serumtrypsin– CCKstim:looksatlipaseconcentrationinduodfluid

Diagnosis

•  Imagingtests–  KUB

•  Costeffective(cheap):Lowsensitivity,highspecificity– MRCP=EUS=ERCPforsensitivity

•  ERCPnotindicatedfordiagnostic•  CTgoodforseeingcalcifications

EUSfindings

•  Rosemontcriteria– Hyperechoicfoci,stranding,lobularity– Dilatedduct,stones,hyperechoicductmargins

AfterESWLBeforeESWL

Treatment

•  Analgesics/Narcotics•  Enzymes•  NerveBlocks•  Endoscopictherapy(targeted)•  Surgicaltherapy

Treatment

•  Cochranereview:2009.10Trials.Pancreaticenzymeshavenobenefitinpainfromchronicpancreatitis.

Shafiqetal.CochraneDatabaseSystRev2009

EndoscopicTherapy

•  EUSguidedceliacnerveblock–  50%havepainrelief,lastsfewweeks(notroutinelyrecommended)

•  Pancreaticstoneextraction–  ESWLforstoneextraction

•  Pancreaticstricturetherapy•  Ductaldisruptiontherapy(oftenrequiresurgery)•  Pseudocystdrainage•  Biliarystricturetherapy

Surgicaloptions

•  Drainage(Peustow-pancreaticojejunostomy)–duct>5mm(>10mm)

•  Resection(Whipple,distalpancreatectomy)•  Totalpancreaticresectionwautoisletcelltransplantation

•  Denervation-thoracoscopicsplanchnicectomy

Endoscopicvs.Surgicaldrainage•  CahenNEJM2007•  Randomizedprospective•  19endoscopic;20pancreaticojejunostomy•  24monthsoffollowup•  Surgicaltherapydecreasedpaincomparedtoendoscopictherapy(75%v32%wpainrelief)

•  Limitations:–  Painreliefunexpectantlylowinendogroup(32%)– Majorcomplicationratehigherinthesurgicalgroup–  Lowrateofendotechnicalsuccess(50%)

Therapy

•  Endoscopictherapymaybeconsideredafirst-lineapproachforpain(pancreaticstones/strictures)

•  MostDEFINITIVEtherapyisconsideredsurgery

•  Peudocysts– Transpapillarydrainage•  Pancreaticstenttobridgetheleak•  SmallercystscommunicatingwithPD

– EUSguideddrainage•  NolongerdonewithoutEUS

–  Visualizevesselsanddebris•  Throughstomachorduodenumintocystcavity•  Increasinglywithlumenopposingstents(littledata)

Pain

•  Painwasthoughttobeduetoductalobstruction– Treatmentwasaimedtorelievingobstruction(ERCP,surgery)

– Resultsunpredictable•  Neurogenicpainandhyperalgesia– Painmedications(opioids,neuropathicagents)

•  Slowprogression– ETOHandsmokingabstinence

•  40yearoldmalewithhistoryofETOHabusewhopresentswithseverechronicepigastricpain.Imagingdemonstratespancreaticcalcificationsandhoneycombing.Thepancreaticductis4mminsize.Noothercauseforhispainhasbeenfound.Whichfirstlinetherapyismostlikelytogivepainrelief

A)  PregabalinB)  PancreaticenzymesC)  AmitriptylineD)  Surgicalpancreaticojejunostomy(Peustow)

•  40yearoldmalewithhistoryofETOHabusewhopresentswithseverechronicepigastricpain.Imagingdemonstratespancreaticcalcificationsandhoneycombing.Thepancreaticductis4mminsize.Noothercauseforhispainhasbeenfound.Whichfirstlinetherapyismostlikelytogivepainrelief

A)  PregabalinB)  PancreaticenzymesC)  AmitriptylineD)  Surgicalpancreaticojejunostomy(Peustow)

•  Pregabalin•  RCTof64ptswithchronicpancreatitis•  300mgbidx3wks•  Reducedpaincomparedtoplacebo(36%v.24%)P:0.02

•  Opioiddoseswerereduced•  Likelyaffectscentralsensitization

OlesunSS.Gastro2011

•  28yofemalewithepigastricpainworsewithmeals.Nowtloss,nodiarrhea.EGD,ultrasound,andCTabdarenormal.Sheisreferredtoruleoutchronicpancreatitis.NoFHofpancreaticdisease.NohxofETOH.Whichistrue?

A)  IfsecretinstimshowshighHCO3secretion,thenshehaschronicpancreatitis

B)  KUBwouldbesensitiveandspecificfordiagnosisC)  ERCPshouldbeperformedD)  MRCPissuperiortoEUSforearlydiagnosisofchronicpancE)  GenetictestingforPRSS1(hereditarypancreatitis)should

notbeperformed

•  28yofemalewithepigastricpainworsewithmeals.Nowtloss,nodiarrhea.EGD,ultrasound,andCTabdarenormal.Sheisreferredtoruleoutchronicpancreatitis.NoFHofpancreaticdisease.NohxofETOH.Whichistrue?

A)  IfsecretinstimshowshighHCO3secretion,thenshehaschronicpancreatitis

B)  KUBwouldbesensitiveandspecificfordiagnosisC)  ERCPshouldbeperformedD)  MRCPissuperiortoEUSforearlydiagnosisofchronicpancE)  GenetictestingforPRSS1(hereditarypancreatitis)should

notbeperformed

•  55yomalewithhxofETOHwith6monthsofepigastricabdominalpain,nausea,wtlossof15lbsover3months.Havingloosestools3-4x/day.RecentdxofDM.Amylase190;lipase66.CBC,chem12normal.Bestnextstep?

A)StoolanalysisB)CTabdomenC)FecalelastaseD)SerumtrypsinogenE)ERCP

•  55yomalewithhxofETOHwith6monthsofepigastricabdominalpain,nausea,wtlossof15lbsover3months.Havingloosestools3-4x/day.RecentdxofDM.Amylase190;lipase66.CBC,chem12normal.Bestnextstep?

A)StoolanalysisB)CTabdomenC)FecalelastaseD)SerumtrypsinogenE)ERCP

•  CTscanshowsdilatedpancreaticductwithobstructingstoneintheheadofthepanc.Whatisthenextbeststepintreatinghispain?

A)EUSceliacblockB)CTceliacblockC)ERCPD)FentanylpatchE)Distalpancreatectomy

•  CTscanshowsdilatedpancreaticductwithobstructingstoneintheheadofthepanc.Whatisthenextbeststepintreatinghispain?

A)EUSceliacblockB)CTceliacblockC)ERCPD)FentanylpatchE)Distalpancreatectomy

•  CTscanshowsadilatedpancreaticductwithmultiplelargestonesinthebody/tailofthepancreasupstreamofastricture.Whatisthemostdefinitivewaytotreathispain?

A)ERCPwithESWLB)Pancreaticojejunostomy(puestow)C)OpioidsD)Pregabalin

•  CTscanshowsadilatedpancreaticductwithmultiplelargestonesinthebody/tailofthepancreasupstreamofastricture.Whatisthemostdefinitivewaytotreathispain?

A)ERCPwithESWLB)Pancreaticojejunostomy(puestow)C)OpioidsD)Pregabalin

•  56yofemalewithchronicpancreatitisundergoingCTscanforworseningpain.Shehaslost15lbsinthepastfewmonths.

•  Whatisthebestwaytomanagethenewpaininthispt?

A)Endoscopicdrainage(cystgastrostomy)B)PancreaticenzymesC)AntioxidanttherapyD)SurgicaldrainageE)Pregabalin

•  Whatisthebestwaytomanagethenewpaininthispt?

A)Endoscopicdrainage(cystgastrostomy)B)PancreaticenzymesC)AntioxidanttherapyD)SurgicaldrainageE)Pregabalin