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DIAGNOSING CHRONIC PANCREATITIS WITHOUT THE CLASSIC TRIAD. DR P BADENHORST. Patient history. Mr J – A 39 year old black male from Bloemfontein Presented with: Chronic abdominal pain – 3 years Worsening of pain over past 3 days Nausea and vomiting Malaise Pain:

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patient history
Patient history
  • Mr J – A 39 year old black male from Bloemfontein
  • Presented with:
    • Chronic abdominal pain – 3 years
    • Worsening of pain over past 3 days
    • Nausea and vomiting
    • Malaise
  • Pain:
    • Epigastric which radiates to the back
    • Multiple similar episodes (never admitted)
    • Slightly relieved by sitting
patient history continued
Patient history (continued)
  • Systemic:
    • GIT
      • No heart burn
      • Stools foul smelling and greasy
      • Weight loss – 4 kg in past year
    • RESP
      • No complaints
    • CVS
      • No complaints
    • CNS
      • No complaints
patient history continued1
Patient history (continued)
  • Medical:
    • Diabetes mellitus diagnosed in 2009
  • Treatment:
    • Protaphane 28U nocte
    • Actrapid 10U before each meal
  • Surgical:
    • No previous surgery
  • Social:
    • Strong alcohol history (20 years)
    • Five (5) smoking pack years
  • Allergies:
    • No known allergies
clinical examination
General

BP: 130/80 mmHg

Pulse: 104/min

Temperature: 36.2 C

Acute on chronically ill

No dehydration

No jaundice/cyanosis/anaemia/ lymphadenopathy

GIT

Epigastric tenderness

No acute abdomen

No mass

No hepatosplenomegaly

No ascitis

CVS

Normal examination

RESP

Normal examination

No signs of basal pneumonia

CNS

Normal examination

Clinical Examination
further investigations
Further investigations
  • Random glucose 14mmol/L
  • HBA1c 13%
  • s- Amylase 344 IU/L (High)
  • u- Amylase 1623 IU/L (High)
  • CXR Normal
  • AXR
abdominal x ray
Abdominal X-ray

Pancreatic

calcifications

diagnosis
Diagnosis
  • CHRONIC PANCREATITIS WITH

AN ACUTE UPFLARING

  • CLASSIC TRIAD
        • CALCIFICATIONS
        • STEATORRHEA
        • DIABETES
focus of discussion
FOCUS OF DISCUSSION
  • WORK UP OF A PATIENT WITH SUSPECTED CHRONIC PANCREATITIS WHERE CLASSIC TRIAD IS NOT PRESENT
background epidemiology
BACKGROUND (EPIDEMIOLOGY)
  • 70% DIAGNOSED AT AGE 35-60
  • MALE 4:1 FEMALE
  • 23/100 000 PEOPLE WORLDWIDE
  • INCIDENCE RISING –INCREASED ALCOHOL CONSUMPTON
  • RECENT POST MORTEM STUDIES SHOWS EVIDENCE OF CHRONIC PANCREATITIS

IN UP TO 45% OF ASYMTOMATIC ALCOHOLICS

clinical manifestations
CLINICAL MANIFESTATIONS
  • PAIN

- DOMINANT FEATURE

    • NO PAIN IN 30% OF PATIENTS
  • PANCREATIC INSUFFICIENCY
    • PANCREATIC DIABETES

# LATE IN COURSE OF DISEASE

    • MALABSORBTION (90% PANCREAS DESTROYED)

# LIPOLYTIC ACTIVITY DECREASES FASTEST WITH STEATORRHEA

# VIT A,D,E,K , B12 RARE AND LATE

differential diagnosis of abdominal pain epigastric
DIFFERENTIAL DIAGNOSIS OF ABDOMINAL PAIN( EPIGASTRIC)
  • PEPTIC ULCER DISEASE
  • GALLSTONES
  • DISEASES OF BILIARY TRACT
  • PANCREAS CA
  • OTHER ABDOMINAL MALIGNANCIES
  • OTHER
      • TB ABDOMEN
      • MESENTERIC ISCHAEMIA
      • NON ULCER DYSPEPSIA
      • MEDICAL CAUSES= DKA

BASAL PNEUMONIAE

INFERIOR MYOCARDIAL INFARCTION

ETC.

work up
WORK-UP
  • DIAGNOSING CHRONIC PANCREATITIS
  • ENDOCRINE INVOLVEMENT
  • EXOCRINE INVOLVEMENT
  • ETIOLOGY
  • COMPLICATIONS
making the diagnosis
MAKING THE DIAGNOSIS

BLOOD AND IMAGING TESTING NOT SENSITIVE IN EARLY CHRONIC PANCREATITIS

BLOOD

- AMYLASE AND LIPASE NOT DIAGNOSTIC

- NORMAL IN > 50%

-TRYPSIN LEVELS NOT DIAGNOSTIC

AND VERY EXPENSIVE

GASTROSCOPY

-TO EXCLUDE PUD AND GASTRITIS

ct pancreas
CT PANCREAS

CALCIFICATIONS

IN PANCREAS

ATROPHIC

PANCREAS

DILATED

PANCREATIC DUCT

slide20
MRCP
  • PREFERRED ABOVE ERCP
  • BEADING OF DUCTS
  • PANCREAS DUCT

OBSTRUCTION

. DILATED PANCREATIC DUCTS

endoscopic ultrasonography
ENDOSCOPIC ULTRASONOGRAPHY
  • MOST SENSITIVE IN EARLY CHRONIC PANCREATITIS
  • ?? DO THIS PATIENTS DEVELOP CP
  • FEATURES
  • IRREGULAR DUCTS
  • SIDE BRANCHES
  • STONES
  • DILATATION OF DUCTS
2 endocrine involvement
2. ENDOCRINE INVOLVEMENT
  • WORK UP FOR DIABETIS
  • USUALLY INSULIN DEPENDANT
  • NB! RISK OF HYPOGLYCAEMIA
3 exocrine involvement
3. EXOCRINE INVOLVEMENT
  • DIRECT AND INDIRECT TESTS
  • DIRECT TESTS DONE IN VERY FEW CENTRES IN SA
indirect tests
INDIRECT TESTS
  • 72H FECAL FAT DETERMINATION IS GOLD STANDARD
  • FECAL ELASTASE BEST OPTION IN ANY SETTING
        • SENSITIVE IN MODERATE TO SEVERE PANCREATIC INSUFFICIENCY( LEVELS <200 UG/G)
        • ONLY ONE SAMPLE NEEDED
        • NOT INFLUENCED BY PANCREATIC ENZYME REPLACEMENT
direct tests
DIRECT TESTS
  • SECRETIN STIMULATION TEST
        • IN VERY FEW SPECIALIZED CENTRES
        • ADMINASTRATION OF A MEAL
        • PANCREAS STIMULATED
        • PANCREATIC SECRETIONS OBTAINED IN DUODENUM- DETERMINE NORMAL PANCREATIC SECRETORY CONTENT
4 etiology tigar o
Toxic-metabolic

Alcohol

Smoking

Hypercalcaemia

Hyperlipidaemia

Chronic renal failure

Drugs

Toxins

Idiopathic

Early

Late

Tropical

Genetic

Hereditary

Cationic trypsinogen

SPINK1

CFTR

Autoimmune

Isolated

Sjogren

IBD

PBC

Recurrent acute attacks

Obstructive

Pancreas divisum

SOD

Tumour

Duodenal wall cyst

4. ETIOLOGY (TIGAR-O)
4 etiology
4. ETIOLOGY
  • IF NO HISTORY OF ALCOHOL AND GALLSTONES EXCLUDED ON SONAR
        • ANF,ANCA,IgG 4, RF TO EXCLUDE AUTO IMMUNE

PANCREATITIS

        • POSITIVE IgG4 IS DIAGNOSTIC OF AUTO IMMUNE

PANCREATITIS

        • ASSOCIATED WITH

# PRIMARY SCLEROSING CHOLANGITIS

# PRIMARY BILLIARY CIRRHOSIS

# SJOGREN SYNDROME

# AUTO-IMMUNE HEPATITIS

- TRIGLYCERIDES AND CALCIUM

genetic testing
GENETIC TESTING
  • MUTATIONS ASSOCIATED WITH CHRONIC PANCREATITIS IN:
        • CFTR GENE
        • SPINK-1
        • PRSS-1
  • CURRENTLY NOT PART OF NORMAL WORK-UP FOR CHRONIC PANCREATITIS

# CFTR GENE MUTATION IN 44% OF PATIENTS WITH CHRONIC PANCREATITIS

# ALSO PRESENT IN 22% OF HEALTHY POPULATION

5 complications
5. COMPLICATIONS
  • PAIN
  • DIABETES MELLITUS
  • EXOCRINE INSUFFICIENCY
  • PSEUDOCYSTS (30%)
  • DUODENAL STENOSIS
  • SPLENIC ARTERIAL THROMBOSIS
  • PANCREATIC ASCITIS
  • PANCREAS CARCINOMA
pancreas ca
PANCREAS CA
  • EXOCRINE INSUFFICIENCY ALONE NOT DIAGNOSTIC OF CRONIC PANCREATITIS- CA CAN PRESENT SIMILARLY
  • SOME STUDIES SHOW 15X INCREASED RISK FOR PANCREAS CA
  • RECOMMENDATION IS YEARLY ENDOSCOPIC ULTRASOUND FROM 40Y OF AGE IN PATIENTS WITH CHRONIC PANCREATITIS
  • DIFFICULT TO DISTINGUISH BETWEEN PANCREATIC TUMOR AND CHRONIC INFLAMMATORY PROCESS
conclusion
CONCLUSION
  • REMEMBER CHRONIC PANCREATITIS IN DDx OF CHRONIC ABDOMINAL PAIN

EVEN IF INITIAL INVESTIGATIONS IS NORMAL

bibliography
BIBLIOGRAPHY
  • UP TO DATE
  • FAUCI,AS ET AL, HARRISONS PRINCIPLES OF INTERNAL MEDICINE. 17TH EDITION
  • WWW.MEDIFOCUS. THE EVALUATION OF SURGICAL TREATMENT OF CHRONIC PANCREATITIS. ANDERSON,DK; FREY,CF
  • Q.LIAO ET AL. HEPATOBILIARY AND PANCREATIC DISEASE INTERNATIONAL VOLUME 1, NO3, 2006,
  • WWW.MEDCONSULT.COM: DIAGNOSIS OF CHRONIC PANCREATITIS