Leah presented a case of a young/early middle age man (45 years old) with a history of NIDDM2 and two prior episodes of pancreatitis (unclear etiology) presenting with worsening abdominal pain for 2 weeks, with associated nausea and vomiting. His appetite has also been poor for the past 3 months, subjectively losing 120lbs over this time period. For the 2-3 days prior to presentation, he started endorsing fever and chills in addition to worsening abdominal symptoms…

CT AP revealed  a necrotizing pancreatitis with large multilocular thick-walled infected pseudocyst with associated phlegmon and serpiginous fluid. Ultimately the patient likely has chronic pancreatitis complicated by development of pseudocyst and walled-off pancreatic necrosis.

Fortunately he is clinically stable, pending endoscopic necrosectomy for definitive management.

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Since acute pancreatitis gets all the rage attention, we will actually spend some time on chronic pancreatitis and discuss potential complications from this condition.

Just a quick recap on acute pancreatitis though…

Acute Pancreatitis

Etiology (I GET SMASHED)

• Idiopathic, IGG4
• Gallstones (40%)
• Ethanol (35%)
• Trauma
• Steroids
• Mumps/Malignancy
• Autoimmune
• Scorpion stings
• Hypercalcemia/Hypertriglyceridemia
• ERCP (4% of pts who undergo ERCP)
• Drugs (1%, thiazide, Lasix, HIV meds)

Diagnosis: 2/3 required

• Acute epigastric pain
• Elevated lipase or amylase 3x ULN, lipase has much better sensitivity and specificity
• Imaging findings
  • US: 1^st line, rule out GS, obstruction
  • CT with con pancreatic protocol: Indicated when suspecting necrotizing pancreatitis or clinical deterioration

General Management Strategies

• Volume: aggressive fluid resuscitation, 250-500cc/hr
  • LR has improved outcomes vs NS! Check out this and this article.
• Pain control
• Nutrition
  • Mild cases: PO within 48 hours, low fat/low residue diet ok
  • Severe cases with organ damage: Start enteral nutrition via NJ or NG if not eating by 3-4 days, early nutrition improves outcome.
    • Consider TPN if unable to tolerate enteral feeding

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Chronic Pancreatitis

Definition: Persistent inflammation of the pancreas, resulting in permanent functional and structural damage.

Epidemiology:

• 50% from alcoholism, M > F, other risk factors include smoking.
• A type of pancreatitis is more common in kids and young adults patients from tropical regions, known as tropical pancreatitis.
• Certain genetic disposition

Pathophysiology: Not well understood but there are theories

• Chronic pancreatic ductal obstruction due to protein plugs from protein-bicarb imbalance, overtime calcifies, overtime leading to fibrosis
• Necrosis-fibrosis: Repeated attacks of acute pancreatitis with tissue necrosis. Fibrotic tissues gradually replace the necrotic tissue, leading to development of chronic inflammation.

Presentation

• Might see the classic triad of abdominal pain, diabetes, and malabsorption.
• Abdominal pain, chronic and often post-prandial, becomes more continuous as disease progresses.
• Pancreatic insufficiency: steatorrhea, flatulence, distension, weight loss, fatigue, malnutrition

Complications

• Pseudocyst (can occur 4 weeks after an acute episode or any time with chronic pancreatitis)
• Bile duct or duodenal obstruction
• Pancreatic ascites or pleural effusion due to disruption of the pancreatic duct
• Splenic vein thrombosis, which can lead to gastric varices (which this patient actually has!)
• Pseudoaneurysms of arteries
• Inc risk of pancreatic adenocarcinoma. Those with hereditary or tropical forms are at high risk.

Diagnosis

• XR: May see calcifications but only in 30% of cases
• CT: also not sensitive, may be normal early on
• MRCP is better than CT with IV Secretin
• EUS: High sensitivity, low spec (low rate of false negative, high rates of false positive)
• Pancreatic function test, usually indirect i.e. serum trypsinogen, 72H fecal fat after a high fat diet (demonstrates steatorrhea but cannot establish cause of the malabsorption), fecal chymotrypsin and elastase concentration)

Treatment

• Pain control, often difficult, opiates, TCA, SSRI, gabapentin have been used with mixed results
• Pancreatic enzyme supplements
• Diabetes management
• Smoking cessation, alcohol abstinence
• Low fat diet (<25g/day) to reduce pancreatic enzyme secretion
• ERCP

Prognosis: Generally prognosis is pretty poor once you have chronic pancreatitis

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Pseudocyst

Epidemiology

• Usually > 4 weeks after onset of acute episode, 5-16% of cases. Starts out as peripancreatic fluid collection, progresses to pseudocyst beyond 4 weeks.
• Can occur in both acute and chronic pancreatitis
• Alcohol use related chronic pancreatitis is associated with highest incidence of pseudocyst formation.

Pathophysiology

• Encapsulated fluid collection, pseudo because the cyst wall lacks epithelial or endothelial cells.

Presentation

• Uncomplicated: Asymptomatic to mild pain, can also lead to early satiety, nausea/vomiting
• Complicated:
  • Gastric outlet or duodenal obstruction
  • Large vessel compression
  • CBD compression
  • Infected pseudocyst (10%)
  • Hemorrhage, UGIB
  • Pancreatico-pleural fistula

Diagnosis

• CT: Well circumscribed, usually round or oval, homogeneous, all fluid
• Transcutaneous or endoscopic US
• ERCP (diagnostic and therapeutic in some cases)

Routine Management

• Observe, with serial imaging.
  • Likelihood for resolution dec if persistent for  > 6 weeks, e/o chronic pancreatitis, pancreatic duct anomaly is present, or thicker-walled pseudocyst.
• Supportive Care
  • Pain control
  • Nutritional support
  • PPI

Complication management

• Drainage is indicated when:
  • Evidence of infection
  • Mass effect causing ductal or duodenal blockage or pancreatic ductal stricture
  • Perforation
• Endoscopic drainage: Preferred over percutaneous
  • Criteria (higher chance of success if the following are met):
    • Fluid collection has to be mature with well defined wall and mostly liquid,
    • The wall of the cyst must be adherent to stomach or duodenum
    • Fluid collection must be at least 6 cm in size.
• Drainage approaches:
  • Transmural: Drain out via the stomach or duodenum
  • Transpapillary: Drain via pancreatic duct
• Contraindication of endoscopic intervention:
  • Pseudoaneurysm, associated with fatal hemorrhage, due to erosions of the gastroduodenal or splenic artery, suspect if drop in H&H or e/o GIB or sudden expansion.