DIAGNOSING CHRONIC DIAGNOSING CHRONIC PANCREATITIS WITHOUT THE PANCREATITIS WITHOUT THE

CLASSIC TRIADCLASSIC TRIAD

DR P BADENHORSTDR P BADENHORST

Patient historyPatient history

• Mr J – A 39 year old black male from BloemfonteinMr J – A 39 year old black male from Bloemfontein• Presented with:Presented with:

– Chronic abdominal pain – 3 yearsChronic abdominal pain – 3 years– Worsening of pain over past 3 daysWorsening of pain over past 3 days– Nausea and vomitingNausea and vomiting– MalaiseMalaise

• Pain: Pain: – Epigastric which radiates to the back Epigastric which radiates to the back – Multiple similar episodes (never admitted)Multiple similar episodes (never admitted)– Slightly relieved by sittingSlightly relieved by sitting

Patient history (continued)Patient history (continued)

• Systemic:Systemic:– GITGIT

• No heart burnNo heart burn• Stools foul smelling and greasyStools foul smelling and greasy• Weight loss – 4 kg in past yearWeight loss – 4 kg in past year

– RESPRESP• No complaintsNo complaints

– CVSCVS• No complaintsNo complaints

– CNSCNS• No complaintsNo complaints

Patient history (continued)

• Medical:Medical:– Diabetes mellitus diagnosed in 2009Diabetes mellitus diagnosed in 2009

• Treatment:Treatment:– Protaphane 28U nocteProtaphane 28U nocte– Actrapid 10U before each mealActrapid 10U before each meal

• Surgical:Surgical:– No previous surgeryNo previous surgery

• Social:Social:– Strong alcohol history (20 years)Strong alcohol history (20 years)– Five (5) smoking pack yearsFive (5) smoking pack years

• Allergies:Allergies:– No known allergiesNo known allergies

Clinical Examination

• GeneralGeneral– BP: 130/80 mmHgBP: 130/80 mmHg– Pulse: 104/minPulse: 104/min– Temperature: 36.2 CTemperature: 36.2 C– Acute on chronically illAcute on chronically ill– No dehydrationNo dehydration– No No

jaundice/cyanosis/anaemia/ jaundice/cyanosis/anaemia/ lymphadenopathylymphadenopathy

• GITGIT– Epigastric tendernessEpigastric tenderness– No acute abdomenNo acute abdomen– No massNo mass– No hepatosplenomegalyNo hepatosplenomegaly– No ascitisNo ascitis

• CVSCVS– Normal examinationNormal examination

• RESPRESP– Normal examinationNormal examination– No signs of basal No signs of basal

pneumoniapneumonia

• CNSCNS– Normal examinationNormal examination

Special investigationsSpecial investigations

Full blood count Full blood count WCCWCC 8,7 8,7 Hb Hb 14,3 (14,3 (MCV= N)MCV= N)

PlateletsPlatelets 226226U+EU+E NaNa 139139

KK 4,54,5UreaUrea 6,66,6CreatinineCreatinine 8484

Special investigations Special investigations (continued)(continued)

Liver functionsLiver functions Bilrubin TotalBilrubin Total 1313Bilirubin (conj)Bilirubin (conj) 88ProteienProteien 7979AlbuminAlbumin 3636ASTAST 4848ALTALT 45 45 ALPALP 9090GGTGGT 112112

Further investigationsFurther investigations

• Random glucoseRandom glucose 14mmol/L14mmol/L• HBA1cHBA1c 13%13%

• s- Amylases- Amylase 344 IU/L (High)344 IU/L (High)• u- Amylaseu- Amylase 1623 IU/L (High)1623 IU/L (High)

• CXRCXR NormalNormal• AXRAXR

Abdominal X-rayAbdominal X-ray

Pancreatic Pancreatic

calcificationscalcifications

DiagnosisDiagnosis

• CHRONIC PANCREATITIS WITHCHRONIC PANCREATITIS WITH

AN ACUTE UPFLARING AN ACUTE UPFLARING

• CLASSIC TRIADCLASSIC TRIAD– CALCIFICATIONSCALCIFICATIONS– STEATORRHEASTEATORRHEA– DIABETES DIABETES

FOCUS OF DISCUSSIONFOCUS OF DISCUSSION

• WORK UP OF A PATIENT WITH WORK UP OF A PATIENT WITH SUSPECTED CHRONIC PANCREATITIS SUSPECTED CHRONIC PANCREATITIS WHERE CLASSIC TRIAD IS NOT WHERE CLASSIC TRIAD IS NOT PRESENTPRESENT

BACKGROUND (EPIDEMIOLOGY)BACKGROUND (EPIDEMIOLOGY)

• 70% DIAGNOSED AT AGE 35-6070% DIAGNOSED AT AGE 35-60• MALE 4:1 FEMALEMALE 4:1 FEMALE• 23/100 000 PEOPLE WORLDWIDE23/100 000 PEOPLE WORLDWIDE• INCIDENCE RISING –INCREASED ALCOHOL INCIDENCE RISING –INCREASED ALCOHOL

CONSUMPTONCONSUMPTON• RECENT POST MORTEM STUDIES SHOWS RECENT POST MORTEM STUDIES SHOWS

EVIDENCE OF CHRONIC PANCREATITISEVIDENCE OF CHRONIC PANCREATITIS

IN UP TO 45% OF ASYMTOMATIC IN UP TO 45% OF ASYMTOMATIC ALCOHOLICS ALCOHOLICS

CLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS

• PAINPAIN- DOMINANT FEATURE- DOMINANT FEATURE- NO PAIN IN 30% OF PATIENTSNO PAIN IN 30% OF PATIENTS

• PANCREATIC INSUFFICIENCYPANCREATIC INSUFFICIENCY– PANCREATIC DIABETESPANCREATIC DIABETES

# LATE IN COURSE OF DISEASE# LATE IN COURSE OF DISEASE– MALABSORBTION (90% PANCREAS MALABSORBTION (90% PANCREAS

DESTROYED)DESTROYED)# LIPOLYTIC ACTIVITY DECREASES # LIPOLYTIC ACTIVITY DECREASES

FASTEST WITH FASTEST WITH STEATORRHEASTEATORRHEA

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

DIFFERENTIAL DIAGNOSIS OF DIFFERENTIAL DIAGNOSIS OF ABDOMINAL PAIN( EPIGASTRIC)ABDOMINAL PAIN( EPIGASTRIC)• PEPTIC ULCER DISEASEPEPTIC ULCER DISEASE• GALLSTONESGALLSTONES• DISEASES OF BILIARY TRACTDISEASES OF BILIARY TRACT• PANCREAS CAPANCREAS CA• OTHER ABDOMINAL MALIGNANCIESOTHER ABDOMINAL MALIGNANCIES• OTHEROTHER

• TB ABDOMENTB ABDOMEN• MESENTERIC ISCHAEMIAMESENTERIC ISCHAEMIA• NON ULCER DYSPEPSIANON ULCER DYSPEPSIA• MEDICAL CAUSES= MEDICAL CAUSES= DKADKA

BASAL PNEUMONIAEBASAL PNEUMONIAEINFERIOR MYOCARDIAL INFERIOR MYOCARDIAL

INFARCTIONINFARCTIONETC.ETC.

WORK-UPWORK-UP

1.1. DIAGNOSING CHRONIC DIAGNOSING CHRONIC PANCREATITISPANCREATITIS

2.2. ENDOCRINE INVOLVEMENTENDOCRINE INVOLVEMENT

3.3. EXOCRINE INVOLVEMENTEXOCRINE INVOLVEMENT

4.4. ETIOLOGYETIOLOGY

5.5. COMPLICATIONSCOMPLICATIONS

1.1. MAKING THE DIAGNOSISMAKING THE DIAGNOSIS

BLOOD AND IMAGING TESTING NOT SENSITIVE IN BLOOD AND IMAGING TESTING NOT SENSITIVE IN EARLY CHRONIC PANCREATITISEARLY CHRONIC PANCREATITIS

BLOODBLOOD- AMYLASE AND LIPASE NOT DIAGNOSTIC- AMYLASE AND LIPASE NOT DIAGNOSTIC- NORMAL IN > 50%- NORMAL IN > 50%

-TRYPSIN LEVELS NOT DIAGNOSTIC-TRYPSIN LEVELS NOT DIAGNOSTICAND VERY EXPENSIVEAND VERY EXPENSIVE

GASTROSCOPYGASTROSCOPY -TO EXCLUDE PUD AND GASTRITIS -TO EXCLUDE PUD AND GASTRITIS

WORK UPWORK UP

BLOODBLOOD IMAGINGIMAGING

AXRAXR((CALCIFICATIONS IN 30%CALCIFICATIONS IN 30%))

ABD ULTRASOUND/ABD ULTRASOUND/CT PANCREAS CT PANCREAS

CT PANCREASCT PANCREAS

CALCIFICATIONSCALCIFICATIONS

IN PANCREASIN PANCREAS

ATROPHICATROPHIC

PANCREASPANCREAS

DILATEDDILATED

PANCREATIC PANCREATIC DUCTDUCT

WORK UPWORK UP

BLOODBLOOD IMAGINGIMAGING

AXRAXR((CALCIFICATIONS IN 30%)CALCIFICATIONS IN 30%)

ABD ULTRASOUND/ABD ULTRASOUND/CT PANCREAS CT PANCREAS

MRCPMRCP

MRCPMRCP

• PREFERRED PREFERRED ABOVE ERCPABOVE ERCP

• BEADING OF BEADING OF DUCTSDUCTS

• PANCREAS DUCTPANCREAS DUCT

OBSTRUCTIONOBSTRUCTION

. DILATED . DILATED PANCREATIC PANCREATIC DUCTSDUCTS

WORK UPWORK UP

BLOODBLOOD IMAGINGIMAGING

AXRAXR

ABD ULTRASOUND/ABD ULTRASOUND/CT PANCREAS CT PANCREAS

MRCPMRCP

ENDOSCOPIC ENDOSCOPIC ULTRASONOGRAPHYULTRASONOGRAPHY

ENDOSCOPIC ENDOSCOPIC ULTRASONOGRAPHYULTRASONOGRAPHY

• MOST MOST SENSITIVE IN SENSITIVE IN EARLY EARLY CHRONIC CHRONIC PANCREATITISPANCREATITIS

• ?? DO THIS ?? DO THIS PATIENTS PATIENTS DEVELOP CPDEVELOP CP

• FEATURESFEATURES• IRREGULAR IRREGULAR

DUCTSDUCTS• SIDE BRANCHESSIDE BRANCHES• STONESSTONES• DILATATION OF DILATATION OF

DUCTSDUCTS

2. ENDOCRINE INVOLVEMENT2. ENDOCRINE INVOLVEMENT

• WORK UP FOR DIABETISWORK UP FOR DIABETIS

• USUALLY INSULIN DEPENDANTUSUALLY INSULIN DEPENDANT

• NB! RISK OF HYPOGLYCAEMIANB! RISK OF HYPOGLYCAEMIA

3. EXOCRINE INVOLVEMENT3. EXOCRINE INVOLVEMENT

• DIRECT AND INDIRECT TESTSDIRECT AND INDIRECT TESTS

• DIRECT TESTS DONE IN VERY FEW DIRECT TESTS DONE IN VERY FEW CENTRES IN SACENTRES IN SA

INDIRECT TESTSINDIRECT TESTS

• 72H FECAL FAT DETERMINATION IS 72H FECAL FAT DETERMINATION IS GOLD STANDARDGOLD STANDARD

• FECAL ELASTASE BEST OPTION IN FECAL ELASTASE BEST OPTION IN ANY SETTINGANY SETTING

– SENSITIVE IN MODERATE TO SEVERE PANCREATIC SENSITIVE IN MODERATE TO SEVERE PANCREATIC INSUFFICIENCY( LEVELS <200 UG/G)INSUFFICIENCY( LEVELS <200 UG/G)

– ONLY ONE SAMPLE NEEDEDONLY ONE SAMPLE NEEDED– NOT INFLUENCED BY PANCREATIC ENZYME NOT INFLUENCED BY PANCREATIC ENZYME

REPLACEMENTREPLACEMENT

DIRECT TESTSDIRECT TESTS

• SECRETIN STIMULATION TESTSECRETIN STIMULATION TEST

– IN VERY FEW SPECIALIZED CENTRESIN VERY FEW SPECIALIZED CENTRES– ADMINASTRATION OF A MEALADMINASTRATION OF A MEAL– PANCREAS STIMULATEDPANCREAS STIMULATED– PANCREATIC SECRETIONS OBTAINED IN PANCREATIC SECRETIONS OBTAINED IN

DUODENUM- DETERMINE NORMAL PANCREATIC DUODENUM- DETERMINE NORMAL PANCREATIC SECRETORY CONTENTSECRETORY CONTENT

4. ETIOLOGY (TIGAR-O)4. ETIOLOGY (TIGAR-O)

• TToxic-metabolicoxic-metabolic– AlcoholAlcohol– SmokingSmoking– HypercalcaemiaHypercalcaemia– HyperlipidaemiaHyperlipidaemia– Chronic renal failureChronic renal failure– DrugsDrugs– ToxinsToxins

• IIdiopathicdiopathic– EarlyEarly– LateLate– TropicalTropical

• GGeneticenetic– HereditaryHereditary– Cationic trypsinogenCationic trypsinogen– SPINK1SPINK1– CFTRCFTR

• AAutoimmuneutoimmune– IsolatedIsolated– SjogrenSjogren– IBDIBD– PBCPBC

• RRecurrent acute attacksecurrent acute attacks

• OObstructivebstructive– Pancreas divisumPancreas divisum– SODSOD– TumourTumour– Duodenal wall cystDuodenal wall cyst

4. ETIOLOGY4. ETIOLOGY

• IF NO HISTORY OF ALCOHOL AND IF NO HISTORY OF ALCOHOL AND GALLSTONES EXCLUDED ON SONARGALLSTONES EXCLUDED ON SONAR

– ANF,ANCA,IgG 4, RF TO EXCLUDE AUTO IMMUNEANF,ANCA,IgG 4, RF TO EXCLUDE AUTO IMMUNEPANCREATITISPANCREATITIS

- POSITIVE IgG4 IS DIAGNOSTIC OF AUTO IMMUNEPOSITIVE IgG4 IS DIAGNOSTIC OF AUTO IMMUNE PANCREATITISPANCREATITIS– ASSOCIATED WITHASSOCIATED WITH

# PRIMARY SCLEROSING # PRIMARY SCLEROSING CHOLANGITISCHOLANGITIS

# PRIMARY BILLIARY # PRIMARY BILLIARY CIRRHOSISCIRRHOSIS

# SJOGREN SYNDROME# SJOGREN SYNDROME# AUTO-IMMUNE HEPATITIS# AUTO-IMMUNE HEPATITIS

- TRIGLYCERIDES AND CALCIUM- TRIGLYCERIDES AND CALCIUM

GENETIC TESTINGGENETIC TESTING

• MUTATIONS ASSOCIATED WITH CHRONIC MUTATIONS ASSOCIATED WITH CHRONIC PANCREATITIS IN:PANCREATITIS IN:

– CFTR GENECFTR GENE

– SPINK-1SPINK-1

– PRSS-1PRSS-1

• CURRENTLY NOT PART OF NORMAL WORK-CURRENTLY NOT PART OF NORMAL WORK-UP FOR CHRONIC PANCREATITISUP FOR CHRONIC PANCREATITIS

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

# ALSO PRESENT IN 22% OF HEALTHY POPULATION# ALSO PRESENT IN 22% OF HEALTHY POPULATION

5. COMPLICATIONS5. COMPLICATIONS

• PAINPAIN• DIABETES MELLITUSDIABETES MELLITUS• EXOCRINE INSUFFICIENCYEXOCRINE INSUFFICIENCY• PSEUDOCYSTS (30%)PSEUDOCYSTS (30%)• DUODENAL STENOSISDUODENAL STENOSIS• SPLENIC ARTERIAL THROMBOSISSPLENIC ARTERIAL THROMBOSIS• PANCREATIC ASCITISPANCREATIC ASCITIS• PANCREAS CARCINOMAPANCREAS CARCINOMA

PANCREAS CAPANCREAS CA

• EXOCRINE INSUFFICIENCY ALONE NOT EXOCRINE INSUFFICIENCY ALONE NOT DIAGNOSTIC OF CRONIC PANCREATITIS- CA CAN DIAGNOSTIC OF CRONIC PANCREATITIS- CA CAN PRESENT SIMILARLYPRESENT SIMILARLY

• SOME STUDIES SHOW 15X INCREASED RISK FOR SOME STUDIES SHOW 15X INCREASED RISK FOR PANCREAS CAPANCREAS CA

• RECOMMENDATION IS YEARLY ENDOSCOPIC RECOMMENDATION IS YEARLY ENDOSCOPIC ULTRASOUND FROM 40Y OF AGE IN PATIENTS ULTRASOUND FROM 40Y OF AGE IN PATIENTS WITH CHRONIC PANCREATITISWITH CHRONIC PANCREATITIS

• DIFFICULT TO DISTINGUISH BETWEEN DIFFICULT TO DISTINGUISH BETWEEN PANCREATIC TUMOR AND CHRONIC PANCREATIC TUMOR AND CHRONIC INFLAMMATORY PROCESSINFLAMMATORY PROCESS

CONCLUSIONCONCLUSION

• REMEMBER CHRONIC PANCREATITIS REMEMBER CHRONIC PANCREATITIS IN DDx OF CHRONIC ABDOMINAL IN DDx OF CHRONIC ABDOMINAL PAINPAIN

EVEN IF INITIAL INVESTIGATIONS IS EVEN IF INITIAL INVESTIGATIONS IS NORMALNORMAL

BIBLIOGRAPHYBIBLIOGRAPHY

• UP TO DATEUP TO DATE• FAUCI,AS ET AL, HARRISONS PRINCIPLES OF INTERNAL FAUCI,AS ET AL, HARRISONS PRINCIPLES OF INTERNAL

MEDICINE. 17MEDICINE. 17THTH EDITION EDITION• WWW.MEDIFOCUS. THE EVALUATION OF SURGICAL TREATMENT . THE EVALUATION OF SURGICAL TREATMENT

OF CHRONIC PANCREATITIS. ANDERSON,DK; FREY,CFOF CHRONIC PANCREATITIS. ANDERSON,DK; FREY,CF

• Q.LIAO ET AL. HEPATOBILIARY AND PANCREATIC DISEASE Q.LIAO ET AL. HEPATOBILIARY AND PANCREATIC DISEASE INTERNATIONAL VOLUME 1, NO3, 2006,INTERNATIONAL VOLUME 1, NO3, 2006,

• WWW.MEDCONSULT.COM:: DIAGNOSIS OF CHRONIC DIAGNOSIS OF CHRONIC PANCREATITISPANCREATITIS

THANK YOU!