Chronic pancreatitis
Updates to Article Attributes
Chronic pancreatitis represents the end result of a continuous, prolonged, inflammatory and fibrosing process that affects the pancreas. This results in irreversible morphologic changes and permanent endocrine and exocrine pancreatic dysfunction.
Epidemiology
The most common cause of chronic pancreatitis in adults is excessive alcohol consumption in developed countries and malnutrition in developing countries 5.
Pathology
Acute pancreatitis and chronic pancreatitis are assumed to be different disease processes, and most cases of acute pancreatitis do not result in chronic disease.
Associations
After 20 years of chronic pancreatitis, there is a 6% cumulative risk of developing pancreatic adenocarcinoma.
Predisposing factors
The major risk factors for development of chronic pancreatitis may be categorized according to the TIGAR-O system 9:
- T toxic-metabolic (e.g. alcohol)
- I idiopathic
- G genetic
- A autoimmune
- R recurrent
- -O obstructive
Clinical presentation
Patients may present with exacerbations (episodes of acute pancreatitis) manifesting as epigastric pain, which may recur over a number of years.
Symptoms may be attributable to failure of:
- biliary outflow: jaundice
- exocrine function: malabsorption
- endocrine function: diabetes
Radiographic features
CT
CT features of chronic pancreatitis include:
- dilatation of the main pancreatic duct
- pancreatic calcification
- changes in pancreatic size, shape, and contour
- pancreatic pseudocysts
MRI
may be undertaken both as morphological and functional imaging 1,6-8:
Morphological
featuresFeatures of chronic pancreatitis can be divided into early and late findings:
-
Earlyearly findings- low-signal-intensity pancreas on T1-weighted fat-suppressed images
- decreased and delayed enhancement after IV contrast administration
- dilated side branches
-
Latelate findings- parenchymal atrophy or enlargement
- pseudocyst formation
- dilatation and beading of the pancreatic duct often with intraductal calcifications
Functional
Exocrine function may be assessed by secretin enhanced magnetic resonance cholangiopancreatography, SMRCP. This relatively new technique has shown promising results and may replace endoscopic measuring techniques in the near future 6-8. Imaging protocols to assess exocrine function may contain:
- measurement of secretory volume after intravenous secretin-stimulation by assessing T2-high signal changes in the duodenum
- post-enhanced dynamic assessment of ADC maps of pancreatic parenchyma, revealing delayed and reduced peak values
Ultrasound
The pancreas might appear atrophic, calcified or fibrotic. Findings that may be present on ultrasound include:
- hyperechogenicity (often diffuse) often indicates fibrotic changes
- pseudocysts
- pseudoaneurysms
- presence of ascites
Ultrasound may also be assist to differentiate between the autoimmune type vs acquired:
- the pancreas is enlarged (either focally or diffusely) in the autoimmune type
- calcifications are visible in acquired types 4
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-<p>Early findings</p>- +<p>early findings</p>
-<li>Late findings<ul>- +<li>late findings<ul>
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