Chronic Pancreatitis. Ara Sahakian, M.D. Assistant Professor of Medicine USC core lecture

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1 Chronic Pancreatitis Ara Sahakian, M.D. Assistant Professor of Medicine USC core lecture

2 What is Chronic Pancreatitis Progressive inflammatory disease Pancreatic parenchyma replaced w/fibrous tissue Destruction of acinar and islet cells. Pain and loss of function (exo and endo) Disease of morbidity (not mortality)

3 Pathogenesis Usually history of acute pancreatitis Risk of progression greatest with smoking/etoh Most with acute panc don t develop chronic panc 2-hit hypothesis Acute panc in genetically susceptible pt, enhanced by environmental factors PRSS1, SPINK1, CFTR ETOH and smoking

4 Presentation Chronic upper abdominal pain Worse with eating Cross sectional imaging can be normal (early) Endocrine/exocrine insufficiency and changes in imaging (late) Phenotypes of chronic panc Cystic fibrosis: exocrine insuff w/o pain Chronic calcific panc in pt w/etoh

5 Diagnosis Histology: Gold standard, Limitations Patchy disease False positives in elderly, smokers, etoh Risk of pancreatitis with bx Not frequently used

6 Diagnosis Functional tests Secretin stimulation (HCO 3 ) Fecal elastase Serum trypsin CCK stim: looks at lipase concentration in duod fluid

7 Diagnosis Imaging tests KUB Cost effective (cheap): Low sensitivity, high specificity MRCP=EUS=ERCP for sensitivity ERCP not indicated for diagnostic CT good for seeing calcifications

8 EUS findings Rosemont criteria Hyperechoic foci, stranding, lobularity Dilated duct, stones, hyperechoic duct margins

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14 Before ESWL After ESWL

15 Treatment Analgesics/Narcotics Enzymes Nerve Blocks Endoscopic therapy (targeted) Surgical therapy

16 Treatment Cochrane review: Trials. Pancreatic enzymes have no benefit in pain from chronic pancreatitis. Shafiq et al. Cochrane Database Syst Rev 2009

17 Endoscopic Therapy EUS guided celiac nerve block 50% have pain relief, lasts few weeks (not routinely recommended) Pancreatic stone extraction ESWL for stone extraction Pancreatic stricture therapy Ductal disruption therapy (often require surgery) Pseudocyst drainage Biliary stricture therapy

18 Surgical options Drainage (Peustow-pancreaticojejunostomy) duct >5mm (>10mm) Resection (Whipple, distal pancreatectomy) Total pancreatic resection w auto islet cell transplantation Denervation-thoracoscopic splanchnicectomy

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21 Endoscopic vs. Surgical drainage Cahen NEJM 2007 Randomized prospective 19 endoscopic; 20 pancreaticojejunostomy 24 months of follow up Surgical therapy decreased pain compared to endoscopic therapy (75% v 32% w pain relief) Limitations: Pain relief unexpectantly low in endo group (32%) Major complication rate higher in the surgical group Low rate of endo technical success (50%)

22 Therapy Endoscopic therapy may be considered a firstline approach for pain (pancreatic stones/ strictures) Most DEFINITIVE therapy is considered surgery

23 Peudocysts Transpapillary drainage Pancreatic stent to bridge the leak Smaller cysts communicating with PD EUS guided drainage No longer done without EUS Visualize vessels and debris Through stomach or duodenum into cyst cavity Increasingly with lumen opposing stents (little data)

24 Pain Pain was thought to be due to ductal obstruction Treatment was aimed to relieving obstruction (ERCP, surgery) Results unpredictable Neurogenic pain and hyperalgesia Pain medications (opioids, neuropathic agents) Slow progression ETOH and smoking abstinence

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26 40 year old male with history of ETOH abuse who presents with severe chronic epigastric pain. Imaging demonstrates pancreatic calcifications and honeycombing. The pancreatic duct is 4mm in size. No other cause for his pain has been found. Which first line therapy is most likely to give pain relief A) Pregabalin B) Pancreatic enzymes C) Amitriptyline D) Surgical pancreaticojejunostomy (Peustow)

27 40 year old male with history of ETOH abuse who presents with severe chronic epigastric pain. Imaging demonstrates pancreatic calcifications and honeycombing. The pancreatic duct is 4mm in size. No other cause for his pain has been found. Which first line therapy is most likely to give pain relief A) Pregabalin B) Pancreatic enzymes C) Amitriptyline D) Surgical pancreaticojejunostomy (Peustow)

28 Pregabalin RCT of 64 pts with chronic pancreatitis 300mg bid x 3 wks Reduced pain compared to placebo (36% v. 24%) P: 0.02 Opioid doses were reduced Likely affects central sensitization Olesun SS. Gastro 2011

29 28 yo female with epigastric pain worse with meals. No wt loss, no diarrhea. EGD, ultrasound, and CT abd are normal. She is referred to rule out chronic pancreatitis. No FH of pancreatic disease. No hx of ETOH. Which is true? A) If secretin stim shows high HCO3 secretion, then she has chronic pancreatitis B) KUB would be sensitive and specific for diagnosis C) ERCP should be performed D) MRCP is superior to EUS for early diagnosis of chronic panc E) Genetic testing for PRSS1 (hereditary pancreatitis) should not be performed

30 28 yo female with epigastric pain worse with meals. No wt loss, no diarrhea. EGD, ultrasound, and CT abd are normal. She is referred to rule out chronic pancreatitis. No FH of pancreatic disease. No hx of ETOH. Which is true? A) If secretin stim shows high HCO3 secretion, then she has chronic pancreatitis B) KUB would be sensitive and specific for diagnosis C) ERCP should be performed D) MRCP is superior to EUS for early diagnosis of chronic panc E) Genetic testing for PRSS1 (hereditary pancreatitis) should not be performed

31 55 yo male with hx of ETOH with 6 months of epigastric abdominal pain, nausea, wt loss of 15 lbs over 3 months. Having loose stools 3-4 x/day. Recent dx of DM. Amylase 190; lipase 66. CBC, chem 12 normal. Best next step? A)Stool analysis B)CT abdomen C)Fecal elastase D)Serum trypsinogen E)ERCP

32 55 yo male with hx of ETOH with 6 months of epigastric abdominal pain, nausea, wt loss of 15 lbs over 3 months. Having loose stools 3-4 x/day. Recent dx of DM. Amylase 190; lipase 66. CBC, chem 12 normal. Best next step? A)Stool analysis B)CT abdomen C)Fecal elastase D)Serum trypsinogen E)ERCP

33 CT scan shows dilated pancreatic duct with obstructing stone in the head of the panc. What is the next best step in treating his pain? A)EUS celiac block B) CT celiac block C)ERCP D)Fentanyl patch E)Distal pancreatectomy

34 CT scan shows dilated pancreatic duct with obstructing stone in the head of the panc. What is the next best step in treating his pain? A)EUS celiac block B) CT celiac block C)ERCP D)Fentanyl patch E)Distal pancreatectomy

35 CT scan shows a dilated pancreatic duct with multiple large stones in the body/tail of the pancreas upstream of a stricture. What is the most definitive way to treat his pain? A)ERCP with ESWL B)Pancreaticojejunostomy (puestow) C)Opioids D)Pregabalin

36 CT scan shows a dilated pancreatic duct with multiple large stones in the body/tail of the pancreas upstream of a stricture. What is the most definitive way to treat his pain? A)ERCP with ESWL B)Pancreaticojejunostomy (puestow) C)Opioids D)Pregabalin

37 56 yo female with chronic pancreatitis undergoing CT scan for worsening pain. She has lost 15 lbs in the past few months.

38 What is the best way to manage the new pain in this pt? A)Endoscopic drainage (cystgastrostomy) B)Pancreatic enzymes C)Antioxidant therapy D)Surgical drainage E)Pregabalin

39 What is the best way to manage the new pain in this pt? A)Endoscopic drainage (cystgastrostomy) B)Pancreatic enzymes C)Antioxidant therapy D)Surgical drainage E)Pregabalin

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