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Chronic Pancreatitis: Evaluation and Treatment

by Carlo Raj, MD
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    00:01 Evaluation of chronic pancreatitis.

    00:03 You’ll find this to be interesting.

    00:06 Serum amylase and lipase, I told you earlier if there’s such extensive damage taking place at the pancreas, that amylase and lipase become less reliable.

    00:15 So now what are you looking for? Watch this.

    00:18 Pancreatic function test.

    00:20 Before we go on, let me ask you a question.

    00:24 If it's digestion and you just had a lipid meal, what is the name of the hormone that’s being released from the duodenum? Good.

    00:33 From the Islet cells, you release CCK and that CCK will then contract the gallbladder, bringing in your bowel, but what kind of enzyme do you need to finish off the job in which the micelles get metabolized? Lipase.

    00:51 Next, pancreas, all this acid.

    00:55 Think about where you are right now.

    00:56 The pancreas, pancreatic duct, hooking up with the second part of the duodenum.

    01:01 All this acid, coming in with the chime from the stomach, don’t you need to neutralize that acid quickly? Sure, you do.

    01:09 And what's the of that substance that neutralizes it? Called bicarb.

    01:14 What’s the name of the hormone responsible for bicarb secretion? Secretin.

    01:18 Keep those in mind. Let’s take a look now.

    01:21 We have something called bentiromide test.

    01:23 Decreased urinary level suggests exocrine insufficiency.

    01:27 That, you’ll have to memorize, bentiromide.

    01:30 Then we have direct measurement of bicarb and enzyme concentration after CCK or secretin stimulation.

    01:39 CCK, normally responsible for stimulating or releasing what? Bicarb in the duodenum.

    01:45 But if you have chronic pancreatitis, that is not happening effectively or you have CCK.

    01:51 CCK normally responsible for releasing lipase into your duodenum and that is not occurring properly.

    01:58 Stool test. What are you looking for in there? If there is pancreatic damage, understand that there might be increased amount of fat in your stool, steatorrhea, or fecal chymotrypsin levels.

    02:11 Low levels suggest once again loss of function.

    02:15 Use your pathophysiology here to properly then diagnose or evaluate your patient with chronic pancreatitis.

    02:23 Radiologic investigation with chronic pancreatitis.

    02:27 Abdominal x-ray.

    02:28 You might find pancreatic calcifications. This will appear what color? White and opaque.

    02:35 The CT, evaluation of CT pseudocyst and maybe perhaps the pancreatic duct size.

    02:41 MRCP, we’ll be checking for the embryologic issue of pancreatic divisum.

    02:48 And if it’s endoscopic ultrasound, at the early diagnosis of pancreatic cancer, chronic pancreatitis and you might be looking for, well, pressures especially if you’re dealing with manometry.

    03:02 ERCP, usually reserved for therapeutic interventions.

    03:07 Important radiologic investigations that you’re keeping in mind when dealing with chronic pancreatitis.

    03:14 With chronic pancreatitis, we expected that abdominal pain, being part of your sequelae.

    03:20 Now with that abdominal pain in chronic pancreatitis, things that you want to keep in mind.

    03:25 If the pancreas isn’t working properly, you need to make sure that you replace the enzymes that are missing from the pancreas.

    03:34 Next, with all that pain, you’re worried about your patient addicted to pain relievers, narcotics.

    03:42 Next, with that type of pain, how do you control or manage it? Celiac nerve block ineffective or temporary. Keep that in mind, ineffective.

    03:50 And worse case scenario -- a surgery question that likes being asked -- it’s called Frye procedure, a surgery for refractory cases of abdominal pain.

    04:01 Chronic pancreatitis sequelae, abdominal pain, how to manage it and things that you’re looking for in your patient.

    04:09 Sequelae of pancreatic insufficiency or pancreatic enzyme replacements, low fat diet because now you know for a fact that the patient doesn’t have enough lipase to take care of the lipid.

    04:21 And you’re worried about infection as well, so treatment of bacterial overgrowth.

    04:27 Always have antibiotics in your arsenal to properly treat your patient with pancreatitis.

    04:35 Pseudocyst, a complication of chronic pancreatitis.

    04:40 And drainage, greater than 5 centimeters and drainage at least six weeks after an episode of pancreatitis.

    04:48 What you want to be careful of: With pseudocyst, technically speaking, just to make sure that we’re clear, you could find it in acute pancreatitis, but it will be absolutely pronounced in chronic pancreatitis.

    05:01 If you find all the symptoms that we talked about with chronic pancreatitis and on CT, you find a pseudocyst, without a doubt, it’s chronic pancreatitis.

    05:12 But if your patient has had their first bout of acute pancreatitis, epigastric pain radiates to the back and increase in lipase and such, then there’s every possibility that a pseudocyst might be thrown into the stem of a question.

    05:25 just to throw you off. Be careful. Stick to your basics.

    05:29 Know what as to what you can expect between acute and chronic pancreatitis.

    05:36 Management of your ascites.

    05:38 Well, here, there might be TPN.

    05:41 ERCP for stent placement and also surgical repair if necessary if ascites is a possible side effect or complication.

    05:51 And biliary obstruction is always a possibility.

    05:53 So therefore, you go in there and then you try to remove your particular stone or try to then place a stent.

    06:00 Surgical bypass, something that you also want to keep in mind.

    06:03 Remember, for chronic pancreatitis, there might be a stone that has moved from the gallstone through the cystic duct, has come down the common bile duct.

    06:12 And over a period of time, that stone might then be causing backup into the pancreas and causing damage.

    06:18 You need to open up that duct.


    About the Lecture

    The lecture Chronic Pancreatitis: Evaluation and Treatment by Carlo Raj, MD is from the course Pancreatic and Biliary Tract Diseases.


    Included Quiz Questions

    1. Serum amylase and lipase levels
    2. Bentiromide test
    3. Direct stimulation of bicarbonate after stimulation with cholecystokinin and secretin
    4. CT of abdomen
    5. Fecal chymotrypsin levels
    1. Serum amylase and lipase - increased Plasma cholecystokinin - increased Fecal fat after 72 hours - increased Fecal chymotrypsin - Decreased
    2. Serum amylase and lipase - increased Plasma cholecystokinin - increased Fecal fat after 72 hours - increased Fecal chymotrypsin - Increased
    3. Serum amylase and lipase - increased Plasma cholecystokinin - increased Fecal fat after 72 hours - decreased Fecal chymotrypsin - Increased
    4. Serum amylase and lipase - increased Plasma cholecystokinin - Decreased Fecal fat after 72 hours - increased Fecal chymotrypsin - Decreased
    5. Serum amylase and lipase - Decreased Plasma cholecystokinin - increased Fecal fat after 72 hours - increased Fecal chymotrypsin - Decreased
    1. 4 cm and asymptomatic
    2. 8cm and asymptomatic
    3. 3cm and symptomatic
    4. 5cm and symptomatic
    5. 1 cm and symptomatic

    Author of lecture Chronic Pancreatitis: Evaluation and Treatment

     Carlo Raj, MD

    Carlo Raj, MD


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