Evaluation of chronic pancreatitis.
You’ll find this to be interesting.
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.
So now what are you looking for?
Pancreatic function test.
Before we go on, let
me ask you a question.
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?
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?
Next, pancreas, all this acid.
Think about where you are right now.
The pancreas, pancreatic duct, hooking
up with the second part of the duodenum.
All this acid, coming in
with the chime from the stomach,
don’t you need to
neutralize that acid quickly?
Sure, you do.
And what's the of that
substance that neutralizes it?
What’s the name of the hormone
responsible for bicarb secretion?
Keep those in mind. Let’s take a look now.
We have something called bentiromide test.
Decreased urinary level suggests
That, you’ll have to memorize,
Then we have direct measurement of
bicarb and enzyme concentration
after CCK or secretin
CCK, normally responsible for
stimulating or releasing what?
Bicarb in the duodenum.
But if you have chronic
pancreatitis, that is
not happening effectively
or you have CCK.
CCK normally responsible
for releasing lipase into
your duodenum and that is
not occurring properly.
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.
Low levels suggest once
again loss of function.
Use your pathophysiology here
to properly then diagnose
or evaluate your patient
with chronic pancreatitis.
with chronic pancreatitis.
You might find pancreatic calcifications.
This will appear what color?
White and opaque.
The CT, evaluation of CT pseudocyst and
maybe perhaps the pancreatic duct size.
MRCP, we’ll be checking for the
embryologic issue of pancreatic divisum.
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.
ERCP, usually reserved for
investigations that you’re keeping
in mind when dealing with
With chronic pancreatitis,
we expected that
abdominal pain, being
part of your sequelae.
Now with that abdominal
pain in chronic
pancreatitis, things that
you want to keep in mind.
If the pancreas isn’t working
properly, you need to make sure
that you replace the enzymes that
are missing from the pancreas.
Next, with all that pain,
you’re worried about your
patient addicted to pain
Next, with that type of pain, how
do you control or manage it?
Celiac nerve block ineffective or
temporary. Keep that in mind, ineffective.
And worse case scenario -- a surgery
question that likes being asked -- it’s
called Frye procedure, a surgery for
refractory cases of abdominal pain.
Chronic pancreatitis sequelae,
abdominal pain, how to manage
it and things that you’re
looking for in your patient.
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.
And you’re worried about infection as well,
so treatment of bacterial overgrowth.
Always have antibiotics
in your arsenal to
properly treat your patient
Pseudocyst, a complication
of chronic pancreatitis.
And drainage, greater than 5 centimeters
and drainage at least six weeks
after an episode of pancreatitis.
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.
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
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.
just to throw you off. Be careful.
Stick to your basics.
Know what as to what you can expect
between acute and chronic pancreatitis.
Management of your ascites.
Well, here, there might be TPN.
ERCP for stent placement and also
surgical repair if necessary
if ascites is a possible
side effect or complication.
And biliary obstruction
is always a possibility.
So therefore, you go in there
and then you try to remove
your particular stone or
try to then place a stent.
Surgical bypass, something that
you also want to keep in mind.
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.
And over a period of time,
that stone might then be
causing backup into the
pancreas and causing damage.
You need to open up that duct.