Incidence
Age	- depends on aetiology
Sex
Geography	- chronic calcifying pancreatitis is most common cause in developed countries
Aetiology	- continuing inflammatory disease of the pancreas characterized by irreversible morphological change and typically causing pain and/or permanent impairment of function - acute pancreatitis does not normally lead to chronic pancreatitis - deposition of protein plugs within pancreatic ducts -> ductular dilatation -> acinar atrophy - varying amount of cellular infiltration - fibrous tissue formed around pancreatic ducts - intraluminal calcification of protein plugs -> stone formation Chronic calcifying pancreatitis - usually due to alcohol - > 150 g per day for 10 years is required - a high protein diet my potentiate the effects of alcohol Tropical pancreatitis - usually occurs in young patients from regions in which there is proteina dn fat malnutrition - pancreatic insufficiency, diabetes mellitus and recurrent attacks of pain occur Hereditary pancreatitis - rare; lack of a protein stabilizer allows formation of protein plugs - mutation in cationic trypsinogen gene Obstructive pancreatitis - obstruction of main pancreatic duct due to e.g. a scar, stricture or tumour - calculi are unusual - may regress if obstructions are removed
Presentation	History - abdominal pain in epigastrium and upper abdomen, radiating to back; may be severe - continuing episodes of pain may occur; these can be mild and of short duration - some acute episodes may be precipitated by heavy alcohol consumption - anorexia and weight loss may accompany pain - steatorrhoea occurs when secretion of pancreatic lipase has been reduced by 90% - development of diabetes - may present with biliary obstruction with jaundice and occasionally cholangitis Differential diagnosis - carcinoma of the pancreas, especially if history is short
Investigations	Exocrine and endocrine function Serum amylase is of no value in chronic pancreatitis Lundh test - useful in investigation of steatorrhoea - duodenal intraluminal trypsin and lipase low Faecal fat estimation - demonstrates steatorrhoea Breath test for fat malabsorption - oral ingestion of labelled fatty acid or labelled triglyceride - amount of 14CO2 in expired air measured for both - impaired triglyceride absorption with normal fatty acid absorption suggests pancreatic cause Endocrine function only useful if hormone-secreting tumour is suspected Endoscopic USS - early changes in ducts and parenchyma - cysts and calcifications - very specific for diagnosis USS abdomen - not very specific in early stages CT abdomen - focal enlargement or atrophy - abnormalities in duct site - calcification ERCP/MRCP
Macro
Micro	- a few acinar and islet cells remain, with widely dilated pancreatic ducts
Staging
Serum markers
Management	Lifestyle - if alcoholic pancreatitis, patient should stop drinking - steatorrhoea can be treated with low-fat diet, pancreatic supplements (e.g. pancreatin 2-4g with each meal) Medical - pain releif - treat diabetes mellitus as appropriate Surgical - intractible pain can be treated by pancreatic resection with drainage of obstructed pancreatic duct into small bowel - good results are only acheived in a few cases
Prognosis	- a good prognosis depends on total abstention from alcohol
Complications	- pancreatic pseudocyst - pancreatic ascites

Hepatobiliary medicine

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