Chronic pancreatitis:

Etiology: most of
the cause of acute pancreatitis in the Us also can
result in chronic pancreatitis. A notable exception
is gallstones, which cause only recurrent acute
attacks of pancreatitis. A- alcohol abuse accounts
for 90 % of cases of chronic pancreatitis in
adults. B- cystuc fibrosis is the most common
cause of chronic disease in children. C- in
pancreas divisum, which results from a
congenital failure of the dorsal & ventral
pancreas to fuse, the main portion of the pancreas
may drain through the small accessory duct of
santorini, not the large duct of wirsung. Chronic
obstruction to drainage & pancreatitis may occur
in approx one third of patients with this drainage.
Pancreas divisum remains controversial as a
cause of chronic pancreatitis. Pathogene: alkaline
ph, defense factors: normal mnet-> normal
circulationnormal drainage. Classification: Ietiological: alcoholic, idiopathic, tropic variant,
congenital, chronic obstructive. II- based on
pathogenesis: chronic calcifine pancreatitis,
chronic obstructive disease, infiltrative fibrotic,
primary fibrotic, cyst variant.Clinical features: aPain, the usual presenting symptoms typically
occurs in the epigastrium after eating & radiates
to the back. B- malabsorption occurs in
association with steatorrhea & weight loss. Cjaundice occurs due to edema & fibrosis in the
pancreatic head & causes obstruction of the
pancreatic portion of the common bile duct. Ddiabetes is common, however ketoacidosis,
nephropathy, & diabetic vascular disease rarely
occur. 3- Diagnosis: The development of
continuous pain & signs of pancreatic
insufficiency in a patient with known recurrent
pancreatitis, especially when due to alcohol
ingestion, is suggestive. Specific test include: aabdominal radiographs, which reveal pancreatic
calcification in 30-40% of cases. B- secretin
stimulation testing with duodenal intubation &
aspiration, which reveals a low bicarbonate
concentration in the pancreatic secretion & low
enzyme output. C- ERCP, which shows diffuse
ductal dilatation with an irregular, beaded
appearance. 4- Therapy: treat at controlling the
manifestation of the disease because the
underlying damage should be withdrawn: Acontrol of pain may require narcotic analgesics,
but care must be taken to avoid addiction. With
abstinence from alcohol over a period of time,
some patientsexperience a lessening of pain. Breplacement of pancreatic enzymes may be
indicated for the treat of steatorrhea or for the
relief of pain. C- insulin may be needed in
advanced cases. D- MCTs which are more easily
absorbed than longer chain fatty-acid, are often
given. E- treatment of pancreas divisum may
involve enlargement of the accessory duct
surgically
or
endoscopically
with
a
sphincterotomy or pancreatic scent. F- surgery is

a last resort & generally is used for severe pain or

recurrent, severe attacks.