Chronic pancreatitis

The incidence of chronic pancreatitis is approximately 1 in 10,000 people. O The most common cause of chronic pancreatitis in adults in Western countries is ethanol abuse. The most common cause in children is cystic fibrosis, due to preexisting pancreatic insufficiency inherent in the disease. Gallstones can occur at the same time as chronic pancreatitis but are not often implicated as the cause. Unlike acute pancreatitis, chronic pancreatitis has an unknown etiology in a significant number of cases (30%).29,3°... 

The major exocrine pancreatic disorders presenting in adult life are acute pancreatitis, chronic pancreatitis, and carcinoma of the pancreas. The use of enzyme tests in the diagnosis of acute pancreatitis is discussed in Chapter 21. The etiologies of pancreatitis are given in Box 48-6. 

Chronic pancreatitis—Chronic inflammation of the pancreas caused by the many sequelae of long-standing pancreatic injury leading to irreversible pancreatic damage. 

Two-thirds of patients with recurrent alcoholic pancreatitis will develop chronic pancreatitis. Chronic pancreatitis is treated by replacing the endocrine and exocrine deficiencies that result... 

Chronic ethanol ingestion can increase serum concentrations of VLDL and triglyceride. This is one of the factors that puts patients with alcoholism at risk of pancreatitis. Chronic ethanol ingestion also has the possibly beneficial effect of raising, not decreasing, serum HDL concentrations. The answer is (E). 

This drug is used cautiously in patients with peripheral vascular disease, neuropathy, chronic pancreatitis, or impaired liver function. Didanosine is a Pregnancy Category B drug and is used cautiously during pregnancy and lactation. There may be a decrease in the effectiveness of dapsone in preventing Pneumocystis carinii pneumonia when didanosine is administered with dapsone Use of didanosine with zalcitabine may cause additive neuropathy. Absorption of didanosine is decreased when it is administered with food. 

These drug are prescribed as replacement therapy for those with pancreatic enzyme insufficiency. Conditions or diseases that may cause a decrease in or absence of pancreatic digestive enzymes include cystic fibrosis, chronic pancreatitis, cancer of the pancreas,... 

Sparmann G, Behrend S, Merkord J, Kieine HD, Grasser E, Ritter T, Liebe S, Emmrich J (2001) Cytokine mRNA ieveis and iymphocyte infiitration in pancreatic tissue during experimentai chronic pancreatitis induced by dibutyitin dichioride. Digestive Diseases and Sciences, 46 1647-1656. 

Cystic fibrosis (CF) is a recessive genetic disorder prevalent among whites in North America and certain parts of northern Europe. It is characterized by chronic bacterial infections of the airways and sinuses, fat maldigestion due to pancreatic exocrine insufficiency, infertility in males due to abnormal development of the vas deferens, and elevated levels of chloride in sweat (> 60 mmol/L). 

KATAOKA K, DiMAGNO E p (1998) Effect of chronic amylase inhibition on pancreatic growth and acinar cell secretory function in rats. Pancreas. 17 50-56. 

Guyan et al. 1990) have used several markers of lipid peroxidation (9-cis-, 11-tmns-isomer of linoleic acid, conjugated dienes and ultraviolet fluorescent products) to demonstrate significant increases in the duodenal aspirate after secretin stimulation in patients with acute and clinic pancreatitis. They interpreted this as indicating induction of hepatic and pancreatic drug-metabolizing enzymes in the face of a shortfidl of antioxidant defences, more marked in chronic pancreatitis. Subsequent studies in patients with chronic pancreatitis have confirmed decreased serum concentrations of selenium, -carotene and vitamin E compared with healthy controls (Uden et al., 1992). Basso aol. (1990) have measured increases in lipid peroxides in the sera of patients with chronic... 

Only one study to date has been conducted on the treatment of acute pancreatitis with antioxidants. Clemens et al. (1991) were unable to show any difference in the incidence or severity of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in a prospective, randomized, double-blind, placebo-controlled trial of allopurinol. However, Salim (1991) performed a similar trial of the effect of allopurinol and DMSO in patients with pain from recurrent pancreatitis, and found significant benefit. On the basis that depletion of antioxidants is important in the pathogenesis of chronic pancreatitis, the administration of a cocktail of antioxidants was assessed for its effect on pain in this disease. Treatment with a combination of organic selenium, d-carotene, vitamins C and E, and methionine was of benefit in the initial pilot study, and in a placebo-controlled trial (San-dilands etal., 1990 Uden et al., 1990). 

Studies of both acute and chronic pancreatitis in humans and in animals support the hypothesis that free radicals are involved in the pathogenesis of pancreatitis. There is some conflicting data from the animal work, which may in part be due to differences in the models used. It does also indicate that free radicals are not the only factors involved and su ests that activation of pancreatic enzymes are also imprortant, particularly in the development of haemorrhagic pancreatitis (Sanfey, 1991). The findings of decreased antioxidant defences and the success of treatment reported in chronic pancreatitis with a cocktail of antioxidants and with allopurinol surest further studies are required to establish the role of antioxidants in pancreatic disease and its prevention. 

Basso, D., Panozzo, M.P., Fabris, C., Del Favero, G., Meggiato, T., Fogar, P., Meani, A., Faggian, D., Plebani, M., Burlina, A. and Naccarato, R. (1990). Oxygen derived free radicals in patients with chronic pancreatic and other digestive diseases. J. Clin. Pathol. 43, 403-405. 

Salim, A.S. (1991). Role of oxygen-derived free radical scavengers in the treatment of recurrent pain produced by chronic pancreatitis. A new approach. Arch. Surg. 126, 1109-1114. 

Sandilands, D., Jeffrey, I.J.M., Haboubi, N.Y., MacLennan, I.A.M. and Braganza, J.M. (1990). Abnormal drug metabolism in chronic pancreatitis. Treatment with antioxidants. Gastroenterology 98, 766-772. 

Differentiate the signs and symptoms of acute from chronic pancreatitis. 

Identify pharmacologic and nonpharmacologic means of preventing repeat episodes of chronic pancreatitis. 

Choose appropriate pancreatic enzyme supplementation for patients with chronic pancreatitis. 

O The most common causes of acute and chronic pancreatitis in adults are ethanol abuse and biliary stones. 

Treatment of chronic pancreatitis is aimed at removing the cause (ethanol abuse or biliary stones), providing analgesia, supplementing with pancreatic enzyme preparations, and implementing dietary restrictions. 

Long -term sequelae of chronic pancreatitis include dietary malabsorption, impaired glucose tolerance, cholangitis, and potential addiction to opioid analgesics. 

Ethanol abuse may cause precipitation of pancreatic enzymes in the ducts of the pancreas leading to chronic inflammation and damage. Ethanol itself may be directly toxic to the pancreatic cells. Gallstones may obstruct the ampulla of Vater causing pancreatic enzymes or bile to move in a retrograde fashion into the pancreas.1... 

Patients at greatest risk for mortality from acute pancreatitis are those who have multi-organ failure (e.g., hypotension, respiratory failure, or renal failure), pancreatic necrosis, obesity, volume depletion, greater than 70 years of age, and an elevated APACHE II score.3,4 The Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II score is a rating scale of disease severity in critically ill patients. 

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