Diagnosis of Chronic Pancreatitis - Essay Example

Chronic Pancreatitis Introduction Pancreas is a complex gland having both exocrine and endocrine functions. The organ has a very important role to play in the digestion of substances in the body but as the pancreas has a retroperitoneal location it does not show the progression of diseases in the initial stages. Thus it is very hard to detect diseases of pancreas in the initial stages. The exocrine part of the gland secretes digestive enzymes which help in digesting food particles whereas the endocrine portion secretes only a limited number of enzymes such as insulin and glucagon. The major abnormalities caused by the non-functioning of the endocrine portion of the pancreas are diabetes mellitus and neoplasms. And the major diseases caused by the exocrine portion are related to the inflammation of the pancreas itself. Acute Pancreatitis is a situation in which the pancreas is inflamed to a certain extent but in such a situation the problem can be reversed i.e. pancreas may be able to revive its normal functions if proper therapy is provided. Chronic Pancreatitis on the other hand is the situation in which pancreas is inflamed to such an extent that the normal functions of pancreas cannot be revived back. This brief would further describe chronic pancreatitis with regard to its clinical diagnosis and all the relevant issues which come with it. Epidemiology The incidence of chronic pancreatitis all over the world is quite less as compared to the acute pancreatitis. In Czech Republic it was found that the incident rate of chronic pancreatitis was 7.9 per 100,000 inhabitants per year. Almost same incident results have been noticed all over the world with European and Western countries having 6.0 incident rates per 100,000 inhabitants. Similarly the rate of hospital admissions for chronic pancreatitis has increased over the time in England and Netherlands as shown by a study. The cause of this increase in is directly linked to the high consumption of alcohol and the newly introduced imaging modalities to detect the presence of chronic pancreatitis in individuals. According to the age and sex the incident rate of chronic pancreatitis was found to be more in men all over the world. And people who used to get this disease were middle aged people around the age group of 35-55. And according to the race factor the incident rate for chronic pancreatitis for blacks was higher than the whites for reasons which can be related to alcohol consumption, congenital disorders, or the differences in diet. Aetiology The aetiology of chronic pancreatitis has been done thrice to finally form the M-ANNHEIM classification. This is based on the risk factors which cause chronic pancreatitis. These risk factors include alcohol consumption, nicotine consumption, nutritional factors, hereditary factors, efferent pancreatic duct factors, immunological factors, and miscellaneous and metabolic factors (Spanier et al, 2008). Case history A 30 year old patient was found to be having a yellowish discoloration in the iris of her eyes. The patient had a history of jaundice about four months back with symptoms of dark yellow urine and pale stools. The patient was recommended Endoscopic Retrograde Cholangiopancreatography and the condition improved but only for a limited number of days. After ten days the patient again started showing signs of jaundice after which a series of tests were run. The patient was suffering from diabetes. The series of test run showed a negative result whereas in the abdominal ultrasound it was found that the patient had developed a pancreatic edema. A CT scan was then done to confirm the bulkiness of pancreas. Several other tests were done to find out that the pancreatic ducts were irregular. And finally pancreaticogram showed that the region of the head was mostly affected and it narrowed down. And further cholangiography showed a hard structure at the distal CBD to suggest that the patient was suffering from chronic pancreatitis (Lodenyo & Gitau 2004). Clinical diagnosis Chronic Pancreatitis can be found in many different forms in the human body. Chronic Pancreatitis destroys or inhibits the action of the exocrine glands of the pancreas. The signs and symptoms of chronic pancreatitis are not seen until its late stages where it is irreversible. Abdominal pain and back pain are the important signs which depict the existence of chronic pancreatitis. As mentioned above, the signs of chronic pancreatitis will only be seen once pancreatic indeficiency occurs or once the Islet of Langerhans are destroyed to cause diabetes mellitus. Moreover, severe jaundice is also one of the signs which show the existence of chronic pancreatitis. Indigestion or overload on the pancreas may also show the signs of chronic pancreatitis. The abdominal pain or all the signs discussed above may become more saturated if the load on the pancreas is increased either by excessive alcohol consumption or by overeating. Similarly some drugs also influence load over the pancreas and they may also cause more of the signs to develop. Weight loss is also a sign of chronic pancreatitis (Catalano et al 2009). When abdominal pain is felt a type of fever may also be present to show that pancreatitis is present. The levels of serum trypsinogen and faecal elastase levels would be noticed in chronic pancreatitis. Gallstone induced obstruction would provide a way for jaundice to happen or it may also increase the serum level of alkaline phosphatase. The tests done with regard to the presence of chronic pancreatitis are Computed tomography, UltraSonography, Endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP). These tests would help to detect any calcification which maybe present in the pancreas or any dilatation within the pancreatic ducts. Moreover at times structural complications are seen with the pancreatitis which includes the stenosis of the pancreatic head or pseudocysts to develop. The less visible signs of chronic pancreatitis include the obstruction of duodenal ducts, thrombosis in the portal or splenic vein, arterial pseudoaneurysm formation and pancreatic ascites (Pancreatitis, 2008) Anatomy of the Pancreas The word pancreas is derived from a Greek word ‘pankreas’ which literally means all flesh. Pancreas is a complex lobulated organ which has both exocrine and endocrine components. In other words it has both endocrine and exocrine glands. The endocrine component is made up of a huge number of clustered cells known as the islet of Langerhans. These cells can secrete insulin, glucagon and somatostatin. While on the other hand the exocrine component of the pancreas which is made of the acinar cells and zymogen granules which secretes digestive enzymes. Pancreas can be said to be an elongated structure which has lobules and is soft in nature. It is located at the level of the first and second lumber vertebrae and is transversely located across the posterior abdominal wall. It is a J shaped structure which is set obliquely in the body. It is divided into four parts i.e. the head, neck, body and the tail of pancreas. From the right side the head is placed which is surrounded by the concave structure of duodenum. And the tail of the pancreas is attached to the hilum of the spleen. The pancreas is 20 cm in length and weighs about 90 grams in men and 85 in women. Two long ducts which can be found in the pancreas are the duct of Wirsung and the accessory duct or the Santorini duct. In embryological terms the pancreas is formed when the ventral and the dorsal pouching of the foregut unite. Human pancreas showing the head body and the tail region. Also the histological sites of pancreas (Netter 2007). Pathology Chronic pancreatitis is a disease of the pancreas in which it is inflamed to mainly destruct or inhibit the functions of the exocrine glands. It is characterized by the destruction of exocrine parenchyma, fibrosis and may also lead to the destruction of the endocrine glands if it continues for a long time. Chronic pancreatitis is an irreversible injury to the exocrine functions of the pancreas while on the other hand acute pancreatitis can be treated and is thus reversible. The most common and foremost cause of chronic pancreatitis is the long term usage of alcohol in adults. Chronic Pancreatitis can be caused by a number of problems. Firstly the obstruction of the ducts by strong structures can cause chronic pancreatitis. Alcohol can be considered the main cause here as it is one of the agents which increases the protein concentrations in the pancreatic juice and thus these proteins are one way through which ductal plugs are formed. These ductal plugs then calcify to become hard ducts which can provide an obstruction for the juices to pass into the duodenum. These duct systems at times calcify to form calculi i.e. calcium carbonate precipitates and finally lead to chronic pancreatitis (Adler, Lichtenstein, Baron, Davila, Egan, Gan, Qureshi 2006). Secondly toxic substances can also cause chronic pancreatitis to occur. Toxic substances such as alcohol can exert a toxic effect on the acinar cells of the pancreas to cause them to puncture. This happens when the toxic cells exert their effect on the acinar cells and lipids are accumulated in these acinar cells which leads to their destruction and hence causes parenchymal fibrosis. Thirdly oxidation effects of alcohol can also be a strong cause of chronic pancreatitis. These oxidative effects can cause free radicals to form in the acinar cells of the pancreas which would further lead to the lipid oxidation in membranes. It would also lead to the activation of various transcription factors such as AP1 and NFKB and this in turn forms chemokines which attract mononuclear cells. Therefore this leads to the destruction of zymogen granules in the exocrine component of the pancreas and also the death of acinar cells and hence inflammation of the pancreas. And fourthly acute pancreatitis can also lead to chronic pancreatitis in the latter stages. Acute pancreatitis in its initial stages distorts the duct system of pancreas and also disrupts the secretion of pancreas (Kwak et al, 2009). If this proceeds for a long time it may lead to the destruction of pancreatic parenchyma and fibrosis. Chronic pancreatitis is characterized by parenchymal fibrosis and the size of acini also tends to get reduced. The pancreatic ducts are also reduced during this disease to cause obstruction. All these changes lead to inflammation around the lobules and the ducts of the pancreas. The protein plugs are formed which in turn dilate the intra and inter lobular plugs of the pancreas. Concretions are found in the ducts and the islet of Langerhans become enlarged as they fuse with the sclerotic tissue. And if the latter stages of the chronic pancreatitis are in phase then these cells may even disappear. And finally the organ becomes hardened with clear concretions found within the organ (Ashizawan 1999, Stringer 2005, Witt et al 2007) Chronic pancreatitis. Contrast enhanced CT. Pancreatic duct calculus and dilatation of the duct proximal to the calculus can be seen. Role of Imaging Modalities in the diagnosis Chronic pancreatitis is a disease which needs to be closely monitored in order to find its development in the body. For this purpose several tests have been derived which help in detecting the disease. Imaging modalities are currently the most important in detecting the presence of chronic pancreatitis. The tests done to detect its presence are done in a series so that the condition can be closely analyzed. Till date the Endoscopic retrograde cholangiopancreatography (ERCP) is used as the most common method to detect its presence in the later stages. Plain abdominal radiograph is the initial step in detecting its presence which helps in detecting calcifications. This test is inexpensive as compared to others but it is not hundred percent effective in detecting the presence of the disease. Computed topography is an important form of the imaging modalities which helps in evaluating the pancreas and its ducts. It also helps to detect the calcifications and lesions formed within the pancreas. It is regarded to be more effective when detecting the presence of chronic pancreatitis. ERCP is regarded as the most effective in all the imaging modalities these days. It helps in finding the ductular changes that occur in chronic pancreatitis. It can help finding stenosis and fibrosis in the pancreas and can thus help in differentiating between the cancer of pancreas and chronic pancreatitis. It can also help in finding pseudocysts and pancreatic divisum. MRCP is another important form of the imaging modalities which helps in analyzing also the parenchymal changes of the pancreas. However this form of imaging modality is limited to only a few people as some of the patients are against the use of magnetic force on their body and people who are severely ill. Moreover, MRCP cannot show the calcifications in the pancreas and also cannot determine the cause of the filling in the pancreas (Fry et al, 2007). ERCP performed in a 55-year-old patient with chronic abdominal pain and alcohol abuse. Note the dilation, irregularity, and tortuosity of the main pancreatic duct and the smooth stricture of the common bile duct due to inflammatory changes in the pancreatic head. MRCP showing the lobulated appearance of the main pancreatic duct. Treatment and Prognosis Chronic pancreatitis is a disease which is irreversible and thus it cannot be fully treated in any patient. However the situation can be handled in such a way as to decrease the effect of pancreatitis. Alcohol is the most important cause of chronic pancreatitis and thus decreasing its consumption may relieve the patient of the pain he is suffering. Non enteric coated pancreatic enzyme supplements can provide a relief of pain to the patient. Surgery and interventional radiology is also a type of treatment which can help to decompress the ducts and decrease the pain of the patient (Mihaljevic, Kleff, Friess, Buchler, Beger, 2008). If analgesics are taken into consideration with proper WHO directives, they can also provide relief to the patient (Baillie 2005, Elmas 2001, Hirschfield & Gimson 2007) Summary and Conclusion Chronic Pancreatitis is a condition which is lethal in its latter stages and quite problematic in its initial stages. It initiates several problems in the human body which can lead to the death of the individual. However with the new imaging modalities this disease can be counteracted but not treated. It can be decreased to a limit where the patient can survive with the new techniques. Exocrine and Endocrine failure are the predominant features of this disease which need to be looked after when the disease is found in some patient. Bibliography Adler DG, D Lichtenstein, TH Baron, R Davila, JV Egan, SL Gan, WA Qureshi, et al. 2006. "The role of endoscopy in patients with chronic pancreatitis". Gastrointestinal Endoscopy. 63 (7): 933-7. ASHIZAWA N, et al. (1999). The morphological changes of exocrine pancreas in chronic pancreatitis. Histology and Histopathology. 14, 539-52. Baillie, J. 2005. "Endoscopy in the management of chronic pancreatitis". CLINICAL UPDATE -AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY-. 13 (1): 1-4. Catalano MF, A Sahai, M Levy, J Romagnuolo, M Wiersema, W Brugge, M Freeman, K Yamao, M Canto, and LV Hernandez. 2009. "EUS-based criteria for the diagnosis of chronic pancreatitis: the Rosemont classification". Gastrointestinal Endoscopy. 69 (7): 1251-61. 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