Postgrad Med J 1996; 72: 327 - 333 (© The Fellowship of Postgraduate Medicine, 1996 Classic diseases revisited Postgrad Med J: first published as 10.1136/pgmj.72.848.327 on 1 June 1996. Downloaded from Chronic pancreatitis: diagnosis and treatment Summary Three-dimensional magnetic reson- ance cholangiopancreatography is Sandeep Sidhu, Rakesh K Tandon currently the most exciting new ima- ging technique for chronic pancrea- titis. Endoscopy-assisted duodenal intubation during the secretin-cho- Chronic pancreatitis is prevalent in most parts of the world although its lecystokinin test reduces intubation aetiology and clinical course may vary in different regions. Community-based time in difficult cases. The NBT- field studies from our centre have revealed that tropical chronic pancreatitis in para-amino benzoic acid test has Southern India is a mild disease with onset of symptoms in early adulthood,' been refined to enhance its discri- and a prevalence of 1:793 in endemic areas. The predominant symptoms are minant power. The cholesteryl- abdominal pain (30.6%), diabetes mellitus (52.8%) and malabsorption [C13]octanoate breath test and the (16.7%).' On the other hand, patients presenting to office practice,2 or to local faecal elastase test are newer highly or tertiary care hospitals3 have severe chronic pancreatitis, with abdominal pain sensitive and specific tubeless tests. as the predominant symptom (approximately 80%); exocrine pancreatic Pain in chronic pancreatitis con- insufficiency and calcification are seen in 80 - 90% patients.2 In a recent tinues to be a vexing therapeutic study,3 surgical treatment for pain was required in 53.9% of chronic pancreatitis issue. Enzyme treatment continues patients referred to the All India Institute ofMedical Sciences, a leading tertiary despite criticism. Neurotensin is the care centre in Northern India. new suspected mediator ofthe feed- Chronic pancreatitis is incurable except in some specific situations such as back mechanism, which is down- hyperparathyroidism where cure can be expected with surgical removal of the regulated by enzyme therapy. Ster- parathyroid glands. Alcohol withdrawal may slow down, but not reverse the oid ganglion block is an exciting progressive damage to the pancreas. Nevertheless, rapidly advancing knowledge therapeutic tool for pain relief. of the pathogenesis of chronic pancreatitis now allows us to adopt a Endoscopic pancreatic sphinctero- multidimensional strategy for its management. Therepeutic strategies in tomy, Dormia basketing and pan- chronic are discussed below with on recent creatic stenting in conjunction with pancreatitis (box 1) emphasis extracorporeal shock wave litho- developments in diagnosis and treatment. tripsy should be performed early in chronic pancreatitis to prevent par- Diagnosis enchymal atrophy with ensuing exo- crine and endocrine pancreatic CONVENTIONAL PANCREATIC IMAGING dysfunction. The modified Pues- Plain film of the abdomen for pancreatic calcification, sonography, tow's procedure preserves endo- computed tomography (CT) and endoscopic retrograde cholangiopancreato- http://pmj.bmj.com/ crine and exocrine pancreatic graphy (ERCP) remain the mainstay of diagnosis of chronic pancreatitis. functions besides relieving pain. Recently, on comparing 1.5-T magnetic resonance imaging (MRI) with Closed loop insulin infusion allows dynamic gadolinium enhancement, with CT and ERCP, Semelka et al4 superior management of pancreatic found MRI scanning to be most sensitive and specific in detecting diabetes following near total pancreatic diseases. pancreatectomy. The standardised incidence rate of pancreatic cancer MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP) is 16.5 in patients with alcoholic MRI is utilised in this latest and most exciting technique to visualise the on September 27, 2021 by guest. Protected copyright. chronic pancreatitis and 100 pancreatic and biliary ductal systems. It is bound to have a significant impact on for tropical chronic pancreatitis. the diagnosis and management of biliary and pancreatic diseases.5 Important Aggressive treatment protocols features of the technique are summarised in box 2. combining neo-adjuvant chemora- MRCP offers a precise, diation and intra-operative radia- noninvasive, three-dimensional coronal and frontal tion with surgery are being used to display of pancreatic and biliary ductal systems. improve the prognosis in this dismal complication of chronic pancreati- SERUM LEVELS OF PANCREATIC ENZYMES tis. Depressed serum levels of pancreatic isoamylase, lipase, and pancreatic polypeptide aid in the diagnosis of chronic pancreatitis. Elastase, deoxyribo- Keywords: pancreatitis, pancreatic cancer, nuclease and ribonuclease are elevated, along with an increased trypsin/ pancreatic function, pain creatinine clearance ratio.6 LACTOFERRIN ASSAY Elevated levels of lactoferrin in the pure pancreatic juice and an increased lactoferrin to lipase ratio in duodenal juice following secretin - Department of Gastroenterology, All cerulein India Institute of Medical Sciences, stimulation7 have been claimed to be very sensitive and specific for detecting New Delhi 110029, India early chronic pancreatitis. S Sidhu RK Tandon PANCREATIC ENZYME SYNTHESIS Demonstration of an increased rate of pancreatic enzyme synthesis using Correspondence to Professor RK Tandon radiolabelled amino acids is another highly sensitive index of early chronic Accepted 16 October 1995 pancreatitis.8 328 Sidhu, Tandon PANCREATIC FUNCTION TESTS (BOX 3) Chronic pancreatitis: The secretin- cholecystokinin stimulation test with duodenal intubation therapeutic strategies standard for diagnosing chronic pancreatitis. Recently, remains the gold Postgrad Med J: first published as 10.1136/pgmj.72.848.327 on 1 June 1996. Downloaded from * symptomatic relief of pain Madrazo-de la Garza et al' reduced the length of the study from 150 to 45 * management of exocrine and minutes by aspirating duodenal fluid through a fibre-optic endoscope. Since endocrine insufficiency endoscopy is costly and adds to the discomfort, Dimagno et al' have suggested * therapeutic interception of the use of endoscopy only during intubation difficulties. In the latter situation pathophysiology they would endoscope patients, place a guidewire in the duodenum, withdraw * management of complications the endoscope, slide the aspiration tube over the wire and then perform the test as usual. This reduces the intubation time and also the frequency ofperforming Box 1 endoscopy to test the pancreatic functions. The Lundh test meal continues to be performed in several centres as a cheap and effective alternative to the secretin test while recognising its relative insensitivity in early chronic pancreatitis."1 Tubeless tests such as the NBT- para-aminobenzoic acid (PABA) test and pancreolauryl test'2-'4 are easy to perform and convenient to the patients, although the kits are not easily available and are expensive. Moreover the NBT-PABA test remains a test of protein malabsorption of end-stage chronic pancreatitis. Fast MRCP Faecal chymotrypsin assay is a cheap test of pancreatic exocrine dysfunction with a sensitivity of49% in early and 80 - 90% in advanced chronic pancreatitis. * individual image pixels assigned a The cholesteryl-CG"-octanoate breath test is a recent innovative addition to high signal to represent ducts the category of highly sensitive and specific noninvasive tests of pancreatic * signal intensities adjusted to give a exocrine function.'5"16 volumetric appearance Most recently, the potential and precision of faecal elastase test in * post acquisition data processing using a maximum intensity comparison with the secretin-pancreozymin test in the diagnosis of chronic projection algorithm pancreatitis was evaluated.'7 There was good correlation between the output of * a three-dimensional work station faecal elastase and that of amylase, lipase and trypsin. Patients with chronic allows the image to be rotated and pancreatitis had significantly lower concentrations of enzyme than normal pruned of peripheral branches so controls. No significant decrease of immunoreactivity was found when stool that strictures and stones can be samples were stored at room temperature for over a week. In contrast to faecal clearly delineated in both common bile duct and main pancreatic duct chymotrypsin, the test results are unaffected by pancreatic enzyme replacement therapy. Box 2 Palliation of pain in chronic pancreatitis A better understanding of the pathophysiology and pathogenesis of chronic pancreatitis has revitalised therapeutic plans to palliate pain. Hence it is necessary to recapitulate the currently understood pathogenic mechanisms of pain before discussing its management. http://pmj.bmj.com/ MECHANISMS OF PAIN (BOX 4) Pancreatic tubeless tests: refinements & innovations Ductal hypertension NBT-PABA test In the normal human pancreas, unstimulated main duct pressure is about * administration of 30 mg/kg rather 7 mmHg. Bradley found that the mean ductal pressure was 25 mmHg in 19 than 15 mg/kg improves its patients with painful chronic pancreatitis and a dilated pancreatic duct.'8 Ductal discriminant power strictures and/or calculi cause obstruction and ductal hypertension. However, on September 27, 2021 by guest. Protected copyright. * spectrofluorometric estimation of ductal hypertension can occur in structurally normal pancreatic ducts and para-aminosalycilic acid & PABA in painful chronic pancreatitis. The restrictive effect of the parenchymal fibrosis in plasma