Chronic pancreatitis. Pseudocysts of the pancreas
CHRONIC PANCREATITIS: DEFINITION AND CAUSES
Chronic pancreatitis is a progressive fibro-inflammatory disease causing irreversible structural damage, ductal distortion and loss of exocrine and endocrine function. Alcohol and tobacco are major risk factors; others include genetic mutations (PRSS1, SPINK1, CFTR), recurrent acute pancreatitis, autoimmune pancreatitis, duct obstruction and metabolic causes. Some cases remain idiopathic.
PATHOPHYSIOLOGY AND CLINICAL FEATURES
Repeated injury activates pancreatic stellate cells and fibrosis, producing calcification, duct strictures and stones. Exocrine failure causes maldigestion, steatorrhoea, bloating and weight loss; endocrine failure causes diabetes (type 3c). Pain is classically recurrent or persistent epigastric pain radiating to the back, sometimes worsened by meals. Examination may be normal or reveal malnutrition, jaundice or a palpable inflammatory mass.
INVESTIGATIONS
CT may show pancreatic calcifications, atrophy, duct dilatation and pseudocysts. MRI/MRCP characterises ducts and parenchyma; EUS detects early disease and allows tissue assessment when needed. Secretin-enhanced MRCP may help in selected cases. Faecal elastase supports exocrine insufficiency; glucose/HbA1c assess endocrine function. Exclude pancreatic cancer when there is new-onset worsening pain, weight loss, jaundice or a new mass.
MANAGEMENT OF CHRONIC PANCREATITIS
Stop alcohol and smoking; provide nutritional support and fat-soluble vitamin replacement when deficient. Treat exocrine insufficiency with pancreatic enzyme replacement taken with meals and snacks; consider acid suppression if response is inadequate. Manage diabetes carefully, recognising hypoglycaemia risk. Analgesia should be stepwise and multidisciplinary; avoid prolonged opioid dependence where possible. Endoscopic therapy may remove duct stones, dilate strictures and place stents in selected patients. Surgery is considered for intractable pain, obstruction, complications or concern for malignancy. Options include drainage procedures (longitudinal pancreaticojejunostomy/Puestow for dilated duct), head-coring procedures (Frey/Beger) or resection in selected disease.
PANCREATIC PSEUDOCYST: DEFINITION AND BIOLOGY
A pseudocyst is an encapsulated collection of pancreatic fluid with a well-defined inflammatory wall and no epithelial lining, usually developing more than four weeks after interstitial pancreatitis or in chronic pancreatitis. It contains enzyme-rich fluid and may communicate with the pancreatic duct. Distinguish it from an acute fluid collection, necrotic collection and walled-off necrosis; these have different contents and treatment.