Chronic Pancreatitis, Pancreatic Insufficiency

Clinical manifestations: recurrent upper abdominal pain (pain ceases with
burned-out pancreatitis); pasty, fatty stools; weight loss, diabetes

DiagnosisOpen-mouthed smile:
>History: With a history of recurrent bouts of pancreatitis, try to elicit the precipitating cause. Many patients have a history of alcoholism, gallstones, drugs,
cystic fibrosis, malnutrition, or enzyme deficiency.
> Stool examination: collect stool for 3 days, weigh the samples. An average daily
weight i150g suggests pancreatic insufficiency

> Laboratory findings: glucose intolerance ranging to frank diabetes mellitus. Elevated cholesterol levels are common. Tests may include stool fat determination
(more than 7g of fat/day is abnormal).

Less common tests are chymotrypsin determination and/or pancreatic lactase in the stool. Vitamin deficiencies are common.
> Secretin-pancreozymin test is rarely necessary.
> Sonography
> Spot radiographs to check the pancreas for coarse calcifications
> ERCP

Sonographic findingsOpen-mouthed smile 

> The pancreas may be normal in size, small, or even enlarged.
> Generally the parenchyma is somewhat nonhomogeneous with coarse, highlevel internal echoes (fibrosis, calcification).
> There may be irregular hypoechoic to anechoic areas indicating pseudocyst
formation.
> The surface of the organ may appear wavy and indistinct.
> There may be irregularity and slight dilatation of the pancreatic duct, with or
without calcification.
> Bowel wall thickening may be noted in the duodenal C loop.
> Incompressibility and “en bloc” movement of the fibrotic organ with aortic
pulsations.
Accuracy of sonographic diagnosisOpen-mouthed smile 

The detection of ductal dilatation, calcification, and pseudocysts confirms the
diagnosis, and this can be done sonographically in almost 85% of cases. If the
findings are equivocal, there is evidence that CT scans can provide a somewhat
higher diagnostic accuracy.
> FNAB can help in distinguishing a segmental pancreatitis or pancreatic cysts
from a pancreatic tumor, although the cytologic and histologic findings are
not always conclusive.
> With a sonographically confirmed tumor or indeterminate lesion that will or
may be treated operatively, percutaneous biopsy is contraindicated because
of the risk of seeding malignant cells along the needle track. A needle biopsy
may be done if guided by endosonography, however, because the needle tract
can subsequently be included in the resection.

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