Present your research work on Diseases of the liver, pancreas, and biliary system 13th World Gastroenterology, IBD & Hepatology Conference 2023.

Chronic pancreatitis has an annual incidence of about one person per 100,000 and a prevalence of 3/100,000. The majority of cases in temperate areas are due to alcohol abuse, which primarily affects men aged 40-50 years. There is no universal alcohol toxicity threshold, but the amount and duration of alcohol consumption correlate with the development of chronic pancreatitis. However, there is little evidence that either the type of alcohol or the pattern of consumption is important. Contrary to popular belief, concomitant cirrhosis and chronic pancreatitis are uncommon.

Malnutrition and ingestion of large amounts of cassava root are implicated in the aetiology in a few tropical areas, most notably Kerala in southern India. With an incidence of up to 50/1000 population, the disease affects both men and women equally.

Chronic pancreatitis caused by alcohol usually has a predictable course. Most patients have been drinking heavily (150-200 mg alcohol/day) for more than ten years before symptoms appear. The first acute attack usually occurs after a binge drinking episode, and these attacks may become more frequent over time, until the pain becomes more persistent and severe. Pancreatic calcification occurs 8-10 years after the initial clinical manifestation. During this time, endocrine and exocrine dysfunction may develop, resulting in diabetes and steatorrhoea.

Continued alcoholism causes significant morbidity and mortality, as do other diseases associated with low living standards (bronchus cancer, tuberculosis, and suicide), and patients are at an increased risk of developing pancreatic carcinoma.

Symptoms and warning signs

The most common symptom is severe dull epigastria pain radiating to the back, which can be alleviated in part by leaning forward. Pain is frequently accompanied by nausea and vomiting, and epigastric tenderness is common. Patients frequently avoid eating because it causes pain. This causes severe weight loss, especially in patients with steatorrhoea.

Steatorrhoea manifests as pale, loose, foul-smelling stools that are difficult to flush away and, if severe, can lead to incontinence. It occurs when more than 90% of the exocrine tissue is destroyed, resulting in low pancreatic lipase activity, fat malabsorption, and excessive lipids in the stools.

One-third of patients will develop diabetes, which is typically mild. Ketoacidosis is uncommon, but the diabetes is frequently "brittle," with patients prone to hypoglycemia due to a lack of glucagon. In patients who continue to drink or have had pancreatic resection, hypoglycemic coma is a common cause of death.

Diagnosis

Chronic pancreatitis is notoriously difficult to diagnose early. Early parenchymal and ductal morphological changes may be difficult to detect because there are no reliable biochemical markers. Endoscopic retrograde cholangiopancreatography usually shows the earliest signs (stubby changes in the side ducts), but a normal appearance does not rule out the diagnosis. Pancreatic function tests are time-consuming and rarely used to confirm the diagnosis. As a result, early diagnosis is frequently made through exclusion based on typical symptoms and a history of alcohol abuse.

Computed tomography reveals an enlarged and irregular pancreas, dilated main pancreatic duct, intrapancreatic cysts, and calcification in patients with advanced disease. Plain abdominal radiographs may also show calcification. Endoscopic retrograde cholangiopancreatography reveals classic changes such as irregular dilatation of the pancreatic duct with or without strictures, intrapancreatic stones, cyst filling, and smooth common bile duct stricture.

Treatment

The treatment focuses on managing acute pain attacks and, in the long run, pain control as well as the metabolic complications of diabetes mellitus and fat malabsorption. It is critical to persuade the patient to completely abstain from alcohol. A collaborative approach is required for the successful long-term management of complex cases.

Pain

Pain that is persistent or nearly permanent is the most difficult aspect of management and is frequently intractable. The source of the discomfort is unknown. Free radical damage has been proposed as a cause, and some patients respond to treatment with micronutrient antioxidants (selenium, carotene, methionine, and vitamins C and E). However, more randomised trials are needed to confirm the effectiveness of this approach. In the later stages of the disease, pain may be caused by increased pancreatic ductal pressure due to obstruction, or by fibrosis trapping or damaging pancreatic nerves.

Abstinence from alcohol is the mainstay of treatment, but it does not always guarantee relief for patients with advanced disease. Because many patients have addictive personalities, analgesics should be prescribed with caution to avoid narcotic dependency. Nonsteroidal analgesics are the preferred treatment, but most patients with chronic and unbearable pain will eventually require oral narcotic analgesics like tilidine, tramadol, morphine, or meperidine. Slow-release opioid patches (such as fentanyl) are becoming more popular. Patients should be referred to a specialist pain clinic once they reach this stage.

Steatorrhoea

Pancreatic replacement therapy is used to control loose stools and increase the patient's weight in patients with steatorrhoea. Pancreatic enzyme supplements are rapidly inactivated below pH5, and the most useful supplements, such as Creon or Pancrease, are high concentration, enteric coated microspheres that prevent deactivation in the stomach. Occasionally, H2 receptor antagonists or dietary fat restriction are required.

Surgery

Only after all other forms of conservative treatment have been exhausted and it is clear that the patient is at risk of becoming addicted to narcotics should surgery be considered. Unless there are complications, the decision to operate is rarely simple, especially in patients who have become dependent on narcotic analgesics.

Stricture of the bile duct

Stenosis of the bile duct resulting in chronic jaundice (lasting more than a few weeks) is uncommon and is usually caused by pancreatic fibrosis. The duct should be surgically drained, which is often done in conjunction with surgery for associated pain or duodenal obstruction. Endoscopic stenting is not a long-term solution and is only indicated for symptom relief in high-risk cases.

Thrombosis of the splenic veins

Splenomegaly and gastric varices can be caused by venous obstruction caused by splenic vein thrombosis (segmental or sinistral hypertension). Most thrombi are asymptomatic, but if surgery is planned, they pose a serious risk. For symptomatic cases, splenectomy is the best option.

Thrombosis of the splenic veins

Splenomegaly and gastric varices can be caused by venous obstruction caused by splenic vein thrombosis (segmental or sinistral hypertension). Most thrombi are asymptomatic, but if surgery is planned, they pose a serious risk. For symptomatic cases, splenectomy is the best option.

Bleeding in the gastrointestinal tract

Gastric varices, coexisting gastroduodenal disease, or splenic artery pseudoaneurysms, which occur in association with pseudocysts, can all cause gastrointestinal bleeding. Endoscopy is required in these patients. Pseudoaneurysms respond best to arterial embolisation or surgical ligation.

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