Recurrent Idiopathic Pancreatitis

Recurrent Idiopathic Pancreatitis
Presentation lecture by:Rebecca Byers, MD
Primary Care Conference

Objectives
* Review the common clinical presentation of chronic pancreatitis.
* Describe the natural course of chronic pancreatitis.
* Discuss the various types of cystic lesions in the pancreas.
* Describe the diagnostic and treatment recommendations
* Disclaimer - I have not received any outside funding in regards to this presentation.

Clinical Cases
Hospitalization
* Stopped Lasix, Lisinopril, Cozaar.
* Renal arteriogram – normal.
* Echo – normal.
* +H. pylori – treated with 2 weeks Biaxin, Flagyl, Prevacid.
* Discharged on Amlodipine and Atenolol.
* BPs never high since.

GI Clinic Follow-up
* Diagnosis of Recurrent Idiopathic Pancreatitis and a mature pancreatic pseudocyst.
* Need to assess for structural abnormality
* Plan for repeat CT in 6 weeks and ERCP and/or endoscopic ultrasound.
* 8/4/03 – Abd CT without change. 4 non-specific pulm nodules, 6-7 mm. Endless f/u.

Surgical Consult
* Diagnosis of acute relapsing pancreatitis.
* Recommendation for resective drainage operation and definitive treatment.

ERPC

* Impression: (1)Recurrent pancreatitis (2) Improved pancreatogram with diffuse pancreatic ductal irregularities less prominent on this exam (3) No definite pancreatic duct stricture(s) visualized (4) s/p 5 mm pancreatic sphincterotomy with prompt drainage of contrast.

Endoscopic Ultrasound
* Impression: 1) Pancreatic tail solid-cystic lesion 2) FNA consistent with a mucinous neoplasm.
* FNA Report - Cytologic Exam: Positive, compatible with a mucinous neoplasm.


Surgery
* Surg Path Report – Predominantly intracystic mucinous adenocarcinoma, with focal infiltrating adenocarcinoma, in a background of chronic pancreatitis.
* Surgical margins were negative for carcinoma.
* Ten out of ten resected lymph nodes were negative for carcinoma. Adrenal gland and spleen also negative for carcinoma.

Surgical Follow-up

* Dilemma – If there was no invasive cancer, her treatment would now be complete; the finding of invasive cancer, along with some previously elevated tumor makers and pulmonary nodules, are concerning.
* Plan – redo all scans and serum markers, discuss at hepatobiliary conference, refer to medical oncologists.

Chronic Pancreatitis
* Chronic pancreatitis is an inflammatory condition that results in permanent structural changes in the pancreas which lead to impairment of exocrine and endocrine function.
* Can be asymptomatic over long periods of time, or can present as recurrent postprandial epigastric pain.

Clinical Features
* The two primary clinical manifestations are abdominal pain and pancreatic insufficiency.
* Pain is typically epigastric, often radiates to the back, often worse 15 to 30 minutes after eating, as the condition progresses, the pain tends to become more continuous.
* Problems digesting food/absorption, fat malabsorption, glucose intolerance/diabetes.
Etiology 1
Etiology 2
Pathogenesis
Diagnosis 1
Diagnosis 2
Complications
* Pseudocysts (10% of patients)
* Mechanical obstruction of the duodenum and common bile duct
* Pancreatic ascites
* Pleural effusion
* Splenic vein thrombosis with portal hypertension
* Pseudoaneurysm formation (e.g., splenic artery)

Cystic Lesions of the Pancreas
* Retention cysts
* Pseudocysts
* Cystic neoplasms.

Pseudocysts

* Result of pancreatic inflammation and necrosis.
* Single or multiple, small or large, located either in or outside of the pancreas.
* Most communicate with pancreatic ductal system, high concentrations of enzymes.
* Walls formed by adjacent structures; fibrous lining; lack an epithelial lining seen in true cystic lesions.

Cystic Neoplasms
* Mucinous cystadenoma/cystadenocarcinoma
* Mucinous duct ectasia (intraductal papillary mucinous neopplasm)
* Serous cystadenoma
* Papillary cystic neoplasm

Mucinous cystadenoma
* Most common cystic neoplasm.
* Typically in middle-aged women.
* Usually a mass lesion composed of one or more macrocystic spaces lined by mucous-secreting cells.
* Most are malignant at time of diagnosis. High potential for malignant change.

Management
Uncertain Etiology
References

Recurrent Idiopathic Pancreatitis.ppt