Practical Approach to Diagnosis of Chronic Pancreatitis in India

1
Practical Approach to Diagnosis of Chronic
Pancreatitis in India

• Prof Yogesh Chawla
• Department of Hepatology
• Postgraduate Institute of Medical Education and
  Research, Chandigarh

2
Etiology

• Alcohol
• Idiopathic - Juvenile
• Senile
• Tropical Pancreatitis
• Hereditary
• Hyperparathyroidism
• Pancreas Divisum

3
History

• Suggestive of pain of CP
• History of alcohol (Daily/Weekends)
• History of family 1st or 2nd generation (1-2)
• Age young tropical pancreatitis
• Hereditary
• Cystic fibrosis
• History of diabetes, renal stones
• Steatorrhea

4
Signs

• Splenomegaly
• Lump abdomen/ascites
• Jaundice, gastric outlet obstruction
• GI bleed

5
Diagnostic Tests

• Consider Sensitivity
• Specificity
• Accuracy
• Cost , Risk , Availability
• Stage Etiology

6
X-Ray Abdomen

• Inexpensive, Risk free
• Widely available
• Calcifications - Alcoholic, idiopathic,
  hereditary
• Tropical (70-80 painless
  CP)
• Detects long standing and advanced CP
• Does not suggest severity of pancreatic
  insufficiency

7
Abdominal US

• Detects pancreatic calcifications and changes
• Inexpensive Risk free
• Widely available
• Sensitivity 50-80
• Specificity 80-90
• Accuracy 56
• Abdominal gas, artifacts
• Fluid in stomach, simethicone
• Mild changes less specific
• Tissue harmonic imaging improves details

8
CT Abdomen

• Consistency, reproducibility
• More sensitive and specific than US
• Sensitivity 75-90
• Specificity 85
• Detects abnormalities in pancreas and adjoining
  
• Poor correlation with functional impairment
• Ionizing radiation, more expensive

9
Routine Laboratory Tests

• Not generally useful
• ? alkaline phosphatase and serum bilirubin
  CP/pseudocysts
• Serum amylase/lipase increased
• Acute exacerbations
• Hyperglycemia

10
Direct Hormonal Stimulation (Secretin with CCK
stimulation test)

• Sensitivity 74-97
• Specificity 80-90
• More sensitive than ERCP
• Not standardised
• Not available widely
• Moderately expensive
• Time consuming
• False positive 8
• False negative - 6

11
Indirect Tests of Pancreatic Exocrine Secretion

• Serum trypsinogen
• Stool chymotrypsin
• Stool elastase
• Limitations
• Instructions to patient
• In pancreatic replacement trt

12
ERCP

• Normal ERCP does not exclude CP
• PD CBD changes best seen
• Subtle morphological changes
• ERCP Stenosis, pleural effusion
• Ascites, pseudocysts
• Therapeutic

13
MRCP

• Correlates well with ERCP
• Risk free, expensive

14
EUS

• Overcomes the imaging problems of transabdominal
  US
• Correlates well with ERCP
• Sensitivity 73, specificity 81 - advanced CP
• Requires further studies in less advanced CP
• Not widely available