Prepared by Porf. Dr. Nabil El-Kady Unit.

Presented by Dr. Marwa Abdelbary.

Chronic Pancreatitis

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STAFF ROUND PRESENTATION

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Personal History

•  Female patient H.W.Masoud, 30 years old, housewife.

•  married 3 years ago and has a one year old infant.

•  Born and is living in El- Maady, Cairo .

•  No history of contact with canal water.

•  No special habits of medical importance.

•  Menarche at age of 11, regular cycles / 28 days.

•  Normal vaginal delivery.

•  History of intake of oral contraceptive pills for 3 months following marriage.

Complaint

Recurrent yellowish discolouration of the eyes for the last 6 months

Present History

•  6 months ago: gradual onset of pruritus.

•  3 weeks later: the patient developed jaundice with dark coloured urine and pale stools.

•  Associated with nausea, vomiting dyspepsia.

•  No abdominal pain, fever or rigors.

•  The patient sought medical advice, lab investigations and abdominal ultrasound were performed (Abd us was suggestive of extrahepatic biliary obstruction) and ERCP was recommended.

•  Following ERCP and therapeutic intervention, the condition subsided completely within 45 days.

•  10 days later, painless jaundice recurred again Where further investigations were done.

The condition wasn't associated with

•  Significant weight loss.

•  Manifestations of chronic liver disease.

•  Symptoms of vitamins deficiency.

•  Bleeding tendency.

•  Perception of body masses.

•  Dermatological or joint affection.

•  Lower GI symptoms.

•  Other system affection.

Past History

•  History of adenoidectomy 2 years ago.

•  Not known to be diabetic or hypertensive (however routine labs revealed elevated blood glucose level).

•  No history of:

• Blood transfusion.

• Drug intake.

• Admission to fever hospital.

Family History

•  Negative consanguinity.

•  No similar condition.

Summary

30 years old female patient

with

recurrent painless jaundice

and recent onset of diabetes

General Examination

•  Patient is conscious, cooperative and ambulant.

•  Pulse:80/min.

•  Blood pressure: 120/80.

•  Temperature: 37 ° C.

Head & Neck

No jaundice or cyanosis at present

No significant abnormality.

Upper & Lower limbs

Show scattered scratch marks

No signs of L.C.F

Abdominal Examination

•  Normal shape and contour.

•  Subcostal angle is not widened.

•  No Divarication of recti.

•  Umbilicus: normal.

•  No hernias.

•  LIVER:

- Upper border : 5th space MCL.

- Lower border :Rt lobe: 4cm in the MCL, smooth surface, rounded border.

Lt lobe: not felt.

•  SPLEEN: not felt.

•  No ascites detected clinically.

CVS
Chest &
Neurological Examination


Free

POSSIBLE D.D

•  Biliary stones

•  Biliary stricture (either due to benign or malignant stricture)

•  Periampullary tumors.

•  Parasitic.

•  PSC.

•  PBC.

•  Pancreatic disease.

INVESTIGATIONS
JULY 2005

URINALYSIS

•  Proteins: nil

•  Glucose: +++

•  Acetone: nil

•  Bile pigments: ++

•  Urobilinogen: nil

•  Pus cells: 1-2

•  RBCs: 1-2

•  Casts: nil

•  Crystals : nil

•  Ova: nil

CBC:

•  WBCs

•  Total:5.700

•  B= o%

•  E= 2 %

•  St= 4 %

•  Seg= 62 %

•  Lymph= 28 %

•  Mon= 2 %

Conclusion:

normal CBC with elevated ESR

Liver Biochemical Profile

•  BIL-T : 8.1mg/dl(up to 1mg/dl)

•  Direct :6.1mg/dl(up to 0.25mg/dl)

•  Indirect :2.0mg/dl

•  AST : 63u/L ( 0 - 31u/L)

•  ALT : 127u/L ( 0 - 31u/L )

•  ALP : 147u/l ( 35 - 104u/L )

•  GGT : 44u/L ( 7 - 32u/L )

•  T.Proteins:7.4g/dl

•  Albumin: 4.4g/dl

•  PC: 82%

Hepatitis markers

•  HBsAg: negative

•  HBcAb Total: negative

IgM : negative

•  HCV Ab : negative

Kidney functions

•  Serum urea : 13 mg/dl (10-50 mg/dl).

•  Serum creatinine :0.58 mg/dl (0.7-1.2 mg/dl).

•  Fasting blood sugar :320mg/dl

•  2h post prandial : 430mg/dl

Abdominal U/S

•  LIVER : Mildly enlarged, of bright echopattern, smooth surface. No focal lesions or IHBR dilatation. Portal vein is not dilated

CBD is dilated 1.2cm

•  GALL BLADDER : Average size and wall thickness, no stones or mud inside.

•  SPLEEN: is mildly enlarged (longest axis14cm), homogenous echo pattern. No focal lesions. Splenic vein not dilated.

•  KIDNEYS : Both are of average size, and parenchymal echogenicity, no typical calculi or back pressure changes.

•  PANCREAS : Shows a bulky and irregular head (4X4.5x4.7cm) with normal homogeneous echopattern.

•  No ascites.

CONCLUSION:

•  Mildly enlarged bright liver with no dilated IHBRs.

•  ? pancreatic head mass, causing CBD obstruction. Further assessment by CT is recommended.

ERCP REPORT

•  Normal papilla, easy cannulation

•  Injection of contrast showed mildly dilated CBD with no filling defects detected inside.

•  The IHBRs are dilated and cystic duct is long, tortuous with low insertion.

•  Wide sphincterotomy was performed and clearance of CBD was achieved by dormia basket and balloon catheter.

CONCLUSION

•  Dilated common bile duct, probably passed stone versus papillary dysfunction.

•  Sphincterotomy performed.

CT SCAN (2 weeks after ERCP)

•  Hepatomegly of diffuse homogenous low attenuation value. Prominent CBD with no evidence of IHBR dilatation.

•  Bulky spleen.

•  Prominent pancreas with no evidence of cystic or solid masses.

•  The peripancreatic fat planes are rather preserved.

•  Nodular mural thickening of the gall bladder.

•  No lymphadenopathy

•  No ascites.

•  Clear scanned lung bases.

Conclusion

•  Mild hepatomegaly.

•  Prominent CBD.

•  Bulky pancreas for correlation with clinical and laboratory findings.

•  Suspected adenomyomatosis of the gall bladder.

•  Serum amylase: 85 IU/L (25-125)

•  Serum lipase : 92 IU/L (10-150)

Tumor markers

•  AFP in serum : 2.27ng/ml(0-11)

•  CA19-9 : Zero U/ml(0.0-37.0)

•  CEA : 3.2ng/ml(Up to 7.0)

•  The condition improved over 45 days.

•  However, 10 days later bilirubin started to rise again.

Total bilirubin : 4.5mg/dl

Direct bilirubin : 3.0mg/dl

ALP : 150u/L (35-104)

FOLLOW UP ABDOMINAL ULTRASOUND(2m after ERCP)

•  There is evident early surgical obstructive jaundice with dilated bile ducts in both lobes of the liver. CBD is dilated(1.2cm) . However no notable calculi along its course.

•  The pancreas is still seen diffusely enlarged (the head measures 3.3cm in its anteroposterior diameter, the body 2.3 cm and the proximal part of the tail 2.1 cm. ? This is likely due to an inflammatory process or otherwise.

Endosonography

•  The pancreatic head, body and tail are considerably enlarged with heterogeneous texture.

•  There are spots of calcification inside. CBD is dilated(13mm) , no evident stones or masses inside.

•  There are mildly dilated IHBR. Pancreatic duct is mildly dilated with irregular outline

•  There is a small cystic area in the pancreatic tail(12x15mm). Highly impressive of severe pancreatitis.

•  No definite papillary masses. No peri pancreatic or celiac LN.

DIAGNOSIS

•  Diffuse enlargement of pancreas with heterogenous texture and calcific spots.

•  Picture is highly impressive of pancreatitis.

Recommendation:

Fine needle aspiration biopsy cytology to verify the nature of chronic pancreatitis .

EUS

•  Serum Ca : 9 mg/dl ( 8.4 - 10.2 mg/dl )

•  Serum triglycerides : 50 mg/dl(0-140mg/dl)

•  Alpha 1 antitrypsin : 1.0 g/dl(0.9-2.0g/dl)

MRI and MRCP

•  Diffusely enlarged pancreas with normal signal pattern and clear peri pancreatic fat planes. The uncinate process in particular appears rounded with dilatation of CBD and to lesser extent IHBRs.

•  The distal segment of the CBD appears markedly attenuated. The pancreatic duct is not dilated

•  The gall bladder is distended show irregular mural thickening

•  No hepatic or splenic focal lesions

Conclusion

Diffuse enlargement of the pancreas. Strictured distal end of the CBD with rounding of the pancreatic uncinate process and evolving extra-hepatic obstruction.

ERCP( 20/11/05 )

•  Evidence of previous sphincterotomy.

•  Cannulation and cholangiography reveald a tight stricture at distal CBD about one cm above papilla

•  Markedly dilated proximal CBD and IHBRs

•  Pancreaticogram showed abnormal pancreatic duct with diffuse irregularity and narrowing mostly in the region of the head and a 1 cm contrast filled cavity at the region of the body.

•  A10 Fr 10 cm stent was inserted in the proximal CBD for biliary drainage

CONCLUSION

Picture suggestive of chronic pancreatitis with

Distal CBD stricture. Biliary stenting performed.

Follow up U/S 21/12

Autoimmune Profile

•  ASMA : Highly Positive.

•  ANA : Negative.

•  AMA : Negative.

•  PANCA : Negative.

•  APL : Negative.

PROTEIN ELECTROPHORESIS

•  Total protein : 7.8 g/dL (6.3-8.7 g/dL).

•  Albumin in serum : 3.7 g/dL(3.5-5.0 g/dL).

•  Alpha 1 globulin : 0.30 g/dL (0.3-0.5g/dl)

•  Alpha 2 globulin : 0.7 g/dl (0.5-0.7g/dl)

•  Beta globulin : 1.1 g/dL (0.6-1.2g/dL).

•  Gamma globulins : 2 g/dL (0.2-1.5g/dl).

Conclusion : Hypergammaglobulinemia with decreased A/G ratio.

D.D which was considered in this
case of chronic pancreatitis

•  CHRONIC PANCREATITIS FOLLOWING ACUTE PANCREATITIS:

-Postnecrotic.

-Recurrent acute pancreatitis.

•  CHRONIC PANCREATITIS DUE TO OBSTRUCTION :

-Congenital anomalies (pancreatic divisum).

-Sphincter of oddi disorder (controversial).

-Pancreatic duct obstruction (eg.tumor).

-Periampullary duodenal wall cyst .

•  AUTOIMMUNE PANCREATITIS :

Primary.

Secondary (PBC, PSC, Sjogren syndrome).

•  IDIOPATHIC CHRONIC PANCREATITIS

•  HEREDITARY PANCREATITIS:

Autosomal dominant.

Autosomal recessive.

•  In this case, autoimmune pancreatitis becomes one of the 1st possibilities according to the following :

1- Presentation of the disease.

2- Autoantibodies.

3- Radiological finding.

•  Further investigations to prove autoimmune pancreatitis (Results are not yet available):

-IgG4

-Pancreatic biopsy

Thank you

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