0521779407-C02 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53
Chronic Pancreatitis 345■thoracoscopic nerve ablation (investigational)
➣considered in patients who do not have a dilated pancreatic duct
that can be surgically drained.
■surgery – reserved for patients with intolerable severe pain. Should
be performed in an institution experienced in pancreatic sur-
gery.
➣surgical decompression of the pancreatic duct. Best candidates
are those who exhibit ductal dilation > 6mm in diameter.
➣pancreatic resection, usually of the pancreatic head, can be con-
sidered in patients with non-dilated ducts. Outcomes are not well
established.follow-up
■dictated by clinical symptoms and extent of complications (e.g. pseu-
docysts, fistulas, ascites)
■50% mortality after diagnosis within 20–25 years. 15–20% die of com-
plications related to pancreatitis
■periodic follow-up for progression of disease. Chronic pancreatitis
is usually progressive and thus patients must be monitored for the
development of malabsorption or diabetes.complications and prognosis
■pseudocyst – represent collections of pancreatic enzymes secondary
to a ruptured pancreatic duct. Develop in 10% of patients. Major
complications include rupture, hemorrhage, and infection.
➣most pseudocyst resolve spontaneously. Treatment is reserved
for growing or symptomatic pseudocysts. Depending on the
expertise of the institution, treatment may incorporate surgi-
cal resection, external drainage, or internal drainage. Depend-
ing on the available expertise, treatment of pseudocyst can be
performed by endoscopy, interventional radiology, or surgery.
■malabsorption – treated with pancreatic enzyme replacement.
➣enzymes are normally given before meals. If non-enteric coated
forms are used, they should be administered with bicarbonate
or acid secretion should be inhibited.
■pancreatic ascites or pleural effusions: secondary to a ruptured pan-
creatic duct
➣diagnosis established by the presence of high levels of amylase
and protein in the fluid
➣medical management may include diuretics, carbonic anhydrase
inhibitors, total parenteral nutrition, or octreotide.