Chronic pancreatitis Ali Khalil, MD Lebanese Univ, Lebanese American Univ Head of Endoscopy Department, RHUH Chief of Gastroenterolgy Division, Zahraa

Chronic pancreatitis

                     Ali Khalil, MD
       Lebanese Univ, Lebanese American Univ
        Head of Endoscopy Department, RHUH
       Chief of Gastroenterolgy Division, Zahraa
                   University Hospital

Chronic pancreatitis

• Irreversible parenchymal destruction leading to
  pancreatic dysfunction

• Persistent, recurrent episodes of severe pain

• Anorexia, nausea

• Constipation, flatulence,Steatorrhea

• Diabetes

Chronic pancreatitis
• Toxic-metabolic; chronic EtOH abuse (90%), Smoking

• Idiopathic

• Genetic

• Autoimmune

• Recurrent and severe A P

• Congenital malformation
                                 MRCP of pancreas divisum

Evaluation

•  or normal amylase and lipase

• Plain AXR / CT may show
  calcified pancreas

• Pain management critiria
   EtOH cessation may improve
    pain
   Narcotic dependency is common

Complications

• Exocrine insufficiency typically manifests as
  weight loss and steatorrhea

    If steatorrhea present, a trypsinogen level < 10 is
     diagnostic for chronic pancreatitis

    Manage with low-fat diet and pancreatic enzyme
     supplements (Pancrease, Creon)

• Endocrine insufficiency may result from islet cell
  destruction which leads to diabetes

Management
• Manifests it self as a recurring, chronic illness
  requiring medication to control abdominal pain
  and efforts to preserve quality of life

• Options to treat abdominal pain include surgical
  and other invasive techniques

• Some patients require pancreatic enzymes to
  help in digestion food and insulin to correct
  diabetes mellitus

Food and diet

• Alcohol restriction as part of the long-term
  management strategy to control pancreatitis pain

• A low-fat diet to limit pancreatic enzyme secretion

• Avoid smoking; studies shown that smoking is an
  independent risk factor for the development of
  both acute and chronic pancreatitis

                             Arch Intern Med. 2009;169:1035-1045

Enzyme Therapy and Vitamin
          Supplementation
• Patients with steatorrhea to achieve optimal
  enzyme activity in the duodenum

• Enteric-coated preparations

• The use of pancreatic enzyme therapy to treat
  pancreatitis associated pain is less certain

• Supplementation with fat-soluble vitamins
                       Aliment Pharmacol Ther. 2009;29:235-246

Pain management

In the absence of prospective studies,

In the absence of randomized studies,

Analysis of the literature is difficult :

Pain management

• Role of abstinence from alcohol, smocking Role of
   medical therapy: enzymes ?

• Variable presentation of pain (chronic, attacks)

• Role of the complications (pseudocyst, bile duct) ?

• Fragile psychology of the patient

• Different endoscopic treatments

Gall stone pancreatitis by ERCP

Endoscopic management

PRINCIPLE 1:
TO ELIMINATE A PANCREATIC CARCINOMA,
Even in patient with an history of chronic pancreatitis,
as no surgical exploration

• US, CT, EUS, MRI…IDUS
• Endoluminal cytology and biopsy : EUS-FNA, ERCP
• Strict and frequent follow-up

Endoscopic management

PRINCIPLE 2:
TO TREAT ONLY IN CASE OF SYMPTOMS AND COMPLICATIONS

• Pain: yes
• Pseudocyst: yes if symptoms or complications
• Fistula: yes

Endoscopic management
PRINCIPLE 2:
TO TREAT ONLY IN CASE OF SYMPTOMS AND COMPLICATIONS

• Biliary stenosis: +/- discussed
• Duodenal stenosis: no

• Vascular stenosis (portal vein, splenic vein): no
• Pancreatic exocrine function: +/- discussed

• Diabetes: no

Endoscopic management
PRINCIPLE 3:
TO USE ADAPTED MATERIAL

• Fluoroscopy: high quality, multiple incidences
• Accessories: multiple, specific; Guide-wires, dilation balloon,
  Soehendra dilat

• Extracorporeal lithotripsy: 31-75% of cases

• EUS (pseudocyst)
PRNICIPLE 4: TO TREAT ONLY COMPLIANT PTS

Endoscopic management
PAIN
  Endoluminal tt

• Aim: drainage of the main pancreatic duct
  (wirsung,santorini)

• Bases: results of surgical bypass
          Immediate effect on pain: 70-90%
          (Sarles 82, Bradley 87, Longnecker 96, Prinz 90)

Endoscopic management

PAIN
• Indications              1: No stenosis
• MRCP +++                 ES alone
                           +/- biliary sphinctero

2: Stenosis, stones           3: Stenosis, no
Extracorp litho (nber ?)      stones
then ES + stent (type ?)      Sphinctero + stent

Endoscopic management

 PAIN
                                                            Long stenosis
 Indicationsto be discussed
                                                            Ex: familial CP

                                   Discussion: length of the stenosis
Minor modif
Cremer Type I

                              Discussion: Tt at the early
                              asymptomatic stage

Endoscopic management

PAIN
Contreindications
                                Distal stenosis
                                Cremer type II

                    Recommendation: left
                    pancreatectomy

Pain management

PAIN: RESULTS

SERIES WITH EXTRACOROPREL LITHOTRIPSY

Summary of Published series (12 series)

  SUCCESS OF FRAGMENTATION: 98%

  MAIN PANC DUCT CLEARANCE: 54%

  PAIN DISAPPEARANCE: IMMEDIATE 88%

Pain disappearance: LATE (>2y) 64%

Pain management

SERIES WITH STENT
Summary of published series (7series)

 Stent insertion: 90%
 Pain disappearance, immediate: 78%

Pain disappearance, late (>2y) :63%

Endoscopic management
MORBIDITY: LOW
Immediate cns: not significative
 Stent: Acute panc 6-43%, rapidly reversible
 ES: 4,1% (bleeding, mild panc) Jakobs 02 175 pts

Late cns: mild
 Stent obstruction:
   13% for 10F (HEH 95) to 100% for 7F (Ikenberry 04)
    few cases of pseudocysts or abscesses
 Stent migration
 Cholangitis, bile obstruction / stent: 4% Cremer 91

EUS-Guided Celiac Plexus
                  Blockade
• Anterior approach and real-time imaging of the celiac plexus

• Its role in the control of pancreatic cancer pain is clearly
  established

• Its benefit in chronic pancreatitis pain is more controversial

• Achieved through the administration of a combined injection
  of a corticosteroid and local anesthetic

EUS-Guided Celiac Plexus
                 Blockade
• A review of 6 studies (n=221 patients) found that EUS-
  guided CPB was effective in about half (51%) of patients
  with chronic pancreatitis

• A meta-analysis and systematic review of 8 studies
  (n=283 patients) concluded that EUS-guided CPB was
  effective in 59% of patients with chronic pancreatitis

                                   J Clin Gastroenterol. 2010;44:127-134
                                   Dig Dis Sci. 2009;54:2330-2337

EUS-Guided Celiac Plexus
           Blockade

EUS GUIDANCE

   STEROIDS

PAIN

  Medical tt: enz, alcohol stopped (and smoking)

                  Endoscopic tt
       90%
     Technical Success      Technical failure
                 85%
  Non efficient   Efficient             Surgery
                        Recurrence
EUS neurolysis Result maintained
                                 65%

PSEUDOCYST
 ENDOLUMINAL TT VS
CYSTOENTEROSTOMY
                          Cystogastrostomy
                          Cystoduodenostomy

                             EUS guided
Main panc duct drainage

                          Cystowirsungostomy

Pseudocyste: Role of EUS

FINAL METHOD: no scope exchange
     large channel EUS scope
         appropriate stent   « Electrical » guide-wire
          delivery system
                             6.5F catheter

        8.5 or 10F stent

A

B       C

Pseudocyste: Role of EUS

            Vilmann 98: first case
Giovannini 98: 6 pts, no bulging into the lumen
                           success: 5/6

        Seifert 00: 6 pts, success: 5/6

    Giovannini 01: 35 pts, 15 with chronic
  pancreatitis and 20 with post-op abcesses

8.5 F stent or 7 F nasocystic drain (8-10 days)
mean FU: 27 months, overall success: 88.5%

Our Experience
case   AGE   Gender   Etiology       Stent        ERCP and ESWL   Associated procedures   Morbidity   Mortality   Clinical
                                     Insertion                                                                    improvement
 1     22    M        Malformation   No           No              Cystogastrostomy        No          No          Yes

 2     65    M        Alcohol        Yes, minor   No              Bilary stent            No          No          Yes
                                     papilla
 3     48    F        Sarcoidosis    Yes          Yes             Bilary stent            No          No          Yes

 4     57    M        Biliary ?      Yes          Yes             Biliary Sphincterotmy   No          No          Yes

 5     28    F        heredity       Yes          Yes             Bilary stent            No          No          Yes

 6     33    M        heredity       Yes          No              No                      No          No          Yes

 7     68    F        IPMT           No           No              Biliary stent           No          No          _

 8     18    F        Heredity?      Yes, minor   No              Bilary stent            No          No          Yes
                      Malformation   papilla

 9     72    M        Alcohol         _           No              Surgery                 Yes         No          Yes

 10    45    M        Autoimmune     Yes          No              Bilary stent            No          No          Yes

 11    62    M        Alcohol        Failure      No              No                      _           _           No

Case n 3

Case n 6

Case n 8

Our Result

• Uncommon Disease
• Gender: Male predominance
• Most common Etiology: Hereditary, Malformation
• Technical success: 90%
• Biliary drainage: 55%
• Procedure Mortality and Morbidity: 0%
• Clinical improvement: 90%
• Combination ES & ESWL: 3/11P

THANK YOU

Pain management

PAIN: RESULTS
SERIES COMBINATION ERCP & ESWL

SUMMARY OF PUBLISHED SERIES (1 PUBLICATION)
 STENT INSERTION : 58.6%
 PAIN DISAPPEARANCE IMMEDIATE 60%
 PANCREATIC SURGERY HAS BEEN AVOIDED 64%

                             South Med J. 2010 Jun;103(6):494-5