Chronic Pancreatitis - Pancreatic Pathologies by Cincinnati Children's Pancreas Care Center

Globalcast MD along with Cincinnati Children's Hospital sharing knowledge to improve child health around the globe. Welcome back to our educational video series on pancreatic pathologies brought to you by the Pancreas Care Center at Cincinnati Children's. Today's topic is chronic pancreatitis and we are joined by two experts from our hospital, Dr. Maisama Bel Hajja, medical director of the Pancreas Care Center and Dr. Andrew Trout, Director of Clinical Research, Department of Radiology and medical imaging. Let's start with learning more on chronic pancreatitis. So chronic pancreatitis is a chronic inflammatory condition with the inflammation over time. It would result in a damage and destruction of the pancreas as the organ, and that could result in replacement of some of the healthy tissue with fibrosis. The fibrosis is basically a scar tissue that takes over that space in the pancreas. And the ongoing damage in the pancreas affects various types of cells, such as acinar cells, ductal cells, and even islet cells, which are responsible for producing insulin. The function that these cells could provide would decline when you have chronic pancreatitis. For instance, the acinar cells make digestive enzymes. So if they're diseased or destructed, then you have less of the pancreatic enzymes. When the islet cells which produce insulin are damaged by chronic pancreatitis, it can lead to endocrine issues such as diabetes. Chronic pancreatitis is a progressive inflammatory disorder that results in the irreversible loss of pancreatic function. Here's how we diagnose this condition. So diagnosis of chronic pancreatitis is mostly relying on image findings. Diagnosis involves identifying calcifications, ductal obstruction or dilation, combined with one of the following three criteria. Either the pain that is consistent with pancreatic origin or exocrine dysfunction or endocrine dysfunction. When imaging chronic pancreatitis, both MRI and CT can play a role. But what is the best modality for assessing patients with chronic pancreatitis? CT when it's performed, a single phase with portal venous contrast is adequate. MRI has advantages over CT in terms of the soft tissue contrast that you get with the multiple different MRI sequences and it's going to provide you the best visualization of both paral and duct changes that we see with chronic pancreatitis. What about using IV contrast? When doing CT with IV contrast, often in adults, multiple phases will be acquired including non-contrast images as well as arterial and portal venous phases. We try to avoid that in children because it markedly increases the radiation dose and it doesn't give us that much additional diagnostic information. A non-contrast CT is essentially never needed in a child with pancreatitis. We can see calcifications on the post-contrast phases of imaging. And in general, we only do portal venous phase imaging. According to Dr. Trout, we reserve arterial phase imaging for when there's a specific question about arterial pseudo aneurysms or when we need to characterize potential masses. What about MRI? The key sequences are going to be your MRCP sequence, your 3D MRCP sequence that allows you to characterize the duct and its relationship to the bile duct, and then a T1 weighted sequence to understand paral health. At an initial characterization of a patient with a history of acute recurrent or chronic pancreatitis, it can be useful to have contrast there to understand vascular complications or fluid collections. But in many cases we can get away doing these exams without IV contrast. These imaging tips are important for diagnosis. Now, let's shift our focus to the role of genetic testing in chronic pancreatitis. There is plenty of genetic testing available that you can order depending on the labs that we send the test to. At Cincinnati Children's, we have a in-house 10 gene pancreatitis risk panel where we screen for the problems with the genetic link and pancreatitis. Of course, it is advised before sending genetic testing to work very closely with a genetic counselor so that they can help the family choose the test but also interpret it afterwards. Genetic testing plays a vital role in the early diagnosis and prognosis of pancreatic diseases, potentially guiding new and effective preventative and therapeutic interventions. Now, let's discuss the consequences of chronic pancreatitis. We need to keep in mind what could happen from this chronic inflammation. So we assess the exocrine and the endocrine function because those could decline over time. Additionally, we need to maintain a thorough evaluation and workup for complications that may arise as a result of this condition. Some of the other problems that we face when we are dealing with a chronic pancreatitis are related to nutrition, macro and micronutrient deficiencies, growth problems, small intestinal bacteria overgrowth, and in some cases, we also see the risk for tumors and that's down the line when they are into the adulthood. There are numerous complications that can arise from chronic pancreatitis. So what are the most effective treatment options? So it starts with assessing the stage of the disease and finding out the extent of the exocrine or the endocrine problems, but also correcting the nutrient abnormalities and nutrition and growth is very important. In terms of pancreatic enzyme replacement, when needed, we follow the cystic fibrosis guidelines for dosing. And we try to reserve them only for the cases that there is a documented exocrine pancreatic insufficiency. In cases where we have tried everything medically and that had failed and the patient continues to have symptoms, we could think next about endoscopic management. And for endoscopic therapy, we rely on two methods, endoscopic ultrasound and endoscopic retrograde colangiopancreatography, which is ERCP. And this is an imaging but also interventional modality where the endoscopist could evaluate the pancreatic duct or the biliary ducts and treat any problems with scarring or strictures that is part of the process of chronic pancreatitis. What about pain management? It is a stepwise approach. So we follow a ladder where we start with opiate sparing medications and reserve opiates for severe pain cases. And some of the opiate sparing chronic pain medications are neuropathic medications like amitryptiline, Gabapentin. And usually those are in partnership with a pain specialist prescribing the medications and part of the multi-disciplinary management of pain is having a pain specialist and a psychologist and a physical therapist so that we can make progress and address all the aspects that the pain could take on a patient's body. Psychologists play a key role in helping patients cope with pain by assessing its functional and emotional impact, as chronic pain can significantly affect daily functioning. But what we know and we incorporate in our management here at Cincinnati Children's is a multi-disciplinary pain management. And in those cases, we apply cognitive behavioral therapy or CBT that has been shown in other chronic conditions to be very helpful in managing the pain. Let's summarize what we learned today. Chronic pancreatitis is a progressive inflammatory condition that leads to the irreversible destruction of pancreatic tissue, affecting both exocrine and endocrine functions. Potentially resulting in nutrient deficiencies and diabetes. Diagnosis relies on imaging techniques such as MRI and CT to detect calcifications, ductal obstruction or dilation. Genetic testing plays a critical role in early diagnosis and guiding treatment strategies. Treatment includes managing nutritional deficiencies, pancreatic enzyme replacement, endoscopic interventions and a stepwise pain management approach involving a multi-disciplinary team of pain specialists, psychologists and physical therapists to address both the physical and emotional aspects of chronic pain. Thank you for watching this video. For a detailed look at the surgical management of chronic pancreatitis and a complete walk through of a TPIAT procedure, stay tuned for our surgical video featuring Dr. Juan Guerra from Cincinnati Children's. Link in the description below.