Arora: Clinical features: India vs west, alcoholic vs nonalcoholic

1
Arora Clinical features India vs west,
alcoholic vs non-alcoholic
Chronic calcific pancreatitis of the tropics
CCPT Hospital study Kerela MF ratio
11.6-11.38 Onset childhood/ adolescence Pain
30-90 IDDM 80 Steatorrhoea 80 Calcification
80-90
CCPT Community study Kerela (Balaji Tandon,
1994) MF 11.8 Age at onset 23.9 years Mild
diabetes
Age/ sex data in pancreatitis Age range 7- 60
years Peak age Males 31-35 years Females 16-
20 years Alcoholics 35 years 30-63 years Non
alcoholic 22.5 years 07-63 years Sex ratio 4 1
MF
2
Arora Clinical features India vs west,
alcoholic vs non-alcoholic
Abdominal pain

• Abdominal pain most serious problem
• Poor intake
• Weight loss
• Malnutrition
• Chronic pain (Most important reason for surgery)
• Poor quality of life
• Loss of social function
• Addiction to narcotic analgesics

3
Arora Clinical features India vs west,
alcoholic vs non-alcoholic
Abdominal pain

• 50-90 will ultimately develop pain 15 of
  asymptomatic patients develop pain over 3 years
• Onset may be gradual
• No characteristic/diagnostic/ patterns natural
  history variable, incompletely understood
  pattern not predictable in an individual
• Epigastrium / back radiation boring / deep/
  penetrating with nausea/ vomiting relieved by
  leaning forward h after meals
• Often nocturnal
• Initially episodic and then continuous
• Once pain develops it commonly changes over time
  in character, severity timing majority show
  decrease in pain over time burn out (? related
  to diffuse pancreatic calcification/ endocrine/
  exocrine deficiency)
• Variable history with surgery / drugs
• Important in outcome of treatment

4
Arora Clinical features India vs west,
alcoholic vs non-alcoholic
Steatorrhea and weight loss

• Steatorrhoea ultimately develops in 50-60 of
  patients
• Pancreatic secretion lt10
• Complete destruction / ductal blockage
• Bulky foul smelling stools gt3-4/d
• Oil droplets in stool
• No watery diarrhoea/ no cramps/ no gas formation,
  because of preserved CHO metabolism
• Average 13.1 years AP
• 16.9 years 1o CP late onset
• 26.3 years 1o CP early onset
• Weight loss
• Maldigestion
• Mostly during periods of pain
• Substantial weight loss (r/o carcinoma )

5
Arora Clinical features India vs west,
alcoholic vs non-alcoholic
Diabetes mellitus

• Consequence of long standing pancreatitis, as
  islets seem to be relatively resistant to
  destruction in chronic pancreatitis
• Brittle diabetes (loss of ? and ? cells vs. IDDM
  loss of ? cells only) no compensatory release
  of Glucagon in response to hypoglycemia
• lt15 yr. 0.8 India
• 4.1 West
• Low SE status
• Gross emaciation
• No hereditary factor
• Ketosis prone
• Male Female - 31

6
Arora Clinical features India vs west,
alcoholic vs non-alcoholic
Malignancy

• Malignancy reported in prospective and
  retrospective studies
• Related to chronic inflammation
• 60 near neck of pancreas
• Major presentation diabetes and pain rather than
  jaundice
• Mean survival 11 months
• Weight loss
• Constant abdominal pain
• Worsening of diabetes control

7
Arora Clinical features India vs west,
alcoholic vs non-alcoholic
Chronic pancreatitis India vs west

• Alcoholic vs. nonalcoholic 12
• Predominantly young adults
• Main presenting feature diabetes and abdominal
  pain
• Need for surgery 39
• Pancreatic carcinoma 2.7-8.3

Abdominal pain Maharashtra 67 France 93
Kerala 100
Mean age at presentation Maharastra 38.4
years France same Kerala 12.5 years Non
alcoholics 22.5 years
Alcohol intake India 30 France 90 Kerala 5
8
Arora Clinical features India vs west,
alcoholic vs non-alcoholic
Chronic pancreatitis India vs west
Steatorrhoea Maharashtra 33 France 33 Kerala
5-10
Weight loss All series 90-100
IDDM (Directly related to age of
onset) Maharashtra 80 France 23 Kerala 100
Family history Maharashtra 0 Kerala 8 ?
Genetics ? Diet/ Infection
9
Arora Clinical features India vs west,
alcoholic vs non-alcoholic
Clinical course of alcoholic vs non-alcoholic
pancreatitis

• Amman et al 1987 Pancreas Lankisch et al 1995
  Pancreas
• 318 patients, FU 10.6 years
• After 10 years 50 of alcoholics still had pain
  vs. 62 non alcoholics
• Only alcoholics had pain relief with increasing
  pancreatic exocrine insufficiency
• No effect of endocrine dysfunction
• ? Prognostic factors affecting the course of pain