Delhaye Myriam, Van Steenbergen Werner, Cesmeli Ercan, Pelckmans Paul, Putzeys Virginie, Roeyen Geert, Berrevoet Frederik, Scheers Isabelle, Ausloos Floriane, Gast Pierrette, Ysebaert Dirk, Plat Laurence, van der Wijst Edwin, Hans Guy, Arvanitakis Marianna, Deprez Pierre H
Acta Gastroenterol Belg. 2014 Mar;77(1):47-65.
Chronic pancreatitis (CP) is an inflammatory disorder characterized by inflammation and fibrosis, resulting in a progressive and irreversible destruction of exocrine and endocrine pancreatic tissue. Clinicians should attempt to classify patients into one of the six etiologic groups according to the TIGARO classification system. MRI/MRCP, if possible with secretin enhancement, is considered the imaging modality of choice for the diagnosis of early-stage disease.In CP, pain is the most disabling symptom, with a significant impact on quality of life. Pain should be assessed using the Izbicki score and preferably treated using the "pain ladder" approach. In painful CP, endoscopic therapy (ET) can be considered as early as possible. This procedure can be combined with extracorporeal shock-wave lithotripsy (ESWL) in the presence of large (> 4 mm), obstructive stone(s) in the pancreatic head, and with ductal stenting in the presence of a single main pancreatic duct (MPD) stricture in the pancreatic head with a markedly dilated MPD. Pancreatic stenting should be pursued for at least 12 months in patients with persistent pain relief. On-demand stent exchange should be the preferred strategy. The simultaneous placement of multiple, side-by-side, pancreatic stents can be recommended in patients with MPD strictures persisting after 12 months of single plastic stenting. We recommend surgery in the following cases: a) technical failure of ET ; b) early (6 to 8 weeks) clinical failure ; c) definitive biliary drainage at a later time point; d) pancreatic ductal drainage when repetitive ET is considered unsuitable for young patients; e) resection of an inflammatory pancreatic head when pancreatic cancer cannot be ruled out; f) duodenal obstruction. Duodenopancreatectomy or oncological distal pancreatectomy should be considered for patients with suspected malignancy. Pediatricians should be aware of and systematically search for CP in the differential diagnosis of chronic abdominal pain. As malnutrition is highly prevalent in CP patients, patients at nutritional risk should be identified in order to allow for dietary counseling and nutritional intervention using oral supplements. Patients should follow a healthy balanced diet taken in small meals and snacks, with normal fat content. Enzyme replacement therapy is beneficial to symptomatic patients, but also in cases of subclinical insufficiency. Regular follow-up should be considered in CP patients, primarily to detect subclinical maldigestion and the development of pancreatogenic diabetes. Screening for pancreatic cancer is not recommended in CP patients, except in those with the hereditary form.
慢性胰腺炎（CP）是一种以炎症和纤维化为特征的炎症性疾病，会导致胰腺外分泌和内分泌组织进行性、不可逆的破坏。临床医生应根据TIGARO分类系统，尝试将患者分为六个病因组之一。MRI/MRCP（若可能，联合促胰液素增强扫描）被认为是诊断早期疾病的首选影像学检查方法。在CP中，疼痛是最致残的症状，对生活质量有重大影响。应使用伊兹比基评分评估疼痛情况，最好采用“疼痛阶梯”方法进行治疗。对于疼痛性CP，应尽早考虑内镜治疗（ET）。若胰头存在大的（>4mm）阻塞性结石，该手术可联合体外冲击波碎石术（ESWL）；若胰头单一主胰管（MPD）狭窄且MPD明显扩张，则可联合导管支架置入术。对于疼痛持续缓解的患者，胰管支架置入应持续至少12个月。按需进行支架更换应作为首选策略。对于单根塑料支架置入12个月后MPD狭窄仍持续存在的患者，可建议同时并排置入多个胰管支架。在以下情况下我们建议进行手术：a）ET技术失败；b）早期（6至8周）临床失败；c）后期进行确定性胆道引流；d）对于年轻患者，若认为重复ET不合适，则进行胰管引流；e）当不能排除胰腺癌时，切除炎性胰头；f）十二指肠梗阻。对于疑似恶性肿瘤的患者，应考虑行十二指肠胰切除术或肿瘤性远端胰腺切除术。儿科医生在慢性腹痛的鉴别诊断中应意识到并系统排查CP。由于CP患者中营养不良非常普遍，应识别有营养风险的患者，以便进行饮食咨询并使用口服补充剂进行营养干预。患者应遵循健康的均衡饮食，少食多餐，脂肪含量正常。酶替代疗法对有症状的患者有益，对亚临床功能不全的情况也有帮助。CP患者应定期随访，主要目的是检测亚临床消化功能不良和胰源性糖尿病的发生。除遗传性CP患者外，不建议对CP患者进行胰腺癌筛查。
