Chronic pancreatitis
1. °³¿ä
¸¸¼º ÃéÀå¿° ȯÀÚ´Â Áö¼ÓÀûÀ¸·Î º¹ÅëÀ» ÀÏÀ¸Å³¼ö ÀÖ´Ù(with or without steatorrhea)
15%´Â ÅëÁõ¾øÀÌ steatorrhea¸¸ º¸ÀδÙ.
¹Ì±¹¼ºÀο¡¼ °¡Àå ¸¹Àº ¿øÀÎÀº ¾ËÄÝÀÌ°í ¾ÆÀÌ´Â cystic fibrosisÀ̸ç
25%´Â ¿øÀÎÀ» ¸ð¸¥´Ù(idiopathic chronic pancreatitis).
= CFTR(cystic fibrosis transmembrane conductance regulator)°¡ Áõ¸íµÊ.
<Á¤¸®>
¸¸¼ºÃéÀå¿°ÀÇ mc cause: ¼ºÀÎ = alcohol, idiopathic(gallstoneÀº ¸¸¼ºÃéÀå¿° ÀÏÀ¸Å°Áö
¾ÊÀ½) ¼Ò¾Æ = cystic fibrosis
±Þ¼ºÃéÀå¿°ÀÇ mc cause: alcohol, gallstone
2. º´Å»ý¸®
1) alcohol-induced pancreatitisÀÇ 1Â÷Àû °áÇÔÀº duct¿¡ ´Ü¹éÀÌ Ä§ÂøµÇ¾î »ý±ä´Ù.
(inspissated enzyme)
-> ductal obstruction
-> ductal dilatation, diffuse atrophy of acinar cells, fibrosis, protein plugÀÇ calcification
*¹Ý·ÐÀÌ ¸¹´Ù.
2) direct toxic effect
3. Áø´Ü
¨ç s-amylase, lipase´Â ÈçÈ÷ Á¤»ó
Bil¡è, ALP¡è : cholestasisÀǹÌ(CBDÁÖÀ§ÀÇ ¸¸¼º¿°Áõ¿¡ ÀÇÇØ)
impaired glu tolerance°¡ ÈçÇÏ´Ù-> glu¡è
¨è Classic triad : pancreatic calcification, steatorrhea, DM
-> chronic pancreatitisȯÀÚÀÇ 1/3¹Ì¸¸¿¡¼¸¸ °üÂûµÈ´Ù.
¨é Secretin stimulation test
pancreatic exocrine fxÀÌ 60%ÀÌ»ó ¼Ò½ÇµÇ¸é ºñÁ¤»ó¼Ò°ßÀÌ ³ª¿Â´Ù.
¨ê Vit B12(Cobalamin) malabsorption
oral pancreatic enzymeÅõ¿©ÈÄ ±³Á¤µÈ´Ù.
¨ë fecal fat¡è : ¿ª½Ã oral pancreatic enzymeÅõ¿©ÈÄ ±³Á¤µÈ´Ù.
¨ì s-trypsinogen, D-xylose urinary excretion test : "pancreatic steatorrhea"
: trypsinogen levelÀÌ ºñÁ¤»óÀ̰í D-xyloseºÐºñ´Â ÈçÈ÷ Á¤»óÀ̹ǷÎ
pancreatic steatorrheaÁø´Ü¿¡ µÎ°¡Áö °Ë»ç¸¦ µ¿½Ã¿¡ Çϸé À¯¿ëÇÏ´Ù.
* s-trypsinogen levelÀÇ °¨¼Ò´Â severe pancreatic exocrine insufficiency¸¦ ÀǹÌÇÑ´Ù.
¨í ¹æ»ç¼±¼Ò°ß - scattered calcification
ductal decompressionÈÄ¿¡ 1/3¿¡¼ pancreatic calcificationÀÌ °¨¼ÒÇÏ¿© ÀúÀý·Î
¼Ò½ÇµÈ´Ù.
USG, CT, ERCPµµ Áø´Ü¿¡ µµ¿òÀÌ µÇ´Âµ¥ pseudocyst, pancreatic ca¸¦ ¹èÁ¦ÇÒ¼ö ÀÖÀ¸¸ç
pancreatic calcification or dilated duct¸¦ °üÂûÇÒ¼ö ÀÖ´Ù.
ERCP´Â alcohol-induced pancreatitis¿¡¼ USG, CT¿¡¼ ¹ß°ßÇÏÁö ¸øÇÑ pseudocyst¸¦
ãÀ»¼öµµ ÀÖ´Ù.
4. ÇÕº´Áõ
¨ç cobalamin(vit B12) malabsorption
alcohol-induced chronic pancreatitisÀÇ 40%
cystic fibrosis·Î ÀÎÇÑ pancreatitisÀÇ ´ëºÎºÐ¿¡¼ »ý±ä´Ù.
- IF¶§¹®ÀÌ ¾Æ´Ï¶ó °ú´ÙÇÑ cobalamin-binding protein ¶§¹®¿¡ »ý±â¸ç pancreatic protease
Åõ¿©·Î ±³Á¤µÈ´Ù.
* cobalamin-binding protein : ¿ø·¡´Â pancreatic protease¿¡ ÀÇÇØ ÆÄ±«µÇ¾î¾ß Çϳª
chronic pancreatitis ¿¡¼± ÆÄ±«°¡ ¾ÈµÈ´Ù.
¨è impaired glucose tolerance : ´ëºÎºÐ »ý±â³ª DKA or diabetic coma´Â µå¹°¸ç
end-organ damage(retinopathy, neuropathy, nephropathy)µµ µå¹°´Ù.
* nondiabetic retinopathy : peripheral location, ÈçÇÏ´Ù.
vit A and/or zinc deficiency¿¡ ÀÇÇØ 2Â÷ÀûÀ¸·Î ¹ß»ýÇÑ´Ù.
¨é Effusion : amylase¡è(pleural, pericardial, peritoneal space)
¨ê GI bleeding
: peptic ulcer, gastritis, pseudocyst erosion, varix ruptureµîÀ¸·Î ÀÎÇØ
¨ë icterus : pancreas head edema¿¡ ÀÇÇØ CBD compressionµÇ¾î ¹ß»ýÇÏ¿©
Áö¼ÓÀû Æó¼â´Â ´ã°ü¿°À» À¯¹ßÇÏ°í °á±¹ biliary cirrhosis¸¦ À¯¹ßÇÏ°Ô µÈ´Ù.
¨ì subcutaneous fat necrosis : tender red nodules on the lower extremites
¨í bone pain : intramedullary fat necrosis¿¡ ÀÇÇØ 2Â÷ÀûÀ¸·Î ¹ß»ý
¨î pancreatic cancer
2³âÀÌ»ó °æ°úÇϸé ÃéÀå¾ÏÀÇ ºóµµ°¡ Áõ°¡ÇÏ°Ô µÇ´Âµ¥
20³â ÀÌ»ó Áö³ ¸¸¼ºÃéÀå¿°ÀÇ pancreatic cancer cumulative risk´Â 4%ÀÌ´Ù.
¨ï narcotics addiction : °¡Àå ÈçÇÑ ¹®Á¦À̰í Áß¿äÇÑ ¹®Á¦ÀÌ´Ù.
5. Ä¡·á - ÅëÁõÀÇ Á¶Àý°ú Èí¼öÀå¾Ö¿¡ ÃÊÁ¡À» ¸ÂÃá´Ù.
1) Pain
¨ç alcoholÁß´ÜÇϰí fat-rich mealÇÇÇÒ°Í
¨è narcotics»ç¿ëÀ¸·Î addictionµÇ±â ½±´Ù.
¨é primary ductal obstruction
: ductal decompressionÀÌ È¿°úÀûÀÎ ÅëÁõ Ä¡·á¹æ¹ýÀÌ´Ù.
short-term pain relief : 80% long-term pain relief : 50%
-> °¢Á¾ Ä¡·á·Î 3/4¿¡¼ ÅëÁõÁ¶ÀýÀÌ °¡´ÉÇÏÁö¸¸
panceatic endocrine & exocrine insuffiency´Â pancreatic enzyme replacement tx·Î
Ä¡·áÇØ¾ß ÇÑ´Ù.
¨ê splanchnectomy, celiac ganglinectomy, nerve block°ú °°Àº ½Ã¼úÀº ÀϽÃÀû È£Àü¸¸À»
°¡Á®¿À¹Ç·Î ÃßõµÇÁö ¾Ê´Â´Ù.
¨ë ERCP with sphincterotomy or dilatation or stenting
Ä¡·áÈ¿°ú¿¡ ´ëÇØ Áõ¸íµÈ ¹Ù°¡ ¾ø´Ù.
¿ÀÈ÷·Á ½ÉÇÑ ÇÕº´Áõ(acute pancreatitis, pancreatic abscess, pancreatic duct damage,
death)ÀÌ ¹ß»ýÇÏ¸ç Æ¯È÷ stentÇÑ °æ¿ì ÇÕº´Áõ ¹ß»ý·üÀº 36%³ª µÈ´Ù.
¨ì small-duct chronic pancreatitis
¸¸¼ºÀû º¹ÅëÀ» º¸ÀÌÁö¸¸ USG, CT, ERCP¿¡¼ Á¤»ó¼Ò°ßÀ» º¸À̰í
secretin test¿¡¼ ÀÌ»ó¼Ò°ßÀ» º¸ÀÌ´Â °æ¿ì¿¡ ÅëÁõÀ» °æ°¨½Ã۱â À§ÇØ pancreatic
enzyme(non-enteric coated)À» »ç¿ëÇϸé Àß ¹ÝÀÀÇÑ´Ù.
¨í severe large-duct disease
ÀϺκ¸°í¿¡¼ octreotide°¡ ÅëÁõÀ» °æ°¨½Ã۴µ¥ È¿°ú°¡ ÀÖ´Ù°í ÇÏ¿´´Ù.
2) Malabsorption: pancreatic enzyme replacement
¨ç Diarrhea, steatorrhea
ºñ·Ï Áö¹æº¯ÀÌ ¿ÏÀüÈ÷ ÁÁ¾ÆÁöÁö´Â ¾Ê´õ¶óµµ enzyme replacement tx·Î ¼³»ç¿Í Áö¹æº¯ÀÌ
ÈçÈ÷ È£ÀüµÈ´Ù.
ÁÖ ¹®Á¦´Â È¿¼Ò¸¦ ½ÊÀÌÁöÀåÀ¸·Î ÃæºÐÈ÷ Àü´ÞÇÏ´Â °ÍÀÌ Áß¿äÇѵ¥ ´ë·« lipase Á¤»óÀÇ 10%
¸¸ ½ÊÀÌÁöÀåÀ¸·Î Àü´ÞµÇ¾îµµ steatorrhea°¡ ÀϾÁö ¾Ê´Â´Ù.
°ú·®ÀÇ È¿¼Ò¸¦ º¹¿ëÇÏ¿©µµ steatorrhea°¡ ¾ø¾îÁöÁö ¾Ê´Â °ÍÀº ´ÙÀ½°ú °°Àº ÀÌÀ¯ ¶§¹®ÀÌ´Ù.
i) À§»ê¿¡ ÀÇÇØ lipase°¡ ºÒȰ¼ºÈµÊ
ii) À½½ÄÀÌ È¿¼Òº¸´Ù ¸ÕÀú ½ÊÀÌÁöÀåÀ¸·Î ³Ñ¾î°¨.
iii) »ó¾÷ÀûÀ¸·Î ÀÌ¿ëµÇ´Â pancreatic extractÀÇ enzyme activity°¡ ´Ù¾çÇÔ.
º¸Åë ȯÀڵ鿡°Ô 2-3 enteric-coated capule or 8 conventional(non-enteric coated)
tabletÀ» º¹¿ëÅä·Ï Çϸç conventional tabletÀ» »ç¿ëÇÏ´Â ÀϺΠȯÀÚµéÀº adjuvant tx°¡ ÇÊ¿ä
ÇÏ´Ù.
* adjuvant tx
H2 blocker, sodium bicarbonate, PPI´Â µµ¿òÀÌ µÇ³ª
Ca, Mg°°Àº Á¦»êÁ¦´Â È¿°ú°¡ ¾øÀ¸¸ç steatorrhea¸¦ ¾ÇȽÃŲ´Ù.
¨è Secretin test : ÀÌ»ó¼Ò°ß, bicarbonate³óµµ¡é
pancreatic enzyme 3-4ÁÖ Åõ¿©ÇÑ´Ù.
¨é Diet
fatÁߵ(30%), high protein(24%), low carbohydrate(40%)
long-chain TG¸¦ Á¦ÇÑÇϰí medium-chain TG¸¦ ¸Ôµµ·Ï ÇÑ´Ù(¡ñlipase°¡ ÇÊ¿ä¾øÀ¸¹Ç·Î).