Kronik Pankreatitin Komplikasyonları
Özet
Kronik pankreatit, pankreasta kalıcı yapısal hasara ve fonksiyon kayıplarına yol açan inflamatuar bir süreçtir. Bu durum, başta psödokistler olmak üzere, pankreatik asit ve plevral efüzyon gibi kanal bütünlüğü bozukluklarına neden olur. İnflamasyon ve fibrozis sonucu safra kanalı ve duodenum obstrüksiyonları gelişebilirken; psödoanevrizma ve splenik ven trombozu gibi ciddi vasküler komplikasyonlar hayati risk oluşturabilir. Hastalığın ilerlemesiyle birlikte endokrin yetmezliğe bağlı Tip 3c diyabet ve ekzokrin yetmezliğe bağlı steatore (yağlı ishal) ortaya çıkar. Ayrıca, kronik inflamasyon zemini pankreatik adenokarsinom riskini yaklaşık %4 oranında artırır. Pankreatik fistüller, gastroparezi gibi dismotilite sorunları ve kalsiyum/D vitamini eksikliğine bağlı gelişen metabolik kemik hastalıkları (osteoporoz) da sürecin diğer önemli bileşenleridir. Tanıda USG, BT, MRG ve EUS gibi görüntüleme yöntemleri kritik rol oynarken; tedavi yaklaşımları konservatif takipten endoskopik stentlemeye ve cerrahi drenaj veya rezeksiyon işlemlerine kadar çeşitlilik göstermektedir.
Chronic pancreatitis is an inflammatory process that leads to permanent structural damage and loss of function in the pancreas. This condition causes ductal integrity disorders, primarily pseudocysts, as well as pancreatic ascites and pleural effusion. While biliary duct and duodenal obstructions may develop due to inflammation and fibrosis, serious vascular complications such as pseudoaneurysm and splenic vein thrombosis can pose life-threatening risks. As the disease progresses, Type 3c diabetes due to endocrine insufficiency and steatorrhea due to exocrine insufficiency emerge. Furthermore, the background of chronic inflammation increases the risk of pancreatic adenocarcinoma by approximately 4%. Pancreatic fistulas, dysmotility issues like gastroparesis, and metabolic bone diseases (osteoporosis) resulting from calcium and vitamin D deficiencies are other significant components of the process. Imaging methods such as USG, CT, MRI, and EUS play a critical role in diagnosis, while treatment approaches range from conservative follow-up to endoscopic stenting and surgical drainage or resection procedures.
Referanslar
Gardner, T. B., Adler, D. G., Forsmark, C. E., Sauer, B. G., Taylor, J. R., & Whitcomb, D. C. (2020). ACG clinical guideline: chronic pancreatitis. Official journal of the American College of Gastroenterology ACG, 115(3), 322-339.
Aghdassi, A., Mayerle, J., Kraft, M., Sielenkämper, A. W., Heidecke, C. D., & Lerch, M. M. (2008). Diagnosis and treatment of pancreatic pseudocysts in chronic pancreatitis. Pancreas 36(2), 105-112.
Baillie, J. (2004). Pancreatic pseudocysts (part I). Gastrointestinal endoscopy, 59(7), 873-79.
Beyer, G., Habtezion, A., Werner, J., Lerch, M. M., & Mayerle, J. (2020). Chronic pancreatitis. The Lancet, 396(10249), 499-512.
Ramsey, M. L., Conwell, D. L., & Hart, P. A. (2017). Complications of chronic pancreatitis. Digestive diseases and sciences, 62(7), 1745-1750.
Banks, P. A., Bollen, T. L., Dervenis, C., Gooszen, H. G., Johnson, C. D., Sarr, M. G., ... & Vege, S. S. (2013). Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut, 62(1), 102-111.
Chauhan, S. S., & Forsmark, C. E. (2013). Evidence-based treatment of pancreatic pseudocysts. Gastroenterology, 145(3), 511-513.
Elmunzer, B. J. (2018). Endoscopic drainage of pancreatic fluid collections. Clinical Gastroenterology and Hepatology, 16(12), 1851-1863.
Teoh, A. Y., Dhir, V., Kida, M., Yasuda, I., Jin, Z. D., Seo, D. W., .& Ho, L. K. Y. (2018). Consensus guidelines on the optimal management in interventional EUS procedures: results from the Asian EUS group RAND/UCLA expert panel. Gut, 67(7), 1209-1228.
Samuelson, A. L., & Shah, R. J. (2012). Endoscopic management of pancreatic pseudocysts. Gastroenterology Clinics, 41(1), 47-62.
Blatnik, J. A., & Hardacre, J. M. (2013). Management of pancreatic fistulas. Surgical Clinics, 93(3), 611-617.
Feldman, M., Friedman, L. S., & Brandt, L. J. (Eds.). (2020). Sleisenger and Fordtran's gastrointestinal and liver disease E-book: pathophysiology, diagnosis, management. Elsevier health sciences.
Lesur, G., Levy, P., Flejou, J. F., Belghiti, J., Fekete, F., & Bernades, P. (1993). Factors predictive of liver histopathological appearance in chronic alcoholic pancreatitis with common bile duct stenosis and increased serum alkaline phosphatase. Hepatology, 18(5), 1078-1081.
Hammel, P., Couvelard, A., O'Toole, D., Ratouis, A., Sauvanet, A., Fléjou, J. F., ... & Lévy, P. (2001). Regression of liver fibrosis after biliary drainage in patients with chronic pancreatitis and stenosis of the common bile duct. New England Journal of Medicine, 344(6), 418-423.
Kahl, S., Zimmermann, S., Genz, I., Glasbrenner, B., Pross, M., Schulz, H. U., ... & Malfertheiner, P. (2003). Risk factors for failure of endoscopic stenting of biliary strictures in chronic pancreatitis: a prospective follow-up study. The American journal ofgastroenterology, 98(11), 2448-2453.
Chan, C. H., & Telford, J. J. (2012). Endoscopic management of benign biliary strictures. Gastrointestinal Endoscopy Clinics, 22(3), 511-537.
Mangiavillano, B., Pagano, N., Baron, T. H., & Luigiano, C. (2015). Outcome of stenting ın biliary and pancreatic benign and malignant diseases: a comprehensive review. World Journal of Gastroenterology: WJG, 21(30), 9038.
Zhao, X., Cui, N., Wang, X., & Cui, Y. (2017). Surgical strategies in the treatment of chronic pancreatitis: An updated systematic review and meta-analysis of randomized controlled trials. Medicine, 96(9).
Plagemann, S., Welte, M., Izbicki, J. R., & Bachmann, K. (2017). Surgical treatment for chronic pancreatitis: past, present, and future. Gastroenterology research and practice, 2017.
Dua, M. M., & Visser, B. C. (2017). Surgical approaches to chronic pancreatitis: indications and techniques. Digestive diseases and sciences, 62(7), 1738-1744.
Forsmark, C. E., Wilcox, C. M., & Grendell, J. H. (1992). Endoscopy-negative upper gastrointestinal bleeding in a patient with chronic pancreatitis. Gastroenterology, 102(1), 320-329.
Yu, P., & Gong, J. (2018). Hemosuccus pancreaticus: A mini-review. Annals of medicine and surgery, 28, 45-48.
Evans, R. P., Mourad, M. M., Pall, G., Fisher, S. G., & Bramhall, S. R. (2017). Pancreatitis: Preventing catastrophic haemorrhage. World Journal of gastroenterology, 23(30), 5460.
Kirby, J. M., Vora, P., Midia, M., & Rawlinson, J. (2008). Vascular complications of pancreatitis: imaging and intervention. Cardiovascular and interventional radiology, 31(5), 957-970.
Butler, J. R., Eckert, G. J., Zyromski, N. J., Leonardi, M. J., Lillemoe, K. D., & Howard, T. J. (2011). Natural history of pancreatitis-induced splenic vein thrombosis: a systematic review and meta-analysis of its incidence and rate of gastrointestinal bleeding. Hpb, 13(12), 839-845.
Andersen, D. K. (2007). Mechanisms and emerging treatments of the metabolic complications of chronic pancreatitis. Pancreas, 35(1), 1-15.
Cui, Y., & Andersen, D. K. (2011). Pancreatogenic diabetes: special considerations for management. Pancreatology, 11(3), 279-294.
Rickels, M. R., Bellin, M., Toledo, F. G., Robertson, R. P., Andersen, D. K., Chari, S. T., ... & Participants, P. R. C. (2013). Detection, evaluation and treatment of diabetes mellitus ın chronic pancreatitis: recommendations from PancreasFest 2012. Pancreatology, 13(4), 336-42.
Andersen, D. K. (2012). The practical importance of recognizing pancreatogenic or type 3c diabetes. Diabetes metabolism research and reviews, 28(4), 326-328.
Linde, J., Nilsson, L. H. S., & Barany, F. R. (1977). Diabetes and hypoglycemia in chronic pancreatitis. Scandinavian journal of gastroenterology, 12(3), 369-373.
Hart, P. A., & Conwell, D. L. (2020). Chronic pancreatitis: managing a difficult disease. The American journal of gastroenterology, 115(1), 49.
de la Iglesia-García, D., Huang, W., Szatmary, P., Baston-Rey, I., Gonzalez-Lopez, J., Prada-Ramallal, G., ... & Sutton, R. (2017). Efficacy of pancreatic enzyme replacement therapy in chronic pancreatitis: systematic review and meta-analysis. Gut, 66(8), 1354-55.
Hart, P. A., & Conwell, D. L. (2016). Challenges and updates in the management of exocrine pancreatic insufficiency. Pancreas, 45(1), 1-4.
Hart, P. A., & Conwell, D. L. (2015). Diagnosis of exocrine pancreatic insufficiency. Current treatment options in gastroenterology, 13(3), 347-353.
Ramsey, M. L., Conwell, D. L., & Hart, P. A. (2017). Complications of chronic pancreatitis. Digestive diseases and sciences, 62(7), 1745-1750.
Domínguez‐Muñoz, J. E. (2011). Pancreatic exocrine insufficiency: diagnosis and treatment. Journal of gastroenterology and hepatology, 26, 12-16.
de la Iglesia-Garcia, D., Vallejo-Senra, N., Iglesias-Garcia, J., López-López, A., Nieto, L., & Domínguez-Muñoz, J. E. (2018). Increased risk of mortality associated with pancreatic exocrine insufficiency in patients with chronic pancreatitis. Journal of clinical gastroenterology, 52(8), e63-e72.
Forsmark, C. E. (2018). Diagnosis and management of exocrine pancreatic insufficiency. Current treatment options in gastroenterology, 16(3), 306-315.
Chonchubhair, H. M. N., Bashir, Y., Dobson, M., Ryan, B. M., Duggan, S. N., & Conlon, K. C. (2018). The prevalence of small intestinal bacterial overgrowth in non-surgical patients with chronic pancreatitis and pancreatic exocrine insufficiency (PEI). Pancreatology, 18(4), 379-385.
DiMagno, M. J., & Forsmark, C. E. (2018). Chronic pancreatitis and small intestinal bacterial overgrowth. Pancreatology: official journal of the International Association of Pancreatology (IAP) [et al.], 18(4), 360-362.
Algül, H., Treiber, M., Lesina, M., & Schmid, R. M. (2007). Mechanisms of disease: chronic inflammation and cancer in the pancreas—a potential role for pancreatic stellate cells?. Nature Clinical Practice Gastroenterology & Hepatology, 4(8), 454-462.
Shelton, C. A., Umapathy, C., Stello, K., Yadav, D., & Whitcomb, D. C. (2018). Hereditary pancreatitis in the United States: survival and rates of pancreatic cancer. The American journal of gastroenterology, 113(9), 1376.
Sheth, S. G., Conwell, D. L., Whitcomb, D. C., Alsante, M., Anderson, M. A., Barkin, J.,... & Hart, P. A. (2017). Academic Pancreas Centers of Excellence: Guidance from a multidisciplinary chronic pancreatitis working group at Pancreas Fest. Pancreatology, 17(3), 419-430.
Lowenfels, A. B. (1993). International Pancreatitis Study Group. Pancreatitis and the risk of pancreatic cancer. N Eng J Med, 328, 1433-1437.
Raimondi, S., Lowenfels, A. B., Morselli-Labate, A. M., Maisonneuve, P., & Pezzilli, R. (2010). Pancreatic cancer in chronic pancreatitis; aetiology, incidence, and early detection. Best practice & research Clinical gastroenterology, 24(3), 349-358.
Eibl, G., Cruz-Monserrate, Z., Korc, M., Petrov, M. S., Goodarzi, M. O., Fisher, W. E., ... & Andersen, D. K. (2018). Diabetes mellitus and obesity as risk factors for pancreatic cancer. Journal of the Academy of Nutrition and Dietetics, 118(4), 555-567.
Andersen, D. K., Korc, M., Petersen, G. M., Eibl, G., Li, D., Rickels, M. R., ... & Abbruzzese, J. L. (2017). Diabetes, pancreatogenic diabetes, and pancreatic cancer. Diabetes, 66(5), 1103-1110.
Loosen, S. H., Neumann, U. P., Trautwein, C., Roderburg, C., & Luedde, T. (2017). Current and future biomarkers for pancreatic adenocarcinoma. Tumor Biology, 39(6), 10104283176922321.
Blatnik, J. A., & Hardacre, J. M. (2013). Management of pancreatic fistulas. Surgical Clinics, 93(3), 611-617.
Malleo, G., Pulvirenti, A., Marchegiani, G., Butturini, G., Salvia, R., & Bassi, C. (2014). Diagnosis and management of postoperative pancreatic fistula. Langenbeck's archives of surgery, 399(7), 801-810.
Vu, M. K., Vecht, J., Eddes, E. H., Biemond, I., Lamers, C. B. H. W., & Masclee, A. A. M. (2000) Antroduodenal motility in chronic pancreatitis: are abnormalities related to exocrine insufficiency? American Journal of Physiology-Gastrointestinal and Liver Physiology, 278(3), G458-G466.
Chowdhury, R. S., Forsmark, C. E., Davis, R. H., Toskes, P. P., & Verne, G. N. (2003). Prevalence of gastroparesis in patients with small duct chronic pancreatitis. Pancreas, 26(3), 235-238.
Duggan, S. N., Smyth, N. D., Murphy, A., MacNaughton, D., O'Keefe, S. J., & Conlon, K. C. (2014). High prevalence of osteoporosis in patients with chronic pancreatitis: a systematic review and meta-analysis. Clinical Gastroenterology and Hepatology, 12(2), 219-228.
Tignor, A. S., Wu, B. U., Whitlock, T. L., Lopez, R., Repas, K., Banks, P. A., & Conwell, D. (2010). High prevalence of low-trauma fracture in chronic pancreatitis. Official journal of the American College of Gastroenterology ACG, 105(12), 2680-2686.
Duggan, S. N., Purcell, C., Kilbane, M., O'keane, M., McKenna, M., Gaffney, P., ... & Conlon, K. C. (2015). An association between abnormal bone turnover, systemic inflammation, and osteoporosis in patients with chronic pancreatitis: a case-matched study. Official journal of the American College of Gastroenterology ACG, 110(2), 336-45.
Bang, U. C., Benfield, T., Bendtsen, F., Hyldstrup, L., & Jensen, J. E. B. (2014). The risk of fractures among patients with cirrhosis or chronic pancreatitis. Clinical Gastroenterology and Hepatology, 12(2), 320-326.
