Chronic Alcoholic Pancreatitis

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In chronic alcoholic pancreatitis (CAP), pancreatic damage is observed in a patchy pattern throughout the pancreas. Parenchymal loss and fibrosis occur mainly interlobularly, leaving remaining lobules with a nodular appearance [3, 4].

Histopathological View of CAP and Progression

CAP is a progressive disease and the pathological characteristics differ depending on the stage of the disease and the area being investigated [5, 6].

Fig. 1. Chronic alcoholic pancreatitis (CAP) by disease stages. a Mild fibrosis is seen at interlobular spaces in the early stage of CAP. HE. X10. b Even when lobules become more atrophic and fibrosis has progressed in advanced stages of CAP, fibrosis is mainly localized interlobularly. HE. X20. c Note the island-like or nodular appearance of the remaining lobules. HE. X20. d In CAP, lamellar arranged collagen and mucoprotein, a protein plug, is often observed in pancreatic ducts. HE. X20.

Fig. 1. Chronic alcoholic pancreatitis (CAP) by disease stages. a Mild fibrosis is seen at interlobular spaces in the early stage of CAP. HE. X10. b Even when lobules become more atrophic and fibrosis has progressed in advanced stages of CAP, fibrosis is mainly localized interlobularly. HE. X20. c Note the island-like or nodular appearance of the remaining lobules. HE. X20. d In CAP, lamellar arranged collagen and mucoprotein, a protein plug, is often observed in pancreatic ducts. HE. X20.

In the early stage of the disease, mild interlobular fibrosis is seen; the original interlobular stroma becomes lengthened or widened with fibrosis (fig. 1a). When this interlobular fibrosis progresses, and protein plugs or stones are formed in the pancreatic duct, atrophy of the lobules commences; atrophy and loss of acinar cells are seen [3]. So called 'nodular pancreatitis' is observed in some cases, in which severe inflammatory and repair reactions leave some lobules island-like, or nodular [7, 8]. In the advanced stage, most parenchyma is lost, leaving ducts and Langerhans islets isolated. Even in such severe cases, the shapes of the lobules usually retain their nodular, or so-called cirrhosis-like, appearance (fig. 1b, c).

There is a tendency that parenchymal loss and fibrosis is more severe at peripheral/pericapsular sites of the pancreas. Hence, progressed fibrosis sometimes results in stenosis of the common bile duct, obstruction of the splenic vein, or duodenal obstruction. So-called 'groove pancreatitis' is the state in which inflammation and fibrosis occur at the 'groove' surrounded by the common bile duct, duodenal C-loop and pancreas head, resulting in duodenal stenosis or obstruction [9]. Also, in CAP localized portal hypertension sometimes occurs as a consequence of stenosis or obstruction of the splenic vein [10].

It is worth noting that, in chronic alcoholism or heavy drinkers, fibrosis is distributed intralobularly, in particular, periacinarly [5, 11]. Hence, the pathology of chronic alcoholism is quite distinct from CAP. Clinically, patients with chronic alcoholism also tend to develop liver cirrhosis rather than pancreatitis [12].

Protein Plugs and Stones

In CAP, protein plugs or protein stones are often observed in the pancreatic ducts [13] (fig. 1d). Protein plugs consist of protein derived from zymogen granules, erythrocytes, duct epithelium cells, and mucoprotein secreted by the pancreatic duct [14]. With time, a lamellar arrangement of collagen and muco-protein can be seen. Pancreatic stones are formed in the protein plugs by the deposition of calcium ions derived from pancreatic juice.

Changes in Islets

In CAP, islets appear in a variety of sizes and irregular shapes, particularly in fibrotic lesions. In fibrotic lesions, a depletion of B cells and a relative increase in A, D and PP cells are observed. Clinically, the risk of complication of diabetes mellitus is higher in CAP, and even higher in CAP cases with pancreatic stones.

Other Histopathological Changes

Several metaplastic and hyperplastic changes are often observed in pancreatic duct epithelia, such as pyloric-gland-like mucinous metaplasia/hyperplasia and squamous metaplasia. Cystic changes of branch ducts are also often seen.

These changes, however, also occur as senile changes, and are not specific to CAP.

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Alcoholism is something that can't be formed in easy terms. Alcoholism as a whole refers to the circumstance whereby there's an obsession in man to keep ingesting beverages with alcohol content which is injurious to health. The circumstance of alcoholism doesn't let the person addicted have any command over ingestion despite being cognizant of the damaging consequences ensuing from it.

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