Tropical Chronic Pancreatitis Research Articles

Comparison of sarcopenia in alcoholic and tropical chronic pancreatitis

Comparison of sarcopenia in alcoholic and tropical chronic pancreatitis

Chronic pancreatitis - an update

Chronic pancreatitis (CP) is a progressive inflammatory process that causes irreversible damage to the pancreas due to fibrosis and scarring. The incidence of CP varies among regions. Alcohol consumption and smoking are the main aetiologicalfactors of CP. In addition, autoimmune diseases, hereditary and genetic factors, and tropical CP also contribute to this condition. Though no single mechanism has been shown to initiate CP pathogenesis, this disease ultimately results in fibrosis, scarring, and insufficiency in the pancreas. Chronic upper abdominal pain, steatorrhea, malnutrition, and diabetes mellitus are the main clinical features of CP. Detecting this disease at an early stage is difficult unless it is explicitly checked for due to strong suspicions. Nevertheless, pancreatic function tests, imaging, and endoscopy are used to diagnose CP . Pain management, exocrine supplementation, diabetic management, and endoscopic or surgical drainage and resection procedures are essential for managing CP. Early surgical intervention can improve the remaining pancreatic reserve, delay pancreatic failure, and improve the quality of life of patients with this disease.

The Current Concepts and Management of Idiopathic (Tropical) Chronic Pancreatitis

Tropical chronic pancreatitis (TCP) is a special variant of idiopathic chronic pancreatitis that is seen mainly in tropical countries. Although the prevalence of tropical pancreatitis is high in southern India, it is reported from most parts of India. It occurs usually in young people, involves the main pancreatic duct, and results in large ductal calculi with high incidence of diabetes and malignancy. Recent reports suggest that the presentation is changing. The age of onset is older and the disease course seems to be milder. The etiology is not known, but genetic mutations and environmental factors are likely causes. This article is a narrative review of the recent trends in the etiopathogenesis and management of tropical calcific pancreatitis (TCP). Extensive literature search was done from PubMed and Ovid. Article was prepared by reviewing full-text articles and abstracts related to chronic calcific pancreatitis (CCP) and TCP.

Unusual type of diabetes: fibrocalculous pancreatic diabetes.

A 34-year-old Thai man complained about recurrent upper abdominal pain, polyuria, and a 5-kg weight loss in 6 months. He had no history of steatorrhea, jaundice, gallstones, alcohol intake, or cassava consumption. Physical examination was unremarkable except for his body mass index of 17.6 kg/m². The plasma glucose level was 672 mg/dL with normal serum amylase and lipase. Laboratory investigation showed serum osmolality of 287 mOsm/kg, bicarbonate 22 mEq/L and negative for serum ketone. Fibrocalculous pancreatic diabetes (FCPD) was diagnosed from a plain abdominal X-ray study showing multiple large calcifications over a pancreatic area (A). Computerized tomography of the abdomen revealed a large tubular calcification in dilated pancreatic duct during entering the duodenum (B). Scattered calcifications along the pancreatic duct were also noted (C). A genetic study revealed a SPINK1 N34S heterozygous mutation. His hyperglycemia responded well to insulin therapy. FCPD, a late stage of tropical chronic pancreatitis (TCP), is classified as a secondary cause of diabetes resulting from pancreatic dysfunction. The clinical picture consists of a triad of pancreatic calcification, abdominal pain, and diabetes. Its distinctive features are young age at onset, lean or underweight, ketosis-resistant diabetes, presence of large intraductal pancreatic calculi, and reported mainly in tropical developing countries. An etiology was previously thought to relate to malnutrition; however, a strong association with SPINK1 mutation is noted. The major morbidities are recurrent abdominal pain, steatorrhea, and malnutrition, while the majority of death is associated with diabetic nephropathy and pancreatic cancer. Treatment includes pancreatic enzyme supplementation, insulin therapy, and surgical drainage.

Chronic Pancreatitis in Thai Patients: A Comprehensive Review of 236 Patients from One Institution

Background: Reports of chronic pancreatitis (CP) in Thailand are rare. Clinical information is lacking. Objective: To study the etiology, genetics, presentations, clinical courses, complications, treatments, and outcomes of CP in Siriraj Hospital. Materials and Methods: Retrospective study of all CP patients during 2005 to 2018 was done. CP was diagnosed by abdominal radiography, ultrasonography, computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasonography (EUS). Etiology, genetics, presentations, clinical courses, complications, treatments and outcomes were analyzed. Results: There were 236 CP patients. The median follow-up was 37 months. There were 160 patients (68%) with alcoholic CP (ACP), 35 (15%) with early-onset idiopathic CP (E-ICP), 36 (15%) with late-onset idiopathic CP (L-ICP), 1 (0.4%) with tropical CP, 3 (1%) with hereditary pancreatitis (HP) and 1 (0.4%) with obstructive CP. Mean ages of onset were 47, 28 and 60 years in ACP, E-ICP and L-ICP, respectively (p<0.001). Male was predominant in all types of CP (98%, 40% and 56%; p<0.001). Initial presentations were abdominal pain (59%), recurrent acute pancreatitis (RAP, 22%), diabetes (DM, 8%) and steatorrhea (8%). Clinical manifestations during the course were abdominal pain in 89%, 89% and 83% (p = 0.832), RAP in 41%, 48% and 11% (p = 0.001), steatorrhea in 31%, 25% and 25% (p = 0.661), weight loss in 38%, 31% and 44% (p = 0.526), DM in 29%, 37% and 25% (p = 0.502), respectively. Median time to pain relief were 33, 74, and 16 months (p = 0.002). Common complications were pseudocyst (16%) and biliary obstruction (15%). SPINK1 mutation was detected in 83% of E-ICP, 45% of L-ICP and 21% of ACP (p<0.001). PRSS1 mutation was found in all HP. Medical therapy included analgesics (62%), pancreatic enzymes (76%) and antioxidants (9%). Endoscopic therapy was done in 48 patients (20%). Surgery was performed in 31 patients (13%). Conclusion: ACP, E-ICP and L-ICP are common etiologies of CP. Presentations were RAP, abdominal pain, DM and steatorrhea. Painless L-ICP was uncommon. Spontaneous pain relief occurred quickly. SPINK1 mutation was common in ICP. Endoscopic and surgical therapy were required in one-fifth. Keywords: Chronic pancreatitis, Etiology, Genetics, Management, Manifestation, Natural course, Review  

Fibrocalculous pancreatic diabetes.

Fibrocalculous pancreatic diabetes (FCPD) is a unique form of diabetes reported from tropical countries, associated with both endocrine and exocrine disease of the pancreas. The pre-diabetic phase of the disease is called tropical chronic pancreatitis (TCP). Currently FCPD is classified as a secondary form of diabetes called pancreatic diabetes, because essentially the disease is caused by pancreatic damage. There is an overlap of these subjects with idiopathic, non-alcoholic pancreatitis. This review will cover the etiopathogenesis, diagnosis and management of this clinical condition. FCPD could lead to endocrine dysfunction (diabetes and its complications) as well as exocrine dysfunction, and is associated with a higher risk of pancreatic cancer, for which early detection is important.

Outcome after surgical management of tropical and alcoholic chronic pancreatitis - A Indian tertiary centre experience

Outcome after surgical management of tropical and alcoholic chronic pancreatitis - A Indian tertiary centre experience

Assessment of insulin sensitivity and secretion in patients with fibrocalculous pancreatic diabetes.

Background: Fibrocalculous pancreatic diabetes (FCPD) is a secondary form of diabetes seen in patients with tropical chronic pancreatitis. Insulin deficiency plays a major role in the etiopathogenesis of FCPD. Limited data suggest a possible role of insulin resistance (IR) in the pathogenesis of FCPD. Sparse data exist on measures of insulin sensitivity (IS) and secretion in patients with FCPD and its comparison to type 2 diabetes mellitus (T2D) patients.Method: Eighty patients with FCPD, 36 patients with T2D and 36 healthy subjects were included. A 75 g oral glucose tolerance test (OGTT) was performed in the morning after an overnight fast. We evaluated IS and secretion using indices derived from fasting (homeostasis model assessment of insulin resistance [HOMA-IR], quantitative insulin sensitivity check index [QUICKI] and homeostasis model assessment of beta-cell function [HOMA-ß]) and OGTT (Matsuda, insulin sensitivity index by Kanauchi [ISI-K], oral glucose insulin sensitivity index [OGIS], Stumvoll, insulinogenic index and oral disposition index [ODI]) measurements of glucose and insulin.Results: HOMA-IR was significantly higher and QUICKI significantly lower in patients with FCPD and T2D than in healthy controls (P<0.001). Matsuda, ISI-K, OGIS and Stumvoll were significantly lower in patients with FCPD and T2D than in healthy controls (P<0.001), indicating reduced IS in both FCPD and T2D patients. HOMA-ß, insulinogenic index and ODI were significantly lower in patients with FCPD and T2D compared to healthy controls (P<0.001).Conclusion: FCPD is associated with reduced IS as assessed by fasting and OGTT-based indices. FCPD is also associated with a greater degree of impairment in insulin secretion than in T2D. IR may play a role in the pathogenesis of FCPD.

A Rare Case of Acute Cholangitis in a Young Male with Tropical Chronic Pancreatitis-Induced Pancreatic Adenocarcinoma with Metastasis to the Liver

Tropical chronic pancreatitis (TCP) is a rare and poorly understood variant of chronic pancreatitis. It is typically diagnosed in young, nonalcoholic patients in tropical regions such as southern Asia, often presenting with abdominal pain, and leading to several complications, including diabetes, malnutrition, and pancreatic adenocarcinoma. Though the link between chronic pancreatitis and cancer is established, the risk for malignancy is highest in those with rare causes of chronic pancreatitis. We present a case of TCP-induced pancreatic adenocarcinoma complicated by acute cholangitis. A 34 year-old Bangladeshi male with TCP complicated by diabetes and stage IV pancreatic adenocarcinoma with liver metastasis, s/p whipple procedure, and 3 cycles of adjuvant Gemcitabine and Abraxane presented with acute worsening of chronic abdominal pain. Labs were remarkable for elevated liver enzymes and a marked increase in CA 19-9. CT Abdomen/Pelvis revealed progression of metastatic disease in the liver and upper abdomen, including the peritoneum and anterior abdominal wall. His pain persisted despite EUS-guided celiac plexus block, but became acutely worse on hospital day 15 when he became febrile, jaundiced, and with blood cultures growing E. Coli, Klebsiella, and Aeromonas. Due to concern for acute cholangitis secondary to stenosis of hepaticojejunostomy, he was taken for ERCP. The biliary system was not successfully identified, so he then underwent IR-guided placement of a biliary drain via percutaneous transhepatic cholangiography, which showed central biliary stenosis and severe bilateral ductal dilation. He was subsequently placed in hospice due to his poor prognosis. The etiology of TCP is multifactorial, but also associated with a mutation of the SPINK1 gene, which causes parenchymal damage by lowering the threshold for trypsin activation. Characteristic radiographic findings include a dilated pancreatic duct with large intra-ductal calculi, pancreatic calcifications, and pancreatic atrophy. Data suggests that only 5% of patients with a 20-year history of chronic pancreatitis develop cancer, but 17% of patients with TCP develop malignancy, which is significantly higher than the near 0% risk of malignancy in those with chronic alcoholic pancreatitis. TCP is a rare disease that potentiates many long-term complications that can significantly increase mortality in an otherwise young and healthy population.1273_A.tif Figure 1: Marked dilation of pancreatic duct measuring up to 18 mm (blue arrow) that terminates at the pancreatic head due to a large calcification (red arrow).1273_B.tif Figure 2: Fine needle aspiration of mass at pancreatic head (blue arrow) and dilated CBD measuring up to 13mm (red arrow).1273_C.tif Figure 3: Multiple hepatic metastatic lesions (blue arrows) and invasion of the pancreatic head mass into the anterior abdominal wall (red arrow).

Laparoscopic lateral pancreaticojejunostomy: an evolution to endostapled technique.

Chronic pancreatitis (CP) is a debilitating condition resulting in severe pain with progressive deterioration of pancreatic function. "Tropical" pancreatitis represents a variant of the disease with widely dilated ducts, numerous calculi, and few strictures. Traditionally, modified Puestow's procedure has been the treatment of choice for a dilated pancreatic ductal system. However, it has only recently been adapted to laparoscopic approach which is a technically demanding procedure primarily due to need for extensive intra-corporeal suturing. Symptomatic cases of CP presenting at our center with minimum 8mm mean ductal diameter at body and head were selected for laparoscopic modified Puestow's procedure. Those with prior pancreatic surgery, pancreatic head masses, endoscopic pancreatic stenting, and portal hypertension were excluded. Twenty-eight cases meeting selection criteria underwent a laparoscopic procedure. Seven patients (25%) underwent a stapled pancreaticojejunal anastomosis, 17 (60.7%) received a sutured anastomosis. Four patients (14.3%) were converted to open surgery due to failure to localize the pancreatic duct with percutaneous needle aspiration. Of those patients who underwent a successful laparoscopic procedure, a single patient developed a pancreatic fistula which resolved spontaneously; another patient had a difficult post-operative course with prolonged intensive care. We suffered no mortality within the series and no patient had any long-term disability. Anastomotic patency rates of 100% were achieved by the third post-operative month. Lateral pancreaticojejunostomy is an effective surgical management for CP with a dilated ductal system. Its laparoscopic adoption is the rational next surgical step. It allows effective duct decompression with low mortality and morbidity. The procedure demands an advanced surgical skill set with an emphasis on intra-corporeal suturing. Those patients suffering from tropical CP with wide ductal dilatation greater than 12mm are suited to an endostapled anastomosis which helps significantly reduce operative time without any corrosion of outcomes.

Fibrocalculous pancreatic diabetes—current scenario in developing countries

Fibrocalculous pancreatitis diabetes (FCPD), a secondary form of diabetes due to tropical chronic pancreatitis (TCP), is seen exclusively in developing countries of the tropical world. From a worldwide perspective, alcoholism is the most common cause of chronic pancreatitis. However, in many tropical countries like India and Bangladesh, the commonest cause of chronic pancreatitis is TCP

Laparoscopic Lateral Pancreaticojejunostomy—the Technique and Early Experience

Laparoscopic lateral pancreaticojejunostomy (LLPJ) in patients with chronic pancreatitis is scarcely reported. This study aimed to describe a technique of LLPJ and to report an early experience. The described technique of LLPJ was used in 24 patients with chronic pancreatitis (CP) starting from January 2012 to April 2017. Clinical characteristics, technical success and post-operative outcome were analysed. Out of 24 patients, 13 patients (54%) were male and mean age was 30.9 years. Incidence of tropical CP was 87.5% and of alcoholic CP was 12.5%. Incidence of exocrine and endocrine deficiency was 25 and 16.6%, respectively. Median diameter of pancreatic duct (PD) was 10 mm (range, 7–20 mm). Conversion rate was 29.2% and reasons for conversion were technical difficulty in intra-corporeal suturing, failure to localise PD and bulky head requiring Frey’s procedure. In addition to LLPJ, four patients required other procedures like pseudocyst drainage, choledochal cyst excision and hepaticojejunostomy. Intra-operative and post-operative complications occurred in 4.2 and 8.4% patients, respectively. Overall outcome was excellent in 70.8%, good in 25% and fair in 4.2%. Mean follow-up was 26 months and during that period one patient (4.2%) died due to myocardial infarction. The described technique of laparoscopic lateral pancreaticojejunostomy is safe and feasible in selected group of patients with chronic pancreatitis.

Visceral Adipose Tissue as a Risk Factor for Diabetes Mellitus in Patients with Chronic Pancreatitis: A Cross-sectional, Observational Study.

IntroductionVisceral adipose tissue (VAT) is a risk factor for diabetes and we investigated the amount of VAT in patients with chronic pancreatitis (CP).MethodsSerial patients with CP seen between January 2015 and June 2016 were included in this cross-sectional, observational study. The study population was divided into alcoholic CP (group 1; N = 67) and tropical CP (group 2; N = 35). VAT was estimated using bioelectric impedance analysis (BIA) and dual energy X-ray absorptiometry (DEXA) methods. The results were analyzed by appropriate statistical methods.ResultsThe study participants (85 male, 17 female) had a mean (SD) age of 40.8 (12.6) years, CP duration of 3.7 (4.7) years, and body mass index of 22.5 (3.2) kg/m2. Pancreatogenic diabetes was seen in 54 patients and the total body fat percentage was lower in the alcoholic CP group. VAT mass was similar in both the groups (p = 0.8749). CP patients with diabetes had a higher VAT mass (436 vs. 341 g) than those without diabetes (p = 0.0132). DEXA and BIA correlated in estimation of total body fat (p < 0.0001) but not in VAT (p = 0.0922).ConclusionVAT is a determinant in the development of diabetes, even in patients with CP. DEXA is a better modality for VAT estimation in comparison to BIA.

Our Experience with Surgical Treatment for Tropical Chronic Pancreatitis (TCP) in a Tertiary Care Hospital in Odisha

Our Experience with Surgical Treatment for Tropical Chronic Pancreatitis (TCP) in a Tertiary Care Hospital in Odisha

A clinical study of insulin resistance in patients with chronic pancreatitis

ObjectiveInsulin resistance (IR) and beta cell dysfunction are the pathophysiological determinants of the diabetes mellitus (DM). We investigated the presence of IR in patients with chronic pancreatitis (CP) and compared the same with the underlying etiology. MethodsIn this cross-sectional, observational study, we included serial patients of CP presented to our hospital. The study population is in different stages of CP and are grouped as alcoholic CP (Group 1; N=67) and tropical CP (Group 2; N=35). IR was estimated by the homeostasis model assessment (HOMA) method. The results were analyzed by appropriate statistical methods. ResultsThe study participants (85M and 17F) had a mean age 40.8±12.6 yr, CP duration 3.7±4.7 yr and body mass index (BMI) of 22.5±3.2kg/m2. DM was seen in 54 patients with average glycosylated hemoglobin of 7.5±1.6%. A total of 9 patients had HOMA-IR more than 3 suggestive of IR with no significant difference between the two groups. The duration of the DM correlated negatively with glycemic parameters and BMI showed a positive correlation with the fasting insulin and HOMA-IR. ConclusionIR was seen in a minority of patients with CP and is not a significant contributor to the pancreatogenic diabetes.

Chronic pancreatitis in Eastern India: Experiencefrom a tertiary care center.

There is a wide variation in the clinical presentation of chronic pancreatitis (CP) in the different parts of India. Data regarding the clinical profile of CP from eastern India are scarce. We describe the clinical and demographic profiles of patients with CP in eastern India. Consecutive patients were evaluated for the clinical presentation, etiology and complication of CP. One hundred and thirty-nine patients with CP (mean age 39.57±14.88 years; M/F 3.48:1) were included. Idiopathic CP (50.35%) was the most common etiology followed by alcohol (33.81%); 68.34% had calcific CP and 31.65% had noncalcific CP. The median duration of symptoms was 24 (1-240) months. Pain was the most common symptom, being present in 93.52% of the patients. Diabetes, steatorrhea and pseudocyst were present in 45.32%, 14.38% and 7.19% of the cases, respectively. Moderate to severe anemia was revealed in 16.53% of the patients. Benign biliary stricture was diagnosed in 19.42% of the cases (symptomatic in 6.47%). The common radiological findings were the following: pancreatic calculi (68.34%), dilated pancreatic duct (PD) (58.99%), parenchymal atrophy (25.89%) and PD stricture (23.74%). In our center, idiopathic CP followed by alcoholic CP was the most frequent form of CP. Tropical CP was distinctly uncommon.

Occult metabolic bone disease in chronic pancreatitis.

Chronic pancreatitis (CP) leads to malabsorption and metabolic bone disease (MBD). Alcoholic CP (ACP) and tropical CP (TCP) are the two common types of CP. We investigated the presence of occult MBD in patients with CP and compared the same between ACP and TCP. In this cross-sectional, observational study, we included serial patients of CP in different stages and are grouped as ACP (Group 1; n = 67) and TCP (Group 2; n = 35). We determined serum calcium, phosphorus, alkaline phosphatase, 25-hydroxyvitamin D (25OHD), and intact parathyroid hormone (PTH) levels. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry in the neck of the left femur. MBD was defined by the presence of either low bone mass (Z-score Results: The study participants (85 males; 17 females) had a mean age of 40.8 ± 12.6 years, CP duration of 3.7 ± 4.7 years, and Body Mass Index of 22.5 ± 3.2 kg/m2. A total of 37 (36%) patients had MBD (osteomalacia in 31 and low bone mass in 6). The frequency of MBD was same in the TCP (16/35) and ACP (21/65) groups (P = 0.1940). Elevated PTH (>70 pg/mL) was seen in 14 patients with 25OHD deficiency and low calcium (<8.5 mg/dL) in 29 patients. BMD did not show a significant correlation with the duration of CP. Occult MBD is seen in a third of patients with CP and is similar irrespective of the etiology. The disease is silent and mandates active screening in all susceptible individuals.

Progression of recurrent acute and chronic pancreatitis: A short-term follow up study from a southern Indian centre.

Little data exist on the progression of recurrent acute (RAP) and chronic pancreatitis (CP) from regions from where the entity of tropical chronic pancreatitis was originally described. The study aimed to follow up patients with RAP and CP seen at a southern Indian centre for progression of disease over time. Prospectively enrolled patients with RAP and CP were followed up, and the alcoholic and idiopathic subgroups were assessed for progression of structural and functional changes in the organ. One hundred and forty patients (RAP=44; 31.4%, CP=96; 68.5%) were followed up over a median 12.2 (interquartile range 12.0-16.8) months. The cause was alcohol in 31 (22.1%) and not evident in 109 (77.8%). The disease progressed from RAP to CP in 7 (15.9%), 6 (16.2%) out of 37 in the idiopathic and 1 (14.2%; p=1.00) out of 7 in the alcoholic subgroups. Three (42.8%) and 1 (14.2%) developed steatorrhea and diabetes mellitus (DM), respectively, and 2 (4.5%) developed calcification. Established CP progressed in 19 (19.7%), 1 (1.0%), 5 (5.2%), 2 (2.0%) and 11 (11.4%) newly developed DM, steatorrhea, calcification and duct dilation during follow up. Among the idiopathic and alcoholic CP, disease progression was seen in 15 (20.8%) out of 72 and 4 (16.6%) out of 24 respectively. Idiopathic RAP and CP progressed during the short-term follow up. This is similar to other etiological forms of pancreatitis, as described from elsewhere in the world.

Clinical profile of PanIN lesions in tropical chronic pancreatitis.

Chronic pancreatitis (CP) found in the tropical countries is known to have a higher risk for carcinoma of the pancreas. This study aimed to explore the clinical profile of pancreatic intraepithelial neoplasia (PanIN), one of the precursors of carcinoma of the pancreas, in tropical CP and to identify the possible clinical predictors of the same. A retrospective study was done enrolling patients who underwent either Frey's procedure or pancreatic resection for symptomatic CP, between January 2008 and December 2012. They were grouped into PanIN positive and PanIN negative based on histopathology. Their clinical and laboratory parameters were compared statistically to identify the predictors of the PanIN status. Sixty-two tropical CP patients who had Frey's procedure or pancreatic resection were enrolled into this study; 38.7 % cases showed PanIN changes and 61.29 % had no PanIN changes. Majority of the clinical and laboratory parameters were found comparable between the two groups except obstructive jaundice and CA 19-9 value >137.5 which were there in 54.2 % of PanIN-positive cases. On histopathology, 54.83 % cases were benign CP and 45.16 % were malignant CP. Among the benign CP, 33.3 % were PanIN positive and among those with malignancy 66.7 % were PanIN positive. Low-grade PanINs were seen in 73 % cases of benign CP and in 26.1 % of malignancy whereas high-grade PanIN-3 lesions were seen exclusively in patients with malignancy. High-grade PanIN-3 lesions showed significant association with pancreatic malignancy. Obstructive jaundice and CA 19-9 ≥ 137.5 could predict PanIN positivity.

Scanning electron microscopic analysis of pancreatic tissue in alcoholic and tropical chronic pancreatitis

IntroductionChronic Pancreatitis (CP) is a heterogenous disease with alcoholic chronic pancreatitis (ACP) dominating in the West, and idiopathic or tropical chronic pancreatitis (TCP) in the tropics. The aim of this study is to assess the feasibility of using a scanning electron microscope (SEM) to analyze the ultra-structural changes in alcoholic and tropical subtypes of CP. MethodsChronic pancreatitis tissue samples were taken from the biopsy samples of 16 patients (seven ACP and nine TCP) who underwent drainage procedures for CP. These samples were subjected to SEM analysis and findings of normal pancreas were compared with those of CP for appreciating differences in their architectural changes. ResultsNormal architecture of pancreas could be observed as lobules of parenchyma, ductal system and definite loci of Islets of Langerhans (IOL). CP samples showed loss of architecture in the form of severe fibrosis and calcifications. In ACP, the fibrosis was predominantly seen towards the periphery of the gland sparing the periductal areas. These fibres were strangulating and damaging the parenchyma. Crystals were seen over these fibres. In TCP, fibrosis was moderate and uniform throughout the parenchyma. Moreover the crystals were larger and intraluminal. Total fatty replacement of parenchyma was a striking feature in TCP, seen exclusively in diabetics with gross atrophy of IOL. ConclusionSEM gives the real-life pictures of fibrosis, fatty change, ductal changes, calcifications and thus the actual extent of damage in CP better than the ordinary light microscopy.