Updated: 6/12/2019

Chronic Pancreatits

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Snapshot
  • A 52-year-old male is brought to the emergency department for recurrent severe abdominal pain. He reports 10/10, stabbing, epigastric abdominal pain that has been happening for the past 2 months intermittently. He also endorses constipation and stool that is difficult to flush. His caregiver reports a long history of alcohol abuse. A laboratory study demonstrates mildly elevated levels of amylase and lipase.
Introduction
  • Clinical definition
    • condition characterized by longstanding and progressive inflammation of the pancreas leading to permanent alterations in the organ’s normal structure and function
    • damage of the organ leads to impairment of exocrine and endocrine function
      • malabsorption leading to fat soluble vitamin (A, D, E, and K) deficiencies
      • diabetes due to pancreas’ inability to produce insulin
  • Epidemiology
    • demographics
      • alcoholism is the most common cause in the United States
  • Pathogenesis
    • various etiologies that can lead to chronic pancreatitis 
      • alcohol abuse
      • smoking
      • genetic causes (e.g., cystic fibrosis or hereditary pancreatitis)
      • ductal obstruction (e.g., trauma, pseudocysts, stones, tumors, or pancreas divisum)
      • tropical pancreatitis
      • systemic diseases (e.g., systemic lupus erythematous, hypertriglyceridemia, or hyperparathyroidism)
      • autoimmune pancreatitis
      • idiopathic pancreatitis
    • the pathophysiology of chronic pancreatitis is not fully understood but some theories to its development are as follows
      • proteinaceous ductal plug secondary to increased secretion of pancreatic proteins
        • plugs acts a nidus for calcification leading to stone formation, ductal lesions and subsequent inflammatory changes
      • ischemia likely important in exacerbating and facilitating the disease
      • lack of antioxidants (e.g., selenium, vitamin C and E, and methionine) leading to increase in free radicals
      • autoimmune mechanisms as a number of autoimmune disorders (e.g., autoimmune pancreatitis) have been linked to chronic pancreatitis
Presentation
  • Symptoms  
    • abdominal pain  
      • often epigastric with radiation to the back relieved by leaning forward 
      • worse 15-30 minutes after eating  
      • repeated pain attacks  
    • nausea 
    • vomiting  
    • steatorrhea  
    • constipation
    • flatulence
  • Physical exam
    • weight loss
Studies
  • Diagnostic testing
    • diagnostic approach
      • diagnosis is primarily based on clinical presentation and confirmed via either imaging or secretin pancreactic function studies
    • imaging 
      • abdominal computed tomography (CT) with contrast 
        • best initial imaging
        • positive findings include calcifications within the pancreas, ductal dilation, enlargement of the pancreas, and fluid collections (e.g., pseudocysts) adjacent to the gland 
      • magnetic resonance cholangiopancreatography (MRCP)
        • becoming the diagnostic test of choice
        • no radiation risk
        • allows for better detection of calcifications and pancreatic duct obstruction consistent with chronic pancreatitis
      • endoscopic retrograde cholangiopancreatography (ERCP)
        • indicated in patients with no calcifications on imaging and have the potential need of therapeutic intervention
    • studies
      • laboratory studies
        • normal to minimal elevation of amylase and/or lipase
          • should not be used for the diagnosis of chronic pancreatitis
        • CBC, electrolytes, and liver functions tests
          • typically normal
          • may see elevations in serum bilirubin and alkaline phosphatase
        • HbA1c levels for evaluation of diabetes
      • pancreatic function tests
        • secretin pancreatic function test
          • low levels of bicarbonate concentration following secretin administration indicates exocrine pancreatic insufficiency
        • stool elastase (< 200 mcg/g)
        • low serum trypsinogen (< 20ng/mL)
Differential 
  • Pancreatic cancer 
    • differentiating factors
      • lesion will be visible on imaging with further support from ERCP findings if needed
  • Acute pancreatitis 
    • differentiating factors
      • clinical presentation (e.g., pain characteristic) and history as well as serum lipase and/or amylase levels
Treatment 
  • Management is multipronged and is aimed to target pain management, correction of pancreatic insufficiency, and management of complications
  • First-line
    • cessation of alcohol and tobacco
    • dietary modifications (eat small meals that are low in fat)
    • acid suppression (e.g.. proton pump inhibitor) along with pancreatic enzyme supplements (e.g., lipase) for pain management and malabsorption
    • oral hypoglycemic agents or insulin therapy if needed
    • vitamin supplementations (e.g., vitamins A, D, E, K, and B12)
  • Second-line
    • analgesics with opiates and/or nonsteroidal anti-inflammatory agents
      • indicated if pancreatic enzyme therapy fails to control pain
      • can be used with adjuvant pregabalin
    • other approaches for pain management include
      • endoscopic therapy
      • extracorporeal shock wave lithotripsy
      • celiac nerve block
  • Third-line
    • surgery
      • generally indicated in patients who fail medical therapy
      • approaches include decompression/drainage, pancreatic resections, and denervation procedures
Complications
  • Chronic pain with addiction to analgesics
  • Exocrine and endocrine insufficiency
  • Pancreatic pseudocyst
  • Ductal obstruction
  • Increased risk of pancreatic cancer
 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M3.GI.26) A 46-year-old male with an extensive history of alcohol abuse and smoking presents with constant epigastric pain, which seems to worsen after meals. The patient has had multiple bouts of acute pancreatitis in the past, but states this pain is not as severe, and has been constant for the last 3 weeks. Review of systems is notable for diarrhea and a 10 lb weight loss. Vital signs are as follow T 98.7 F HR 92 bpm BP 139/87 mmHg RR 19 Sat 92%. Laboratory studies demonstrate ALT 236 U/L AST 603 U/L, with a normal total bilirubin. The patient is referred for further imaging which is shown in Figure A. Which of the following is the next best step in management? Review Topic

QID: 102967
FIGURES:
1

Low fat diet, pancreatic enzyme supplementation, alcohol cessation and counseling

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Transgastric drainage of pancreatic pseudocyst

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ERCP with sphincterotomy and stenting

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Steroids and analgesia with hydromorphone as needed

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5

Pancreaticoduodenectomy (Whipple procedure)

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SUBMIT RESPONSE 1

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(M3.GI.24) A 49-year-old male presents to his primary care physician for the first time in twelve years. His chief complaint is a new onset of diarrhea, which nothing seems to improve. He first noticed this diarrhea about a month ago. He complains of greasy stools, which leave a residue in his toilet bowl. Review of systems is notable for alcohol consumption of 12-16 cans of beer per day for the last two decades. Additionally, the patient endorses losing 12 lbs unintentionally over the last month. Vital signs are within normal limits and stable. Exam demonstrates a male who appears older than stated age; abdominal exam is notable for epigastric tenderness to palpation. What is the next step in diagnosis? Review Topic

QID: 102965
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d-Xylose absorption test

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Endoscopic retrograde cholangiopancreatography (ERCP)

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CT abdomen with IV contrast

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EGD with biopsy of gastric mucosa

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Somatostatin receptor scintigraphy

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