Updated: 10/11/2020

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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(M3.GI.16.26) 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? Tested Concept

QID: 102967
FIGURES:
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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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Pancreaticoduodenectomy (Whipple procedure)

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M 11 C

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(M3.GI.16.24) 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? Tested Concept

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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M 10 C

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