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Updated: Dec 15 2021

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
  • ETIOLOGY
    • 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
  • 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
    • Diagnostic testing
      • diagnostic approach
        • diagnosis is primarily based on clinical presentation and confirmed via either imaging or secretin pancreactic function studies
      • 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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