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