Chronic pancreatitis

Last reviewed: September 2018

Last updated: June 2018

Summary

Most commonly associated with chronic alcohol ingestion (>75%).

Hallmark features are epigastric abdominal pain radiating to the back, steatorrhoea, malnutrition, and diabetes mellitus.

Diagnosis is based on clinical findings and imaging.

Underlying causes and precipitating factors are treated. There is no definitive therapy; treatment is otherwise aimed at symptoms.

Common complications include narcotic addiction, pancreatic pseudocysts, pancreatic calcification, diabetes mellitus, and malabsorption.

Definition

Pancreatitis is a clinical diagnosis defined by pancreatic inflammation. Although not always clinically distinguishable, pancreatitis can be defined as acute or chronic. Acute pancreatitis is a self-limiting and reversible pancreatic injury associated with mid-epigastric abdominal pain and elevated serum pancreatic enzymes, whereas chronic pancreatitis is characterised by recurrent or persistent abdominal pain and progressive injury to the pancreas and surrounding structures, resulting in scarring and loss of function. In those with recurrent attacks of pancreatitis, identifying the cause and type of pancreatitis involves distinguishing between 4 entities: [1]

(1) Recurrent acute pancreatitis: there is an identifiable cause of acute pancreatitis that does not lead to chronic pancreatitis (e.g., gallstones, drugs, hypercalcaemia, etc.).

(2) Idiopathic pancreatitis: exhaustive evaluation identifies no cause. Most commonly this represents chronic relapsing pancreatitis or definite chronic pancreatitis.

(3) Chronic relapsing pancreatitis: patients have relapsing pain not recognised clinically as chronic pancreatitis (no hallmark features) but have pathological changes.

(4) Established chronic pancreatitis: hallmark features of chronic pancreatitis are present, including reduced pancreatic exocrine function, malabsorption, diabetes, and pancreatic calcifications.

History and exam

Key diagnostic factors

presence of risk factors
abdominal pain
steatorrhoea
jaundice

Full details

Other diagnostic factors

weight loss and malnutrition
nausea and vomiting
skin nodules
painful joints
low-trauma fracture
abdominal distension
shortness of breath

Full details

Risk factors

alcohol
smoking
family history
coeliac disease
high-fat, high-protein diet
tropical geography

Full details

Diagnostic investigations

1st investigations to order

blood glucose
CT scan
abdominal ultrasound
abdominal x-ray

Full details

Investigations to consider

endoscopic ultrasound (EUS)
endoscopic retrograde cholangiopancreatography (ERCP)
magnetic resonance cholangiopancreatography (MRCP)
faecal elastase-1
faecal fat
steatocrit
direct pancreatic function tests
genetic screening
biopsy
IgG4 levels
therapeutic trial of corticosteroids

Full details

Emerging tests

investigational pancreatic function tests

Full details

Treatment algorithm

ACUTE

acute episodic pain

ONGOING

chronic symptoms

Contributors

Authors VIEW ALL 

Matthew J. DiMagno, MD

Assistant Professor of Internal Medicine

Division of Gastroenterology and Hepatology

University of Michigan School of Medicine

Ann Arbor

Disclosures

MJD receives grant support from University of Michigan, Cystic Fibrosis Foundation, and National Institutes of Health. MJD has consulted for or received honoraria from American Gastroenterological Association, Oakstone Publishing, Cystic Fibrosis Foundation, and American College of Physicians. MJD sits on committees, advisory boards and/or editorial boards for AGA Institute, PancreasFest, Faculty of 1000 Research, Pancreatology, the Pancreapedia, and Pancreas.

Erik-Jan Wamsteker, MD

Assistant Professor of Internal Medicine

Division of Gastroenterology and Hepatology

University of Michigan School of Medicine

Ann Arbor

Disclosures

EJW declares that he has no competing interests.

Allen Lee, MD

Assistant Professor of Internal Medicine

Division of Gastroenterology and Hepatology

University of Vermont College of Medicine

Burlington

Disclosures

AL declares that he has no competing interests.

Peer reviewers VIEW ALL 

Christopher Forsmark, MD

Professor of Medicine

Chief

Division of Gastroenterology, Hepatology, and Nutrition

University of Florida

Gainesville

Disclosures

CF is an author of a number of references cited in this monograph.

Jakob R. Izbicki, MD, FACS

Chairman, Surgeon in Chief

Department of General, Visceral and Thoracic Surgery

University Hospital Hamburg-Eppendorf

Hamburg

Germany

Disclosures

JRI declares that he has no competing interests.

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Chronic pancreatitis

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Emerging tests

Treatment algorithm

acute episodic pain

chronic symptoms

Contributors

Authors VIEW ALL 

Matthew J. DiMagno, MD

Disclosures

Erik-Jan Wamsteker, MD

Disclosures

Allen Lee, MD

Disclosures

Peer reviewers VIEW ALL 

Christopher Forsmark, MD

Disclosures

Jakob R. Izbicki, MD, FACS

Disclosures

Differentials

Guidelines

Patient leaflets

Procedural videos

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