Chronic pancreatitis is 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.
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 four entities:
Recurrent acute pancreatitis: there is an identifiable cause of acute pancreatitis that does not lead to chronic pancreatitis (e.g., gallstones, drugs, hypercalcaemia, etc.).
Idiopathic pancreatitis: exhaustive evaluation identifies no cause. Most commonly this represents chronic relapsing pancreatitis or definite chronic pancreatitis.
Chronic relapsing pancreatitis: patients have relapsing pain not recognised clinically as chronic pancreatitis (no hallmark features) but have pathological changes in tissue specimens.
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
Other diagnostic factors
- weight loss and malnutrition
- diabetes mellitus/glucose intolerance
- nausea and vomiting
- skin nodules
- painful joints
- low-trauma fracture
- abdominal distension
- shortness of breath
- family history
- coeliac disease
- high-fat, high-protein diet
- tropical geography
1st investigations to order
- computed tomography (CT) or magnetic resonance imaging (MRI)
- endoscopic ultrasonography (EUS)
- secretin-enhanced magnetic resonance cholangiopancreatography (s-MRCP)
Investigations to consider
- histological examination
- genetic testing
- indirect pancreatic function test (faecal elastase-1)
- faecal fat
- direct pancreatic function tests
- IgG4 levels
- therapeutic trial of corticosteroids
acute intermittent episodic pain
persistent pain management
- Pancreatic cancer
- Acute pancreatitis
- Biliary colic
- Adverse events associated with EUS and EUS-guided procedures
- Chronic pancreatitis
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