Chronic pancreatitis

Last updated: May 10, 2022

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Chronic pancreatitis (CP) is characterized by progressive inflammation that results in irreversible damage to the structure and function of the pancreas. Chronic heavy alcohol use is the most common cause of CP, followed by pancreatic ductal obstruction. Approximately 30% of CP cases are idiopathic. Affected individuals may be asymptomatic or present with abdominal pain and features of exocrine pancreatic insufficiency (e.g., steatorrhea, weight loss) or endocrine pancreatic insufficiency (e.g., prediabetes, diabetes). Diagnosis is confirmed with imaging, which typically shows pancreatic calcifications, ductal strictures, and ductal dilations. Pancreatic function tests (e.g., fecal elastase-1 measurement, 72-hour fecal fat estimation) assess the degree of enzyme deficiency. Medical therapy should include patient counseling and education, pain management, and monitoring and management of complications (e.g., via oral pancreatic enzyme replacement therapy). Interventional therapy may be required for patients with intractable pain or other complications (e.g., celiac ganglion block, partial or complete pancreatic resection).

The TIGAR-O system categorizes etiologies of chronic pancreatitis: Toxic-Metabolic, Idiopathic, Genetic, Autoimmune, Recurrent acute/severe pancreatitis, and Obstructive. [4][5]

References:[6]

In the later stages of chronic pancreatitis, patients may not experience any pain.References:[1][7]

Autoimmune pancreatitis [8][9]
Autoimmune pancreatitis type I Autoimmune pancreatitis type II
Definition
Epidemiology
  • >
  • Onset: most commonly at 60–70 years of age
  • =
  • Onset: most commonly at 40–50 years of age
Etiology
Clinical features
Diagnostics Serology
  • Characterized by ↑ IgG4 (typically > 2 × ULN)
  • Findings are often normal.
Histology
Imaging
Management
Prognosis [10]
  • Relapse rate: ∼ 50%
  • Rarely relapses

Rule out underlying pancreatic malignancies before starting steroids for autoimmune pancreatitis; reassess for pancreatic malignancy in the case of autoimmune pancreatitis that does not respond to treatment. [8]

Approach [4][11][12][13][14]

There is no single test for the diagnosis of chronic pancreatitis; risk factors, clinical features, imaging studies, and pancreatic function tests may all be considered in the determination of a diagnosis.

A STEP-wise approach to diagnosing chronic pancreatitis may include: Survey, Tomography/imaging, Endoscopic imaging, and Pancreatic function testing.

Imaging [4][11][15]

First-line imaging

Additional imaging [4][16]

  • Abdominal ultrasound [16]
    • Low sensitivity for detecting pancreatic pathologies
    • Findings
      • Indistinct margins and enlargement
      • Pancreatic calcifications
      • Ductal strictures, dilation, or stones
  • Abdominal x-ray: visible pancreatic calcifications (highly specific, but only seen in ∼ 30% of cases) [17]
  • Endoscopic ultrasound (EUS)
    • Can detect early changes that indicate chronic pancreatitis
    • Indication: reserved for cases in which a CT scan and/or MRI are nondiagnostic [4]
    • Findings include: [18]
  • Secretin-enhanced MRCP
  • ERCP: Not routinely recommended because of availability of noninvasive imaging, high risk, and cost [14]
    • Can simultaneously identify and treat early pathologies (e.g., duct dilation, stent insertion)
    • Findings
      • Ductal stones, which are visible as filling defects
      • Chain of lakes” or “string of pearls” appearance (characteristic feature)
      • Irregularity and/or dilation of the main pancreatic duct [20]

Laboratory studies [11]

Pancreatic enzyme levels are often normal in chronic pancreatitis and cannot be used to confirm or rule out the diagnosis. In contrast, acute pancreatitis typically causes significant enzyme elevation.

Pancreatic function tests [4][11]

Consider for patients with features of exocrine pancreatic insufficiency or for those in whom diagnosis of chronic pancreatitis has not been confirmed by imaging.

The presence of exocrine pancreatic insufficiency (as confirmed by pancreatic function tests) is not required to establish a diagnosis of chronic pancreatitis but can further support the diagnosis.

Histology [4]

  • Indications: reserved for high-risk patients if the diagnosis has not been established after thorough evaluation
  • Characteristic findings [13]

Histology is rarely used to diagnose chronic pancreatitis because of procedural risks and the possibility of sampling errors that lead to false-negative results.

Genetic testing [22]

Approach [4][11][12][14]

Patients with CP may benefit from a multidisciplinary team providing individualized pain management and addressing psychosocial factors. [14]

Pharmacological pain management [4]

Provide pain management in a stepwise approach (see “Treatment of pain” for dosages).

Pain management in chronic pancreatitis requires careful assessment and frequent reevaluation.

Interventional therapy

Endoscopic

Surgical [11]

Total pancreatectomy is the only known cure for chronic pancreatitis; it should be reserved for select patients with chronic pain after all other measures have failed. [4]

Recurrent acute pancreatitis [11]

See “Acute pancreatitis.”

Exocrine pancreatic insufficiency [4][12]

Pathophysiology

Tissue atrophy and fibrosis → deficiency of lipase, amylase, and proteasemaldigestion, steatorrhea, and malabsorption

Clinical features

Diagnostics

Management

Endocrine pancreatic insufficiency

Pancreatic pseudocysts [11][25]

Definition

Encapsulated collection of pancreatic fluid that develops 4 weeks after an acute attack of pancreatitis (can occur in both acute and chronic pancreatitis) [11]

Pathophysiology

Pancreatic secretions leak from damaged ducts → inflammatory reaction of surrounding tissue → encapsulation of secretions by granulation tissue

Clinical features [26]

Diagnostics [27]

  • First line: CT abdomen with contrast
  • Findings: Extrapancreatic fluid collection within well-defined wall or capsule with contrast enhancement
  • Other imaging modalities

Treatment

  • Indications
    • Symptomatic cysts
    • Large asymptomatic cysts
    • Urgent intervention may be needed if patients develop complications.
  • Procedures

Complications

Pancreatic ascites

Pathophysiology

Ductal disruption (due to an acute attack of pancreatitis, pancreatic surgery and/or trauma) or a pseudocyst leak/rupture → pancreatic ascites

Clinical features

Diagnostics

Management

Splenic vein thrombosis [30]

Further complications

General screening for pancreatic cancer is not currently recommended. Screen patients (with a triphasic pancreas protocol CT) who develop weight loss, protracted abdominal pain, or functional decline. [4][11]

We list the most important complications. The selection is not exhaustive.

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  16. Issa Y, Kempeneers MA, van Santvoort HC, Bollen TL, Bipat S, Boermeester MA. Diagnostic performance of imaging modalities in chronic pancreatitis: a systematic review and meta-analysis. Eur Radiol. 2017; 27 (9): p.3820-3844. doi: 10.1007/s00330-016-4720-9 . | Open in Read by QxMD
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  22. Witt H. The SPINK in chronic pancreatitis: similar finds, different minds. Gut. 2002; 50 (5): p.590-591. doi: 10.1136/gut.50.5.590 . | Open in Read by QxMD
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  24. Hart PA, et al. Type 3c (pancreatogenic) diabetes mellitus secondary to chronic pancreatitis and pancreatic cancer. The Lancet Gastroenterology & Hepatology. 2016; 1 (3): p.226-237. doi: 10.1016/s2468-1253(16)30106-6 . | Open in Read by QxMD
  25. Pancreatic pseudocyst. https://medlineplus.gov/ency/article/000272.htm. Updated: October 16, 2019. Accessed: November 13, 2020.
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