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Chronic pancreatitis

Last updated: May 31, 2021

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Chronic pancreatitis (CP) is caused by progressive inflammation and irreversible damage to the structure and function (exocrine and endocrine) of the pancreas. Chronic heavy alcohol use is the most common cause, followed by pancreatic ductal obstruction. Idiopathic pancreatitis accounts for up to 30% of cases. Patients may be asymptomatic or present with abdominal pain and features of pancreatic enzyme insufficiency (e.g., steatorrhea, weight loss, impaired glucose tolerance). Diagnosis is confirmed on imaging, which demonstrates 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. Symptomatic patients are managed with oral pancreatic enzyme replacements and analgesics. Patients with chronic pain require additional interventions (e.g., celiac ganglion block, partial/complete pancreatic resection).

References:[4]

In the later stages of chronic pancreatitis, patients may not experience any pain.References:[1][5]

Autoimmune pancreatitis [6]
Autoimmune pancreatitis type I Autoimmune pancreatitis type II
Definition
Epidemiology
Etiology
Clinical features
  • Asymptomatic jaundice (∼ 60%)
  • Epigastric pain and features of pancreatic insufficiency (see “Clinical features” above)
  • Multiorgan involvement (IgG4-associated autoimmune diseases)
Diagnostics Serology
  • Characterized by ↑ IgG4
  • Often normal findings
Histology
Management
Prognosis [7]
  • Relapse rate: ∼ 50%
  • Rarely relapses

Approach [8]

The STEP-wise approach involves Survey, Tomography/imaging, Endoscopy, and Pancreatic function testing.

Laboratory tests

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

Pancreatic function tests

Imaging [8][11]

  • Abdominal CT (plain and contrast-enhanced CT): best initial imaging modality to screen for CP
  • ERCP: detection of early pathologies and simultaneous treatment possible (e.g., duct dilation, stent insertion)
    • 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
  • MRCP [12]
    • Indicated when CT findings are equivocal but clinical suspicion of CP is high
    • Findings
      • Ductal strictures and dilations
      • Pancreatic calcifications
  • Abdominal ultrasound
    • Indistinct margins and enlargement
    • Pancreatic calcifications
    • Ductal strictures, dilation, or stones
  • Endoscopic ultrasound (EUS)
    • An invasive test that is reserved for cases in which a CT scan and/or MRCP are nondiagnostic (can detect early changes of CP )
    • Findings
      • Parenchymal lobularity and hyperechoic foci
      • Ductal dilation and calcification [13]
  • Abdominal x-ray: visible pancreatic calcifications (highly specific, but only seen in ∼ 30% of cases)

Genetic testing [14]

Indications: family history of chronic pancreatitis, young patients with idiopathic pancreatitis

General measures

Pain management

Surgery

Pancreatic insufficiency

Tissue atrophy and fibrosis cause:

Pancreatic pseudocysts [17]

Splenic vein thrombosis [19]

Pancreatic ascites

Further complications

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

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