Pancreatitis, Chronic


Article Author:
Onecia Benjamin


Article Editor:
Sarah Lappin


Editors In Chief:
William Gossman


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Pritesh Sheth
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes
Kavin Sugumar


Updated:
10/27/2018 12:31:46 PM

Introduction

The pancreas is an accessory organ of digestion known to have dual functions in the endocrine and exocrine systems. It is necessary for the hydrolysis of macromolecules including proteins, carbohydrates, and fats (in combination with bile from the common bile duct). The pancreas has a main pancreatic duct running through the length of it, an accessory duct, and many various cell types. The ducts can become blocked, or they can be genetically deformed. During constant inflammation, scarring and fibrosis of the ducts lead to permanent damage to many structures, impairing its secretory functions.

Chronic pancreatitis is a progressive inflammatory disease of the pancreas that affects both functions of the pancreas. For example, when the exocrine function is affected, patients will present with pancreatic insufficiency, steatorrhea, and weight loss. Pancreatic insufficiency results when greater than 90% of the organ is damaged. The incidence depends on the severity of disease and can be as high as 85% in severe chronic pancreatitis. On the other hand, impairment of the endocrine function of the pancreas will eventually result in pancreatogenic diabetes (Type 3c diabetes).

Chronic pancreatitis is unlike acute pancreatitis. The latter presents with acute onset abdominal pain radiating to the back. Patients with chronic pancreatitis may be asymptomatic for long periods of time. At other times, they may also have unrelenting abdominal pain with breakthrough pain requiring hospitalization. This disease process varies from acute pancreatitis in another way, in other words, histologically. The types of inflammatory cells present are different. Acute pancreatitis has a predominance of neutrophils, while chronic pancreatitis has more mononuclear infiltrates.[1][2][3]

Etiology

Causes of chronic pancreatitis include alcohol abuse, ductal obstruction (malignancy, stones, trauma), genetics (cystic fibrosis, hereditary pancreatitis), chemotherapy, and autoimmune diseases such as systemic lupus erythematosus (SLE) or autoimmune pancreatitis. New studies are finding that deficiencies in certain vitamins and antioxidants may be linked to the disease.[4][5]

Epidemiology

When compared to other illnesses, the incidence of chronic pancreatitis is hard to identify. In cases where the disease is secondary to alcohol, it can go largely undiagnosed since chronic pancreatitis is progressive. The diagnosis can take a long time to be discovered. The latest epidemiological report in 2014 estimated an incidence that has been consistent over the years. However, the prevalence might be underestimated. Further studies are needed.[6][7]

Pathophysiology

The pathogenesis of chronic pancreatitis seems to involve genetic factors and environmental factors. Studies have identified pancreatitis susceptibility genes associated with loss of function mutations. There are two main theories on the pathogenesis of chronic pancreatic disease. One theory is that of impaired bicarbonate secretion which cannot respond to the increased secretion of pancreatic proteins. These abundant proteins subsequently combine to form plugs within the lobules and ducts. This leads to calcification and stone formation. The other theory involves intraparenchymal activation of digestive enzymes within the pancreatic gland (possibly due to genetics or external influences such as alcohol). One recent study proposes that alcohol diminishes the cell's ability to respond to calcium signaling. This alters the feedback mechanism and promotes a cycle leading to cell death.[8][9]

History and Physical

Chronic pancreatitis can present with prolonged abdominal pain with intermittent pain-free periods, weight loss, and relief of abdominal pain when leaning forward. However, in some cases, patients can be asymptomatic. Nausea, vomiting, and steatorrhea or greasy, foul-smelling, difficult-to-flush stools can also occur. Glucose intolerance or pancreatic diabetes is another finding later in the disease process. These are classic presentations in patients with a past medical history of alcohol abuse, tobacco use, malignancy (with ductal obstruction), hyperlipidemia, systemic disease, autoimmune disease, cystic fibrosis, among others).

Evaluation

Basic lab studies for chronic pancreatitis can include a CBC, BMP, LFTs, lipase, amylase, lipid panel and a fecal-elastase-1 value. Lipase and amylase levels can be elevated, but they are usually normal secondary to significant pancreatic scarring and fibrosis. Of note, amylase and lipase values should not be considered diagnostic nor prognostic.

In cases where chronic autoimmune pancreatitis is suspected, inflammatory markers including ESR, CRP as well as ANA, RF, antibodies, and immunoglobulins can be obtained. To workup steatorrhea, a 72-hour quantitative fecal fat is gold standard (whereby values greater than 7 gm per day is confirmatory). As an alternative, a fecal elastase-1 level can be obtained from a single random stool sample to help evaluate pancreatic insufficiency. This is the most sensitive and specific alternative to the qualitative fecal fat test available.

The MRCP is the premier diagnostic imaging study because it can reveal calcifications (hallmark sign), pancreatic enlargement, ductal obstruction or dilation. MRCP has higher sensitivity and specificity for chronic pancreatitis than does the transabdominal ultrasound or plain films (though both can reveal calcifications). Management could also include CT scan of the abdomen as an alternative.

ERCP has been the traditional test of choice in diagnosing chronic pancreatitis. It is used when there is no steatorrhea or when plain films do not reveal calcifications. However, currently, many hospitals are trending towards using MRCPs instead and are relying on ERCP only when therapeutic intervention is needed. Endoscopic ultrasound is another imaging modality that can be used to diagnose the disease.[10][11][12]

Treatment / Management

The goal of treatment is to decrease abdominal pain and improve malabsorption. Pain is secondary to inflammation, neuropathic mechanisms, and blocked ducts. Eating small, frequent low-fat meals is generally recommended along with replacement of fat-soluble vitamins and pancreatic enzymes. In cases where pain relief is not achieved with enzyme replacement treatment and dietary modification, non-opioid regimens should be utilized (TCA, NSAIDs, pregabalin) initially before starting a trial of opioid. Studies regarding the benefit of antioxidants are unconfirmed. New studies show some benefit of using medium chain triglycerides. Surgery should be considered in patients who fail medical therapy and continue to have pain. [1][11][13]

Differential Diagnosis

Chronic, unrelenting abdominal pain that is acutely worsening should entertain a differential diagnosis not limited to peptic ulcer disease, cholelithiasis, biliary obstruction/biliary colic, acute pancreatitis, pancreatic malignancy, pseudocyst, chronic mesenteric ischemia, among others.

Complications

Chronic pancreatitis has many complications including:

  • Formation of a pseudocyst, which can obstruct the bile duct
  • Recurrent acute pancreatitis, especially in alcoholics who continue to drink
  • Splenic venous thrombosis
  • Pancreatic ascites or pleural effusion (rare)
  • Pseudoaneurysms (rarely of the vessels close to the pancreas)
  • Pancreatic diabetes (later in disease course)

Of note, patients with chronic pancreatitis are at increased risk of developing pancreatic cancer.

Deterrence and Patient Education

Patients diagnosed with chronic pancreatitis secondary to chronic alcohol use should be encouraged to avoid alcohol (and to stop smoking, if applicable). Follow up should take place within 1 to 2 months.

Pearls and Other Issues

Chronic pancreatitis is an inflammatory disease caused by multiple factors including genetic predisposition and external factors. It is different from acute pancreatitis in many ways. In acute pancreatitis, abdominal pain is usually sudden onset, while chronic pancreatitis can be painless or can be an unrelenting, dull pain with breakthrough episodes of acute pain. The pathophysiology is also different between the two diseases, but more importantly, workup for chronic pancreatitis does not have to include amylase and lipase levels. The MRCP is the test of choice in diagnosing chronic pancreatitis, and the goal of treatment is to control pain and manage malabsorption from pancreatic insufficiency. Severe pancreatic insufficiency should be managed with enzyme replacement, fat-soluble vitamin replacement and frequent, small meals. Decompression surgery can be considered in those with intractable pain who have failed medical therapy.

Enhancing Healthcare Team Outcomes

Chronic pancreatitis costs the healthcare system billions of dollars each year. These patients develop a wide range of complications including chronic pain and multiple admissions to the hospital are not unusual. The patients are generally managed by a team of healthcare professions that include a surgeon, gastroenterologist, radiologist, pain specialist, dietitian, pharmacist, and a nurse. To reduce the morbidity and mortality of the disorder, the emphasis today is on behavior modification. Both the pharmacist and nurses play a critical role in educating the patient about the adverse effects of alcohol and tobacco smoking. By abstaining from alcohol, these patients can also obtain pain relief in the early stage of the disease. Patients who continue to drink alcohol, have a death rate 3 times higher than those who do not drink alcohol. For those who have malabsorption, the pharmacist should recommend the use of pancreatic enzymes. At the same time, the patients should be referred to an alcohol and chemical dependency program. The pharmacist should recommend aids to stop tobacco and educate the patients on the benefits of a healthy diet. Continual reassessment and monitoring of these patients is necessary to ensure that they abstain from alcohol.[14][15][16] (Level V)

Outcome

The outcome for patients with chronic pancreatitis depends on many factors such as smoking, age at diagnosis, continued use of alcohol, the presence of liver disease and other comorbidities. Data indicate that at 10 years, 70% of patients are alive and at 20 years, about 40% to 50% are alive. Furthermore, these patients also have a risk of developing pancreatic cancer in the future. With time, patients with chronic pancreatitis are also at risk of developing pseudocysts, pancreatic ascites, pleural effusions, portal hypertension, splenic vein thrombosis, and pseudoaneurysm. A significant number of these patients continue to have moderate to severe pain and malabsorption. Finally, about one-third of patients will end up with diabetes. For those who require surgery for a pseudoaneurysm, there are additional risks of death.[17][18] (Level V)




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Pancreatitis, Chronic - Questions

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A patient still has pain despite medical therapy for chronic pancreatitis. Endoscopic retrograde cholangiopancreatography reveals a long, dilated pancreatic duct. What is the best treatment?



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Which is not true of chronic pancreatitis?



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Chronic pancreatitis is MOST often caused by which of the following?



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In a patient with chronic pancreatitis, one would expect to see an elevation of which of the following?



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Which condition is treated with celiac ganglion neurolytic blockade?



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Which of the following is false about the Puestow procedure?



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Which of the following is true about surgery for chronic pancreatitis?



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A 38-year-old male with alcohol use disorder is admitted with abdominal pain. He has been having nausea and steatorrhea for 1 month and the pain has been constant. He says he has lost 15 pounds over the past 2 months. He says he was a heavy drinker in the past and has had many admissions to the hospital because of intolerable pain. He says his only medication is oxycodone for pain. His physical exam is negative except for some mild pain in the epigastrium. A CT scan of the abdomen reveals a dilated pancreatic duct with diffuse narrowing of the branches. The main pancreatic duct is about 1.2 centimeters in diameter. The radiologist described the pancreatic duct as a "chain of lakes." Which of the following is the best treatment for his pain?



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What is the most common cause of chronic pancreatitis?



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Fat malabsorption is a common feature of what condition?



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What is the most common cause of chronic pancreatitis in North America?



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In a patient with chronic pancreatitis, one might not expect to see an elevation of which of the following?



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Which of the following is not a classic presentation of a patient with chronic pancreatitis?



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Which of the following collagen vascular disorders is associated with chronic pancreatitis?



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In a patient with chronic pancreatitis, what is the most common reason for obstructive jaundice?



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Which of the following indicates a poor prognosis for an adult male who is admitted with an acute episode of pancreatitis?



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Which of the following is NOT a potential complication of chronic pancreatitis?



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Which of the following lab values indicates a poor prognosis for an adult male with chronic pancreatitis who is admitted with an acute episode?



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A 62-year-old male presents with steatorrhea found to be secondary to chronic pancreatitis. He reports drinking at least 6 beers a day but has never had withdrawal symptoms. He has lost 20 pounds and has complaints of epigastric pain that worsens with eating and improves with taking ibuprofen. CT scan confirms calcifications of the pancreas and amylase and lipase levels are normal. What is the appropriate management?



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What is the most common cause of chronic pancreatitis?



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Which of the following tests is most likely used to diagnose chronic pancreatitis?



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A patient with chronic pancreatitis needs further teaching if he or she makes which of the following statements?



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Which is true about groove pancreatitis?



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A 49-year-old male presents to the emergency department with mid-abdomen pain. The pain radiates in a band-like fashion to the midback and is associated with nausea. This is his third visit to the emergency department in the past 12 months. He is afraid to eat as the pain often comes within a few minutes after a meal. He also complains of weight loss of 10 pounds over the past 3 months and has very foul smelling stools. He admits to heavy alcohol use for the past 24 years. Last year, he had a CT scan which revealed the presence of calcifications around the pancreas. On physical exam, the patient is found to be in distress and lying on his side. Which of the following is true regarding the presumed condition in this patient?



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Pancreatitis, Chronic - References

References

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