chronic pancreatitis
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Etiology
(also see causes of acute pancreatitis)
- alcoholism: > 75 gm ETOH/day for > 5-15 years
- smoking is an independent risk factor[5]
- uncommon causes
- idiopathic
- obstruction
- hereditary (see genetics)
- tropical: nutritional deficiencies
- hyperlipidemia
- hypercalcemia, hyperparathyroidism
- fibrocystic disease of the pancreas
- recurrent acute pancreatitis
- autoimmune pancreatitis
- chronic renal failure[3]
- vascular disease, ischemia[3]
Pathology
- pancreatic duct obstruction by precipitated proteins
- calcification of protein plugs
- recurrent or severe necrotizing acute pancreatitis may result in deposition of collagen & chronic pancreatitis
- pancreatic ascites may occur
Genetics
- hereditary chronic pancreatitis associated with mutations in PRSS1 (trypsin-1)
- genetic variations in chymotrypsin C (CTRC) can predispose to chronic pancreatitis by diminishing its protective trypsin-degrading activity
- mutations in cationic trypsinogen gene[3]
- defects in SPINK1 are a cause of chronic pancreatitis
- defects in CFTR predispose to chronic pancreatitis[3]
- deficiency of lithostatin may predispose
- defects in calcium sensing receptor (CaSR)[3]
- defects in claudin-2 (CLDN2)
Clinical manifestations
- abdominal pain
- recurrent episodes of abdominal pain
- epigastric pain & tenderness
- often radiating to back
- duration: hours to days
- often precipitated by EtOH
- many patients transition between continuous pain, intermittent pain, & no pain[20]
- patients with continuous pain report worse quality of life
- malabsorption
- pancreatic exocrine insufficiency
- steatorrhea when > 90% of pancreas has been destroyed
- malnutrition, poor eating habits
- weight loss[3]
- osteopenia, osteoporosis
- diabetes mellitus
- late manifestation
- brittle in nature
- hypoglycemic episodes may be fatal
- other complications
Laboratory
- blood tests are not useful, amylase & lipase are elevated only during acute exacerbations & diminish with diminishing residual functional pancreatic tissue
- ancillary biochemical studies
- sweat test for cystic fibrosis (young adults)[3]
- genetic testing for familial pancreatitis
- PCR/southern blot for cystic fibrosis (young adults)
- serum IgG4 (older patients to exclude autoimmune pancreatitis)
- see ARUP consult[6]
Diagnostic procedures
- secretin stimulation test
- duodenal aspiration after IV secretin administration
- estimate bicarbonate excretion by pancreas
- most sensitive test, but not practical
- endoscopic retrograde cholangiopancreatography (ERCP) not indicated for diagnosis[3]
- endoscopic ultrasonography
- pancreatic biopsy not indicated for diagnosis[3]
Radiology
- plain film of the abdomen (KUB)
- pancreatic calcifications may be seen
- ductal & parenchymal changes
- pancreatic protocol computed tomography (CT) of abdomen
- pancreatic pseudocysts
- ductal dilatation
- pancreatic calcium deposits
- parenchymal atrophy
- MRI or MRCP[21]
Complications
- increased incidence of carcinoma of the pancreas
- increased incidence of other malignancies
- lung
- esophagus
- oral cavity
- pancreatic pseudocysts, +/- vascular aneurysms
- bile duct obstruction, gastric outlet obstruction
- portal hypertension, ascites
Management
- abstinence from alcohol & tobacco
- analgesia to relieve pain
- non-narcotic analgesics
- pregabalin may be useful for idiopathic chronic pancreatitis[3]
- opiates
- celiac plexus block (short-duration effect)
- intrathecal anesthesia (investigational)
- thorascopic splanchnicectomy (investigational)
- non-narcotic analgesics
- low-fat diet
- pancreatic enzyme replacement
- medium-chain triglycerides for steatorrhea & calorie malnutrition
- loperamide or Lomotil may be useful for persistent diarrhea
- insulin for diabetes
- small doses
- frequent interval dosing
- diabetes may be brittle; hypoglycemia may occur
- error on the side of hyperglycemia
- octreotide 200 ug SQ TID is recommended by some
- endoscopy
- ERCP with pancreatic sphincterotomy, stone removal, stricture dilation, stent therapy[19]
- placement of long multiholed stent into the pancreatic duct to facilitate drainage of pancreatic secretions
- transpapillary drainage of cyst into stomach or duodenum
- angiography & embolization of vascular aneurysms that develop with pseudocysts
- surgery
- surgical decompression of pancreatic ductal strictures[3]
- lateral pancreaticojejunostomy[19]
- pancreatectomy vs pancreatoduodenectomy as a last resort for intractable pain[3]
- early surgery may provide pain relief in 58% of patients[12]
- decompression with drainage, pancreatic resection, or denervation of celiac ganglion & splancnic nerves[2]
- age alone should not preclude a pancreatic resection[17]
- surgical decompression of pancreatic ductal strictures[3]
- antioxidant cocktail daily may diminish abdominal pain[4]
- selenium 600 ug
- ascorbic acid 540 mg
- beta carotene 9000 IU
- tocopherol 270 IU
- methionine 2 g daily
- antioxidants do not reduce pain in chronic pancreatitis[16]
More general terms
More specific terms
Additional terms
References
- ↑ Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 514-517
- ↑ 2.0 2.1 Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 379-81
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ 4.0 4.1 Bhardwaj P et al A randomized controlled trial of antioxidant supplementation for pain relief in patients with chronic pancreatitis. Gastroenterology 2009 Jan; 136:149. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18952082
- ↑ 5.0 5.1 Cote GA et al. Alcohol and smoking as risk factors in an epidemiology study of patients with chronic pancreatitis. Clin Gastroenterol Hepatol 2011 Mar; 9:266 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21029787
- ↑ 6.0 6.1 ARUP Consult: Chronic Pancreatitis The Physician's Guide to Laboratory Test Selection & Interpretation https://www.arupconsult.com/content/pancreatitis-chronic
ARUP consult: Idiopathic and Hereditary Pancreatitis Testing https://arupconsult.com/ati/idiopathic-and-hereditary-pancreatitis-testing - ↑ ARUP Consult: Autoimmune Pancreatitis The Physician's Guide to Laboratory Test Selection & Interpretation https://www.arupconsult.com/content/pancreatitis-autoimmune
- ↑ Cahen DL, Gouma DJ, Nio Y et al Endoscopic versus surgical drainage of the pancreatic duct in chronic pancreatitis. N Engl J Med. 2007 Feb 15;356(7):676-84. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17301298
- ↑ Lieb JG 2nd, Forsmark CE. Review article: pain and chronic pancreatitis. Aliment Pharmacol Ther. 2009 Apr 1;29(7):706-19 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19284407
- ↑ Forsmark CE Management of chronic pancreatitis. Gastroenterology. 2013 Jun;144(6):1282-91.e3 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23622138
- ↑ Mergener K, Baillie J. Chronic pancreatitis. Lancet. 1997 Nov 8;350(9088):1379-85. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/9365465
- ↑ 12.0 12.1 Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
- ↑ Ahmed Ali U, Nieuwenhuijs VB, van Eijck CH et al Clinical outcome in relation to timing of surgery in chronic pancreatitis: a nomogram to predict pain relief. Arch Surg. 2012 Oct;147(10):925-32. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23117832
- ↑ Amann ST, Yadav D, Barmada MM et al Physical and mental quality of life in chronic pancreatitis: a case-control study from the North American Pancreatitis Study 2 cohort. Pancreas. 2013 Mar;42(2):293-300. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23357924 Free PMC Article
- ↑ Cahen DL, Gouma DJ, Nio Y, Rauws EA Endoscopic versus surgical drainage of the pancreatic duct in chronic pancreatitis. N Engl J Med. 2007 Feb 15;356(7):676-84. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17301298 Free Article
- ↑ 16.0 16.1 Siriwardena AK, Mason JM, Sheen AJ, Makin AJ, Shah NS. Antioxidant therapy does not reduce pain in patients with chronic pancreatitis: the ANTICIPATE study. Gastroenterology. 2012 Sep;143(3):655-63.e1. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22683257
- ↑ 17.0 17.1 Oliveira-Cunha M, Malde DJ, Aldouri A et al Results of pancreatic surgery in the elderly: is age a barrier? HPB (Oxford). 2013 Jan;15(1):24-30. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23216776 Free PMC Article
- ↑ Majumder S, Chari ST. Chronic pancreatitis. Lancet. 2016 May 7;387(10031):1957-66. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26948434
- ↑ 19.0 19.1 19.2 Issa Y, Kempeneers MA, Bruno MJ et al. Effect of early surgery vs endoscopy-first approach on pain in patients with chronic pancreatitis: The ESCAPE randomized clinical trial. JAMA 2020 Jan 21; 323:237. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31961419
Hines OJ. Tracing the evidence to address painful chronic pancreatitis with surgery. JAMA 2020 Jan 21; 323:219 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31961398 - ↑ 20.0 20.1 Kempeneers MA, Issa Y, Verdonk RC et al. Pain patterns in chronic pancreatitis: A nationwide longitudinal cohort study. Gut 2021 Sep; 70:1724 PMID: https://www.ncbi.nlm.nih.gov/pubmed/33158979 https://gut.bmj.com/content/70/9/1724
- ↑ 21.0 21.1 Cohen SM, Kent TS Etiology, Diagnosis, and Modern Management of Chronic Pancreatitis. A Systematic Review. JAMA Surg. 2023;158(6):652-661 PMID: https://www.ncbi.nlm.nih.gov/pubmed/37074693 https://jamanetwork.com/journals/jamasurgery/fullarticle/2803632
- ↑ NIDDK: Pancreatitis https://www.niddk.nih.gov/health-information/digestive-diseases/pancreatitis
Patient information
chronic pancreatitis patient information