Gastroenterology Book

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Chronic Pancreatitis

Aka: Chronic Pancreatitis
  1. Pathophysiology
    1. Recurrent episodes of Acute Pancreatitis
    2. Pain episodes may resolve once pancreatic function fails completely
  2. Causes
    1. Chronic Alcoholism (most common U.S. cause)
    2. Idiopathic (25% of cases)
    3. Autoimmune Pancreatitis related conditions
      1. Inflammatory Bowel Disease
      2. Sjogren's Syndrome
      3. Primary biliary Cirrhosis
    4. Hypertriglyceridemia
    5. Hyperparathyroidism or Hypercalcemia
    6. Hereditary Pancreatitis
    7. Hemochromatosis
    8. Cystic Fibrosis
    9. Occult neoplasm or other causes of pancreatic obstruction
    10. Chronic Renal Failure
  3. Symptoms
    1. Abdominal Pain
      1. Chronic and disabling Abdominal Pain
      2. Midepigastric postprandial pain with radiation to the back
      3. Relieved on sitting upright or leaning forward
    2. Bowel malabsorption
      1. Steatorrhea
      2. Weight loss
      3. Vitamin Deficiency (rare)
        1. Deficiency of Vitamins A,D,E,K
        2. Vitamin B12 Deficiency
  4. Labs
    1. Pancreatic Enzymes
      1. Serum Amylase normal
      2. Serum Lipase normal
      3. D-Xylose urinary excretion normal
      4. Pancreatic Exocrine function abnormalities (not typically done)
        1. Bentiromide test may be abnormal
        2. Secretin Stimulation Test abnormal in pancreatic exocrine insufficiency
          1. Peak bicarbonate concentration: Abnormal if <80 mEq/L in duodenal secretions
        3. Serum trypsinogen (Abnormal if <20 ng/ml)
    2. Liver Function Tests
      1. Increased Serum Bilirubin and Alkaline Phosphatase if obstruction present
    3. Stool studies (Late findings)
      1. Steatorrhea (abnormal if fecal fat concentration >9.5% or >7 grams/day)
      2. Fecal elastase (Abnormal if <200 mcg/gram of stool)
    4. Electrolytes
      1. Glucose Intolerance or Diabetes Mellitus (50% of patients)
  5. Differential Diagnosis
    1. Acute Cholecystitis
    2. Acute Pancreatitis
    3. Mesenteric Ischemia
    4. Peptic Ulcer Disease
    5. Pancreatic Carcinoma
  6. Imaging
    1. Abdominal XRay
      1. Pancreatic calcifications (30-60% of cases)
    2. CT Abdomen (preferred first-line test)
      1. Pancreatic Pseudocyst
      2. Pancreatic duct dilatation
  7. Diagnosis
    1. Endoscopic Ultrasound
      1. Preferred over ERCP due to much lower complication rate and high sensitivity
      2. Can be combined withg FNA biopsy to evaluate mass lesions for malignancy
    2. Endoscopic Retrograde Cholangiopancreatography (ERCP)
      1. Irregular dilation of main pancreatic duct
      2. Pruning of pancreatic duct branches
  8. Management: Medical
    1. Treat exacerbations as in Acute Pancreatitis
    2. Pain control
      1. Tylenol
      2. NSAIDs
      3. Cautious use of Narcotics (high abuse potential and common outcome in chronic cases)
    3. Avoid exacerbating factors
      1. Abstain from Alcohol use
      2. Avoid Tobacco
      3. Follow Low Fat Diet
      4. Eat smaller meals
    4. Malabsorption Management (if steatorrhea)
      1. Pancreatic enzyme replacement (40,000 units of Lipase with Proton Pump Inhibitor)
      2. Consider one-time DEXA Scan and Vitamin D level
    5. Glucose Intolerance management
  9. Management
    1. ERCP Indications
      1. Painful pancreatic duct stricture or gall stones
      2. Pseudocysts (ERCP for drainage)
    2. Surgical Indications
      1. Intractable pain refractory to ERCP and other measures
      2. Suspected Pancreatic Cancer
      3. Compression from surrounding tissue
    3. Surgical procedures: Decompression for large duct disease
      1. Lateral pancreaticojejunostomy
      2. Cystenterostomy (for pseudocyst)
    4. Surgical procedures: Resective for pancreatic tumor or small duct disease
      1. Whipple Procedure (most common surgery for Chronic Pancreatitis)
        1. Pain relief in 85% of Chronic Pancreatitis cases and <3% mortality
      2. Total pancreatectomy (procedure of last resort)
  10. Complications
    1. Vitamin B12 Malabsorption
      1. Alcoholism
      2. Cystic Fibrosis
    2. Diabetes Mellitus (occurs in most patients within 5 years of onset Chronic Pancreatitis)
    3. Non-Diabetic Retinopathy
      1. Vitamin A Deficiency
      2. Zinc Deficiency
    4. Gastrointestinal Bleeding
    5. Pancreatic carcinoma (very high risk)
    6. Subcutaneous Fat Necrosis
    7. Narcotic Addiction (secondary to Chronic Pain)
  11. References
    1. Forsmark in Feldman (2006) Sleisenger & Fordtran's Gastrointestinal and Liver Disease, Chap 57
    2. Ahmad (2006) Curr Probl Surg 43: 127-238 [PubMed]
    3. Fry (2007) Am J Surg 194: S45-S52 [PubMed]
    4. Nair (2007) Am Fam Physician 76: 1679-94 [PubMed]

Pancreatitis, Chronic (C0149521)

Definition (NCI) A chronic inflammatory process causing damage and fibrosis of the pancreatic parenchyma. Signs and symptoms include abdominal pain, malabsorption and diabetes mellitus.
Definition (MSH) INFLAMMATION of the PANCREAS that is characterized by recurring or persistent ABDOMINAL PAIN with or without STEATORRHEA or DIABETES MELLITUS. It is characterized by the irregular destruction of the pancreatic parenchyma which may be focal, segmental, or diffuse.
Concepts Disease or Syndrome (T047)
MSH D050500
ICD9 577.1
ICD10 K86.1
SnomedCT 123289004, 15974001, 155835007, 197462002, 235494005, 233870001, 234689009
English PANCREATITIS CHRONIC, PANCREATITIS RELAPSING, Pancreatitis recurrent, Pancreatitis, Chronic, chronic relapsing pancreatitis, chronic pancreatitis (diagnosis), chronic pancreatitis, chronic relapsing pancreatitis (diagnosis), Pancreatitis chronic, Pancreatitis relapsing, Relapsing chronic pancreatitis, Chronic pancreatitis NOS, Pancreatitis, Chronic [Disease/Finding], recurrent pancreatitis, pancreatitis chronic, Chronic pancreatitis, Recurrent pancreatitis, Relapsing pancreatitis, CP - Chronic pancreatitis, Chronic pancreatitis (disorder), Recurrent pancreatitis (disorder), Relapsing pancreatitis (disorder), chronic; pancreatitis, relapsing, chronic; pancreatitis, pancreatitis; chronic, relapsing, pancreatitis; chronic, pancreatitis; recrudescent [Brill-Zinsser], pancreatitis; relapsing, recrudescent [Brill-Zinsser]; pancreatitis, relapse; pancreatitis, Chronic pancreatitis, NOS, Chronic pancreatitis (disorder) [Ambiguous], Relapsing pancreatitis -RETIRED-, Pancreatitis, recurrent, Pancreatitis, relapsing, Chronic Pancreatitis, Pancreatitis;chronic
Italian Pancreatite recidivante, Pancreatite cronica
Dutch pancreatitis recidief, chronische pancreatitis, chronisch; pancreatitis, met relaps, chronisch; pancreatitis, pancreatitis; chronisch, met relaps, pancreatitis; chronisch, pancreatitis; met relaps, pancreatitis; recidiverend, recidiverend; pancreatitis, relaps; pancreatitis, pancreatitis chronisch, pancreatitisrecidivering
French Pancréatite récidivante, PANCREATITE A RECHUTE, PANCREATITE CHRONIQUE, Pancréatite à rechutes, Pancréatite chronique
German chronische Pankreatitis, rezidivierende Pankreatitis, PANKREATITIS CHRONISCH, PANKREATITIS REZIDIV, Pankreatitis Rezidiv, Pankreatitis chronisch, Chronische Pankreatitis, Pankreatitis, chronische
Portuguese Pancreatite recidivante, PANCREATITE CRONICA, PANCREATITE RECIDIVANTE, Pancreatite recorrente, Pancreatite crónica, Pancreatite Crônica
Japanese 再発性膵炎, マンセイスイエン, サイハツセイスイエン, 慢性膵炎, 膵炎-慢性, 膵頭部限局性特殊型慢性膵炎, グルーブ膵炎
Swedish Bukspottkörtelinflammation, kronisk
Finnish Krooninen haimatulehdus
Russian PANKREATIT KHRONICHESKII, ПАНКРЕАТИТ ХРОНИЧЕСКИЙ
Spanish PANCREATITIS CRONICA, PANCREATITIS RECURRENTE, pancreatitis indolora, pancreatitis recurrente - RETIRADO -, pancreatitis recurrente - RETIRADO - (concepto no activo), pancreatitis crónica (concepto no activo), pancreatitis crónica (trastorno), pancreatitis crónica, pancreatitis recidivante (trastorno), pancreatitis recidivante, pancreatitis recurrente (trastorno), pancreatitis recurrente, Pancreatitis recurrente, Pancreatitis crónica, Pancreatitis Crónica
Czech Chronická pankreatitida, Recidivující pankreatitida, Relabující pankreatitida, pankreatitida chronická, chronická pankreatitida
Polish Przewlekłe zapalenie trzustki, Zapalenie trzustki przewlekłe
Hungarian Chronikus pancreatitis, Visszatérő pancreatitis, Idült pancreatitis
Norwegian Kronisk pankreatitt
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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