Chronic inflammation of the pancreas leading to irreversible damage and pancreatic insufficiency.
Epidemiology of chronic pancreatitis
Incidence approximately 1 per 100,000 per annum
Prevalence 3 per 100,000
M:F = 4:1
Average age of onset 40 years
Causes of chronic pancreatitis
Alcohol
Gallstone disease
Cystic fibrosis
Haemachromatosis
Congenital (pancreas divisum)
Presentations of chronic pancreatitis
Epigastric pain that ‘bores through’ to the back
Relieved by sitting forward/hot water bottle applied to front
Anorexia
Nausea
Weight loss
Diarrhoea
Steatorrhea
Diabetes
Examination is often unremarkable – sometimes epigastric tenderness is present
Differential diagnosis of chronic pancreatitis
Acute pancreatitis
Pancreatic cancer
Diagnostic criteria
Direct biopsy if the pancreas is usually too risky
Diagnosis is a combination of clinical findings and investigation results
See below for investigations
Initial management of chronic pancreatitis
Imaging:
Ultrasound – often non-diagnostic but may show pseudocyst
Abdominal x-ray – may show pancreatic calcification
CT scan – more detailed than ultrasound
MRI scan – may show up more subtle abnormalities of the pancreas and pancreatic ducts
EUS – endoscopic ultrasound can allow for direct visualisation of the pancreas
Fasting blood glucose (to check for diabetes)
Amylase and lipase usually normal
Faecal elastase – if < 100 micrograms/gram stool then indicates exocrine pancreatic insufficiency
Liver function tests – can be elevated if there is stricturing of the common bile duct
Analgesia:
Oral analgesia – chronic pain can be problematic in these patients with some developing intractable pain and opioid dependency. Involvement of the chronic pain team can be helpful.
Coeliac plexus block
Pancreatic enzyme replacement e.g. Creon (40-50,000 units with meals plus 10,000 units with snacks)
Insulin if patients develop diabetes
Alcohol avoidance
Further management of chronic pancreatitis
ERCP plus sphincterotomy and/or cholecystectomy for gallstone disease.
Surgery – this can be performed for patients with unremitting pain – i.e. pancreatectomy or pancreaticojejunostomy.
Splanchnicectomy can be used for pain control
Complications of chronic pancreatitis
Malabsorption
Diabetes
Chronic pain
Pancreatic pseudocyst
These can rupture, bleed, or occlude nearby structures like the duodenum or CBD. If present for >6 weeks, spontaneous resolution is unlikely and they should be drained, either surgically or endoscopically into the stomach or duodenum.
Ascites or pleural effusions if pancreatic duct is occluded
Ascitic or pleural amylase will be elevated
Pancreatic carcinoma
Prognosis of chronic pancreatitis
There is an increased mortality and morbidity
Approximately 1/3 of patients will die within 10 years
