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Chronic Pancreatitis


Definition of chronic pancreatitis

  • 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



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