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Chronic Pancreatitis

AJ De Witte

Definition

A syndrome characterized by irreversible chronic progressive pancreatic inflammation, fibrosis, and scarring, resulting in damage to and loss of exocrine (acinar), endocrine (islet cells), and ductal cells

Etiology

TIGAR-O mnemonic

  • Toxic Metabolic: EtOH, tobacco use, hyperCa (Ca > 12), HLD (fasting TG > 300, nonfasting > 500), CKD 5, medications, toxins
  • Idiopathic: early onset (age \< 35), late onset (age > 35)
  • Genetic: Autosomal dominant (PRSS1 gene), recessive (CFTR, SPINK1, etc.)
  • Autoimmune: IgG4-related (AIP type 1), AIP type 2
  • Recurrent, severe acute pancreatitis
  • Obstructive: pancreas divisum, ampullary stenosis, main duct pancreatic stones or strictures, widespread calcifications, mass causing duct obstruction

Presentation

  • Abdominal pain (most common)
  • Exocrine insufficiency: diarrhea, steatorrhea, weight loss
    • Typically occurs later in disease process
  • Endocrine insufficiency: diabetes
  • Occasionally asymptomatic

Evaluation

  • Imaging: CT or MRI (may be negative early in course of disease)
    • If CT or MRI negative but suspicion for CP remains high, consider EUS ± biopsy or secretin-enhanced MRCP
  • Labs:
    • BMP, LFTs, lipid panel, PeTH
    • Consider genetic testing, especially in younger patients and/or patients without clear etiology
    • Pancreatic function testing diagnoses exocrine insufficiency but is not necessary for diagnosis of CP
      • Gold standard = 72-hour fecal fat (> 7g of fat per 100g stool per day) - rarely done
      • More practical = fecal elastase (<100 = diagnostic, 100-200 = indeterminate)
        • Must be performed on formed stool, can be false positive If watery specimen
        • Do not have to stop pancreatic enzymes to measure
    • Lipase and amylase levels can be elevated, but are usually normal due to pancreatic scarring and fibrosis

Management

  • Tobacco and EtOH cessation
  • Pancreatic enzyme replacement therapy if evidence/diagnosis of exocrine insufficiency
    • Usual dose: 50,000 units/meal + 25,000 units with snacks
    • Should take with first bite of a meal and consider adding extra enzymes or splitting up dose throughout meal if lasting longer than 15 mins
    • If lack of response: try increasing dose, confirm compliance, add PPI, split up dose throughout meal, look for concurrent GI disorders
  • Pain: Tylenol + NSAIDs > Opioids (Tramadol), consider SSRI/SNRI/TCA or gabapentin
    • For refractory pain, other options include celiac plexus blockade or total pancreatectomy with islet auto transplant
  • Vitamin supplementation + Vit D + Ca
  • Consider antioxidants (selenium, ascorbic acid, β-carotene, and methionine, vitamin E) – mixed evidence but some studies have shown improved pain control
  • Routine testing for osteoporosis and fat-soluble vitamin deficiencies