Chronic pancreatitis 

Introduction

-Chronic pancreatitis is a syndrome involving inflammation, fibrosis, and loss of acinar and islet cells in the pancreas. 

-Causes: Alcoholism (70%), smoking, duct obstruction, hyperparathyroidism, cystic fibrosis, hyperlipidemia

-the most common cause of clinically apparent chronic pancreatitis in adults is alcoholism; in children is cystic fibrosis 

-Smoking is an independent, dose-dependent risk factor for chronic pancreatitis

Symptoms & Signs 

Abdominal pain: epigastric, often radiating to the back, may be relieved by sitting upright or leaning forward, often worse 15 to 30 minutes after eating;  nausea, vomiting, fat malabsorption (poorly formed greasy, malodorous stools); Diabetes 

Diagnosis 

Diagnosis relies on a combination of clinical findings, laboratory findingsimaging tests, and pancreatic function testing.

Labs: Secretin pancreatic function test

Amylase and lipase: elevated in the early disease; normal or low in later stages. Thus, unlike in acute pancreatitis, they are neither diagnostic nor prognostic in chronic pancreatitis 

Fecal Pancreatic Elastase-1 (FPE-1): A level >200 μg/g of stool is considered normal, and FPE-1 levels <100 μg/g of stool correlate with severe exocrine pancreatic insufficiency. 

Imaging: Transabdominal ultrasound, Contrast-enhanced CT and MRI

The diagnosis is confirmed if there are calcifications within the pancreas on CT Scan. 

Pancreatogram: beading of the pancreatic ducts 

Steatorrhea: A 72-hour quantitative fecal fat determination is the gold standard. 

Treatment 

Life style modifications: Cessation of alcohol and of smoking; 

Pain control: Analgesics

Supplements: Pancreatic enzymes, lipase, vitamins 

Ductal stone obstruction: Endoscopic clearance, surgical therapy, ESWL

Check for IBS: Pancreatic exocrine insufficiency is also seen in Diarrhea-predominant irritable bowel syndrome (D-IBS). So, check for PEI in D-IBS. 

Prognosis 

Complications: Pseudocyst, biliary ductal obstruction, fistula, pseudoaneurysms, pancreatic cancer