INDEX

    Chronic Pancreatitis

    Gastrointestinal

    Last Updated Apr 16, 2021
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    By Ellie Bay, Julian Marsden

    Context

    • Chronic pancreatitis (CP) usually develops after recurrent episodes of acute pancreatitis in many but not all patients. CP can be asymptomatic until severe complications present.
    • Typically middle-aged males.
    • Most common cause is chronic alcohol use.
    • Other etiologies/risks can be categorized by the TIGAR-O acronym:
      • T – Toxic-Metabolic (smoking, hypercalcemia, hypertriglyceridemia, medications, toxins, CKD, DM)
      • I – Idiopathic
      • G – Genetic
      • A – Autoimmune (type 1 and type 2)
      • R – Recurrent acute or severe pancreatitis
      • O – Obstructive (stones, calcifications, mass, stenosis, strictures, etc.)
    • 20–25-year mortality rate of CP = 50%.
    • Significant consequences including chronic pain, malnutrition, osteoporosis, diabetes mellitus (type 3c), and pancreatic cancer.
    • Supportive care is the mainstay of treatment.

    Diagnostic Process

    Clinical Signs and Symptoms

    • Abdominal pain – epigastric, +/- radiation to back, worsened with food and alcohol, tender on exam.
    • Jaundice – biliary obstruction or cirrhosis.
    • Signs of endocrine and/or exocrine insufficiency:
      • Glucose intolerance
      • Malabsorption and weight loss
      • Steatorrhea (fatty stools)
      • Edema

    Labs

    • Serum lipase
      • Serum levels of pancreatic enzymes may not be elevated in CP due to loss of exocrine function.
    • Liver function tests
      • Elevated alkaline phosphatase, bilirubin and hepatic transaminases may suggest biliary tract obstruction or coexisting alcoholic liver disease.
    • Glucose
    • Serum calcium
    • Serum albumin and protein
    • Pancreatic function tests can be conducted as secondary/adjunctive testing. They are used primarily to diagnose exocrine pancreatic insufficiency (EPI) and have low sensitivity in the diagnosis of CP.

    Imaging

    • CT or MRI are recommended as the first-line diagnostic tests.
      • Possible CT findings: Dilated pancreatic ducts, atrophy, calcifications, complications (e.g. pseudocyst).
    • Endoscopic US should be reserved for cases where MRI or CT is inconclusive.
    • Transabdominal US may be used to look for complications or to rule out other conditions on the differential but is less useful that CT/MRI.
    • Pancreatic calcification = pathognomonic of CP.

    Potential Complications of CP

    • Pseudocyst
      • Can lead to complications such as compression of the gastric outlet, duodenum, bile duct, and/or vessels; infection; bleeding; and fistulas.
    • Pseudoaneurysm
      • Can form secondary to pseudocysts or pancreatic surgery.
      • Possible clinical features: abdominal pain, anemia, GI bleeding.
    • Pancreatic fistulas
    • Pancreatic ascites or pleural effusion
    • Splenic vein thrombosis
      • Can lead to variceal bleeding
    • Bile duct obstruction
    • Duodenal obstruction
    • Pancreatogenic diabetes
    • Exocrine pancreatic insufficiency (EPI)
    • Pancreatic cancer
    • Dysmotility

    Recommended Treatment

    Pain Management

    • Analgesics
      • Stepwise approach: NSAIDs and opiates should be avoided if possible.
    • Antioxidants
      • Inconclusive evidence for the role of antioxidants in improving pain in CP.
      • Combinations of antioxidants may be more beneficial than monotherapy.
    • Pancreatic enzyme therapy
      • Evidence points to limited efficacy for improving primary pain in CP and therefore not suggested by the ACG. (Pancreatic enzyme therapy has an established role in the treatment of Exocrine Pancreatic Insufficiency).

    Fluid and electrolyte correction

     

    Potential Next Steps

    • Most patients require admission.
    • Referral to gastroenterology or surgery:
      • Endoscopic decompressive therapy (ERCP/EUS) is performed in patients with symptomatic pancreatic duct obstruction.
      • Surgical procedures to reduce pain may include decompression, resection or a combination. Surgical decompression may be considered if endoscopic drainage is unsuccessful in obstructive CP.
    • Referral to pain management specialist.

    Long-Term Recommendations

    • Alcohol and smoking cessation
    • Nutrition replacement
    • Interdisciplinary approach that incorporates behavioural interventions to help address impact on quality of life.
    • No evidence to support pancreatic malignancy screening.

    Quality Of Evidence?

    Justification

    ACG Clinical Guideline – recently published guideline (2020) based on a literature review of RCTs, meta-analyses and systematic reviews. See guideline for grading of individual recommendations, some of which are included in this summary.

    High

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