Editors

PauliPuolakkainen

Chronic Pancreatitis

Withdrawal of alcohol before the disease emerges
Consider chronic pancreatitis as the cause of recurrent upper abdominal pain, weight loss and diarrhoea.
Detect diabetes at an early stage in patients with chronic pancreatitis. Be careful not to induce hypoglycaemia in patients on insulin.
Chronic pancreatitis is associated with an elevated risk of pancreatic cancer.

Recurring acute pancreatites may lead to chronic pancreatitis.
Alcohol is a causative factor in up to 90% of cases
- With few exceptions the patient is a heavy drinker who has consumed 150-175 g of pure alcohol daily over 10-15 years before disease onset
Gallstone disease
Metabolic disorders (hypertriglyceridaemia, hyperparathyroidism)
Hereditary chronic pancreatitis (hereditary pancreatic calcification)
The autoimmune form of chronic pancreatitis is associated with primary sclerosing cholangitis Primary Sclerosing Cholangitis, primary biliary cirrhosis Primary Biliary Cholangitis, and Sj�gren's syndrome Primary Sj�gren's Syndrome.

Upper abdominal pain that radiates to the back with possibly associated nausea and vomiting; weight loss, jaundice.
The pain is caused by increased ductal pressure and by neuritis.
Within approx. 8 years 50% of the patients develop endocrine and exocrine pacreatic insufficiency manifested as steatorrhoea, weight loss and diabetes Pancreatic Insufficiency.

Plasma/urine amylase, urine trypsinogen-2, blood leucocyte count and CRP may be increased during the pain attacks.
Plasma concentrations of alkaline phosphatase and bilirubin are increased in biliary obstruction.
Fasting blood glucose should be determined for detection of diabetes.
CA 19-9 antigen as a differential diagnostic test Carcinoma of the Pancreas
Determination of faecal elastase-1 http://www.dynamed.com/condition/chronic-pancreatitis#PANCREATIC_FUNCTION_TESTING is the easiest investigation if chronic pancreatitis is suspected.
For tests of exocrine pancreatic function see Pancreatic Insufficiency
Ultrasonography to reveal calcifications in the pancreas and to assess the condition of the pancreatic duct, CT http://www.dynamed.com/condition/chronic-pancreatitis#CONTRAST_ENHANCED_COMPUTED_TOMOGRAPHY__CT_ and magnetic resonance imaging (MRCP) http://www.dynamed.com/condition/chronic-pancreatitis#MAGNETIC_RESONANCE_CHOLANGIOPANCREATOGRAPHY__MRCP__AND_IMAGING__MRI_ as further investigations.

The patient has to give up alcohol use immediately and completely.
Treatment of diabetes
- Insulin doses should often be small (hypoglycaemia tends to develop easily).
Small meals are of benefit in cases of pain and steatorrhoea. The diet should be low in fat with no fibre. MCT-oil may be used. Enzyme substitution http://www.dynamed.com/condition/chronic-pancreatitis#PANCREATIC_ENZYMES is indicated if 24-hour faecal fat is > 15 g. The effect of enzyme substitution on pain is not proven Pancreatic Enzymes for Chronic Pancreatitis.
Appropriate analgesics http://www.dynamed.com/condition/chronic-pancreatitis#ANALGESICS
Acute attack in chronic pancreatitis
- Treated primarily as a mild acute pancreatitis, see Acute Pancreatitis
- Conservative treatment, ample rehydration
- Analgesics
Recurrent severe pain and complications, like pseudocysts, are indications for endoscopic or surgical treatment in chronic pancreatitis.

The diagnosis of chronic pancreatitis is based on imaging (CT, MRCP, ERCP, PET, endoscopic ultrasound http://www.dynamed.com/condition/chronic-pancreatitis#ENDOSCOPIC_GUIDED_ULTRASOUND__EUS_). Therefore, the confirmation of the diagnosis, including differential diagnostics (e.g., pancreatic cancer), often require hospital examinations.
Recurrent bouts of severe pain
- Treatment in a hospital: ERCP and stenting http://www.dynamed.com/procedure/procedural-interventions-for-chronic-pancreatitis#MANAGEMENT_RECOMMENDATIONS / Puestow's lateral virsungojejunostomy
Suspected complications
- Pancreatic pseudocyst
  - Symptoms: pain, bowel obstruction, biliary obstruction
  - Treatment: ERCP and stenting / endoscopic or operative pseudocyst-gastrostomy / pancreatic resection
- Pancreatic pseudocyst / bleeding pseudoaneurysm
  - Treatment: endovascular coiling or operative treatment
- Pancreatic fistulae
  - Treatment: endoscopic / operative
- Infected pancreatic pseudocyst
  - Treatment: draining and antibiotics
- Biliary obstruction
  - Treatment: ERCP and stenting