Editors

PauliPuolakkainen

Chronic Pancreatitis

Quitting alcohol consumption and smoking 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 the underlying factor in 2/3 of cases, and smoking is a significant factor in more than half of cases.
- If alcohol is the aetiology, the patient is often a heavy drinker who has consumed 150-175 g of pure alcohol daily over 10-15 years before the clinical onset of the disease.
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 Sjögren's syndrome Primary Sjögren'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 amylase of pancreatic origin, 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 plasma glucose and blood HbA_1c should be determined for detection of diabetes.
CA 19-9 antigen as a differential diagnostic test Carcinoma of the Pancreas
Faecal elastase-1 reflects pancreatic exocrine insufficiency Pancreatic Insufficiency, but it is not diagnostic for chronic pancreatitis.
A normal ultrasound finding is not exclusionary, but pancreatic calcification or other hints of chronic pancreatitis may be visible.

The diagnosis of chronic pancreatitis is primarily based on a CT scan. Therefore, confirmation of the diagnosis and differential diagnosis (pancreatic cancer etc.) often require hospital examinations.

The patient has to give up alcohol use and smoking 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.
Low-fat diet, no fibre (inhibits pancreatic enzymes), enzyme substitution and, in exceptional cases, also MCT-oil
Appropriate analgesics
Acute attack in chronic pancreatitis
- Treated primarily as a mild acute pancreatitis, see Acute Pancreatitis
- Conservative treatment, moderate rehydration
- Analgesics
Recurrent severe pain and complications, like pseudocysts, are indications for endoscopic or surgical treatment in chronic pancreatitis.

Confirmation of diagnosis (CT)
Recurrent bouts of severe pain
- Treatment in a hospital: ERCP and stenting / surgical treatment if endoscopic treatment fails or is inadequate
Suspected complications
- Pancreatic pseudocyst
  - Symptoms: pain, bowel obstruction, biliary obstruction
  - Treatment: ERCP and stenting / endoscopic or operative pseudocyst-gastrostomy / pancreatic resection
- Bleeding pancreatic pseudocyst or 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

Singh VK, Yadav D, Garg PK. Diagnosis and Management of Chronic Pancreatitis: A Review. JAMA 2019;322(24):2422-2434 [PubMed]
Kylänpää L, Heikkinen M, Grönroos J. [Chronic pancreatitis]. In: Färkkilä M, Heikkinen M, Isoniemi H, Puolakkainen P (eds.). [Gastroenterology and hepatology]. Duodecim Publishing Company 2018. Available in Finnish.