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Chronic Pancreatitis 

Written by Chin Ming Huay

Last Reviewed: April 2019

Review Due: April 2020

 

DEFINITION

'recurrent episodes of inflammation of the pancreas, leading to structural damage and loss of function'

 

AETIOLOGY

Longstanding alcohol excess is the most common cause.

 

Other causes:

Recurrent acute pancreatitis

Obstruction of pancreatic duct

Structural issues

Gallstones

Hereditary

Cystic fibrosis

Trypsinogen and inhibitory protein deficits

Autoimmune

IgG4

Trauma

Smoking

SIGNS AND SYMPTOMS

Pain

Site: Epigastric

Onset: Gradual

Character: Dull

Radiation: Radiates to the back

Timing: Hours

Exacerbating factors: Worse after eating

Relieving factors: Sitting forwards

Severity: Moderate

Other associated signs and symptoms 

Steatorrhoea 

Weight loss and malnutrition

Diabetes

Obstructive jaundice 

 

PATHOPHYSIOLOGY

The common pathway for chronic pancreatitis is an increase in activated trypsin within the pancreas. Over a long period of time, plugs form within the duct lumen due to precipitation of proteins. These plugs can become calcified and may also lead to ductal obstruction which exacerbates damage to the pancreas.

 

Histologically, there is loss of pancreatic acini which are replaced by fibrosis, leading to reduced secretion of pancreatic enzymes. The islets of Langerhans may be damaged, leading to diabetes mellitus.

 

Investigations

Blood Glucose

If raised, may be sign of pancreatic endocrine insufficiency

CT Scan

Diagnose chronic pancreatitis, look for pancreatic calcifications and changes to ductal structure

 

TREATMENT

It is important to treat the effects of chronic pancreatitis such as pain and pancreatic insufficiency, and it is also important to treat the underlying cause if possible.

 

Pain

NSAIDs

May add opiate analgesia according to the WHO pain ladder

Tricyclic antidepressants

Pregabalin

Coeliac axis nerve block

 

Managing Pancreatic Insufficiency

Pancreatic enzyme supplements

Improves steatorrhoea and malabsorption symptoms

Given with a protein pump inhibitor (e.g., omeprazole) or H2 receptor antagonist (e.g., ranitidine) to prevent acid degradation of enzyme supplements in the stomach

Insulin replacement

Stabilises blood glucose control

 

Treating the underlying cause

Alcohol – Counselling, referral to addiction services if required, vitamin replacement

Autoimmune – Steroids

 

EPIDEMIOLOGY

Incidence in the UK is estimated to be 5 to 12 cases per 100,000 people, and the prevalence is 50 per 100,000 people.

 

 
 

COMPLICATIONS

Pancreatic pseudocyst

Ascites

Pleural effusions

Increased risk of pancreatic cancer

 

REFERENCES