Guest Poster:  Chronic pancreatitis  by Dr. Josh Stripling

 Definition: Irreversible destruction of the pancreatic parenchyma causing varying degrees of endocrine and exocrine dysfunction

•  most patients typically present with persistent abdominal pain and steatorrhea
• exocrine dysfunction – chronic diarrhea and weight loss
• approx 20% present with maldigestion without pain

Causes:

• The most common cause of chronic pancreatitis is alcohol use (usually more than 10y and more than 50g/day)
• TIGAR-O (Toxic-metabolic, Idiopathic, Genetic, Autoimmune, Recurrent and severe acute pancreatitis, Obstructive)
• tobacco also increase the risk of developing chronic pancreatitis

Diagnosis:  there are two specific entities: large- duct and small-duct (minimal change)

• no consensus on gold standard for diagnosis: difficult testing and not always available
• typical diagnosis is clinical based on symptoms and imaging
• available testing includes: Secretin and CCK stimulation tests, fecal elastase, serum tripsinogen, stool sudan stain
• most patients should undergo MRCP (not ERCP) or EUS to evaluate pancreatic ducts
• patients can progress to development of pancreatic cancer

Plain film or CT can highlight pancreatic calcification to support the diagnosis

Management

• avoidance of cause: EtOH cessation, pancreatic duct stenting, etc.
• enteric coated pancreatic enzyme supplementation (40,000 units of lipase recommended) plus acid suppressant
• fat-soluble vitamin replacement
• monitor for endocrine dysfunction
• pain management is difficult and theoretical improvement in pain with enzyme supplementation may occur
• total pancreatectomy with islet cell transplantation is becoming more frequent

Resources: MKSAP 16, Harrison’s, “Chronic Pancreatitis” AFP 2007

Images: Medscape, http://www.meddean.luc.edu, healthcentral.com, drug3K.com