Pancreatitis, Chronic

Key Features

• Chronic pancreatitis is differentiated from acute pancreatitis in that the pancreas remains structurally or functionally abnormal after an attack

• Causes are multiple and can be divided into

  • Toxic-metabolic (eg, alcohol, chronic kidney disease, hypercalcemia)

  • Idiopathic

  • Genetic (increasingly recognized in children and adolescents)

  • Autoimmune

  • Recurrent and severe acute pancreatitis

  • Obstructive pancreatitis (eg, pancreas divisum, choledochal cyst)

• Diagnosis often is delayed by the nonspecificity of symptoms and the lack of persistent laboratory abnormalities

• There is usually a prolonged history of recurrent upper abdominal pain of variable severity

Clinical Findings

• Radiation of the pain into the back is a frequent complaint

• Fever and vomiting are rare

• Diarrhea, due to steatorrhea, and symptoms of diabetes may develop later in the course

• Malnutrition due to acquired exocrine pancreatic insufficiency may also occur

Diagnosis

• Serum amylase and lipase levels are usually elevated during early acute attacks, but are often normal in the chronic phase

• Pancreatic insufficiency may be diagnosed by demonstration of a low fecal pancreatic elastase 1

• Mutations of the cationic trypsinogen gene, the pancreatic secretory trypsin inhibitor, the cystic fibrosis transmembrane conductance regulator (CFTR), carboxypeptidase A1 and chymotrypsin C are associated with recurrent acute and chronic pancreatitis

• Elevated blood glucose and glycohemoglobin levels and glycosuria frequently occur in protracted disease

• Radiographs of the abdomen may show pancreatic calcifications in up to 30% of patients

• Ultrasound or CT examination demonstrates an abnormal gland (enlargement or atrophy), ductal dilation, and calculi in up to 80%

• CT is the initial imaging procedure of choice

• MRCP or ERCP can show ductal dilation, stones, strictures, or stenotic segments

Treatment

• If ductal obstruction is strongly suspected, endoscopic therapy (balloon dilation, stenting, stone removal, or sphincterotomy) should be pursued

• Pancreatic enzyme therapy should be used in patients with pancreatic insufficiency

• Lateral pancreaticojejunostomy or the Frey procedure can reduce pain in pediatric patients with a dilated pancreatic duct and may prevent or delay progression of functional pancreatic impairment

• Pancreatectomy and islet cell autotransplantation has been used in selected cases