Pancreatitis (Chronic)
Aetiology
Important causes and risk factors: [Ref1][Ref2]
- Alcohol (dose-dependent risk) – most common identified aetiological factor
- Cigarette smoking
- Repeated acute pancreatitis
- Pancreatic duct obstruction (e.g. stones, strictures, trauma)
- Autoimmune pancreatitis (most commonly IgG4-related disease)
- Genetic predisposition (autosomal dominant PRSS1 mutation causes hereditary pancreatitis)
- Systemic diseases
- Cystic fibrosis
- Severe hypertriglyceridaemia
- Hypercalcaemia (typically from primary hyperparathyroidism)
Clinical Features
Most common: chronic / recurrent epigastric pain (continuous / intermittent) [Ref1][Ref2]
- The pain classically radiates to the back
- The pain is often worse after meals
- Over time, pain may decrease or become absent due to associated pancreatic atrophy
Pancreatic insufficiency is another key presentation, but it takes time to manifest clinically (only when ~90% of the pancreas is destroyed) [Ref1][Ref2]
| Pancreatic portion | Presentation |
|---|---|
| Pancreatic exocrine insufficiency |
|
| Pancreatic endocrine insufficiency |
|
Investigation and Diagnosis
Diagnostic tests: [Ref]
- 1st line: CT abdomen with contrast (pancreatic protocol)
- Typical findings: pancreatic calcifications, ductal dilatation, atrophy
- 2nd line: MRI with MRCP
Pancreatic function tests: [Ref]
- Testing for exocrine insufficiency → faecal elastase (↓ in chronic pancreatitis)
- Testing for endocrine insufficiency → diabetes testing with HbA1c
Pancreatic function testing is adjunctive, NOT required to diagnose chronic pancreatitis. [Ref]
Don’t mix up the tests for acute and chronic pancreatitis. They are classic distractors in exam questions:
- Acute pancreatitis: 1st line diagnostic test: amylase and/or lipase; 1st line imaging: ultrasound
- Chronic pancreatitis: 1st diagnostic test: CT; testing for exocrine insufficiency: faecal elastase
Do not confuse faecal elastase with faecal calprotectin (which is used to test for IBD).
Acute Vs Chronic Pancreatitis
| Feature | Acute Pancreatitis | Chronic Pancreatitis |
|---|---|---|
| Clinical Features | Short history of sudden onset, severe epigastric pain
|
Long-standing history of recurrent or persistent epigastric pain
May have: history of prior acute episodes, features of exocrine & endocrine pancreatic insufficiency (commoner in chronic pancreatitis) |
| Pancreatic Enzymes
(Amylase/lipase) |
>3x upper limit of normal | Often normal or mildly elevated |
| Other Labs | May show leukocytosis / elevated liver enzymes (if biliary etiology) | Evidence of exocrine insufficiency: low fecal elastase-1, fat-soluble vitamin deficiencies
Evidence of endocrine insufficiency: hyperglycemia (type 3c diabetes) |
| Imaging Findings | CT/MRI: Enlarged, edematous pancreas; peripancreatic fluid collections; necrosis (if severe) | CT/MRI: Pancreatic atrophy, calcifications, ductal irregularity/dilation, glandular fibrosis |
Management
The management of chronic pancreatitis requires a comprehensive MDT approach:
| Category / purpose | Management |
|---|---|
| Treat reversible underlying causes | Examples:
|
| Lifestyle modification |
|
| Nutritional optimisation | Dietitian involvement and assessment are important:
|
| Complication monitoring | Regular surveillance of the following is recommended:
|
| Pancreatic pseudocyst | Pancreatic pseudocyst is a common complication, where there are encapsulated collections of pancreatic fluid.
Indication to treat:
Management:
|