Chronic Pancreatitis

Chronic pancreatitis is a progressive fibroinflammatory disease with irreversible damage to pancreatic structure and function.

• Incidence 5 to 12 per 100,000 per year, men more than women.
• Aetiology (TIGAR-O): toxic metabolic (alcohol in 50 to 70%, smoking, hypertriglyceridaemia, hypercalcaemia), idiopathic, genetic (PRSS1, SPINK1, CFTR, CTRC), autoimmune, recurrent acute pancreatitis, obstructive (divisum, tumour, stricture).
• Natural history: abdominal pain early, exocrine insufficiency (steatorrhoea after 90% loss), endocrine insufficiency (type 3c diabetes) at 10 to 20 years.
• Complications: pseudocysts, biliary and duodenal obstruction, splenic vein thrombosis, pancreatic ductal stones, malnutrition, osteoporosis, pancreatic cancer (risk 5 to 8 fold).

• Epigastric pain radiating to the back, postprandial, relieved by leaning forward, constant or episodic.
• Steatorrhoea, weight loss, fat soluble vitamin deficiency.
• Diabetes, nausea, anorexia.
• Examination often unremarkable; cachexia in advanced disease.
• Red flags: new onset diabetes with weight loss and jaundice (cancer).

• Imaging: CT (calcifications, ductal dilatation, atrophy), MRI/MRCP with secretin stimulation (ductal changes, duct compliance), endoscopic ultrasound (Rosemont criteria: hyperechoic foci with shadowing, lobularity, ductal changes).
• Plain abdominal film: pancreatic calcification (late).
• Exocrine function: faecal elastase 1 (below 200 micrograms/g), 72 hour faecal fat (over 7 g/day), 13C mixed triglyceride breath test; secretin tests are specialised.
• Endocrine function: HbA1c, fasting glucose, oral glucose tolerance.
• Etiology: lipids, calcium, IgG4, genetic panels in early onset or family history, alcohol history, CA 19-9 for suspected cancer.
• Vitamin A, D, E, B12, zinc, magnesium, DEXA.

• Abstain from alcohol and smoking; small frequent low fat meals; adequate calories; correct deficiencies.
• Pain: stepwise (paracetamol 1 g, NSAIDs short term, tramadol 50 to 100 mg, then strong opioids with care), neuropathic agents (pregabalin 75 to 300 mg twice daily, amitriptyline 10 to 50 mg), antioxidants (limited), pancreatic enzymes (non enteric coated, high dose) for pain with preserved function.
• Pancreatic enzyme replacement therapy for exocrine insufficiency: lipase 40,000 to 50,000 units with main meals, half with snacks (maximum 10,000 units/kg/day), PPI to improve efficacy, titrate to steatorrhoea and weight.
• Diabetes: insulin (metformin may be used early); beware of hypoglycaemia.
• Endoscopic therapy: pancreatic duct stone removal (extracorporeal shock wave lithotripsy followed by ERCP), stricture dilatation and stenting, bile duct stenting; celiac plexus block for refractory pain.
• Surgery for failure of endoscopic therapy: Frey procedure (head coring with lateral pancreaticojejunostomy), Beger, Berne, Puestow, distal pancreatectomy, total pancreatectomy with islet autotransplantation in selected patients.
• Bone health: vitamin D 2000 IU, calcium, bisphosphonate.
• Cancer surveillance in hereditary disease.
• Follow up every 6 to 12 months.