Phys · gastrointestinal
Chronic Pancreatitis
Also known as chronic pancreatitis · chronic calcific pancreatitis · fibrocalculous pancreatic diabetes · tropical calcific pancreatitis · autoimmune pancreatitis · hereditary pancreatitis · pancreatogenic diabetes · type 3c diabetes
Consultant-physician-depth guide to chronic pancreatitis — the irreversible fibroinflammatory destruction of pancreatic parenchyma, the TIGAR-O mechanistic aetiology (alcohol 70 per cent, hereditary PRSS1/SPINK1/CFTR, autoimmune IgG4-related type 1, tropical calcific, obstructive), the clinical triad of chronic epigastric pain, steatorrhoea from exocrine insufficiency, and type 3c brittle diabetes, the investigations (faecal elastase below 200, CT calcification, MRCP ductal anatomy, EUS Rosemont early changes), the analgesic ladder and endoscopic-surgical drainage (Puestow, Frey, Beger, Whipple, Cahen trial), pancreatic enzyme replacement, and pancreatic cancer surveillance. Structured for FRACP DWE and DCE preparation.
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Red flags
- Weight loss, new change in pain pattern, or jaundice in established chronic pancreatitis — exclude pancreatic adenocarcinoma
- Steatorrhoea indicating 90 per cent loss of exocrine function with malnutrition and fat-soluble vitamin deficiency
- Brittle type 3c diabetes with dangerous hypoglycaemia from loss of glucagon counter-regulation
- Splenic vein thrombosis causing left-sided portal hypertension and gastric variceal bleeding
- An inflammatory head mass indistinguishable from and coexisting with pancreatic cancer
Chronic Pancreatitis
[1]Meet the patient
A 52-year-old heavy drinker has had recurrent epigastric pain for years; now he brings foul, greasy stools he cannot flush and erratic new blood sugars. His abdominal X-ray shows pancreatic calcification and his faecal elastase is 90.[1]
The gland is burning out — and the pain may even quieten as the insufficiency takes over, a pyrrhic victory. The disease is irreversible, so the whole game is structured management around the four pillars, with the one reversible exception always in mind.[3]
References10ShowHide
- [1]Whitcomb DC, Frulloni L, Garg P, Greer JB, Schneider A, Yadav D, Shimosegawa T Chronic pancreatitis: An international draft consensus proposal for a new mechanistic definition Pancreatology, 2016.PMID 26924663
- [2]Whitcomb DC Pancreatitis: TIGAR-O Version 2 Risk/Etiology Checklist With Topic Reviews, Updates, and Use Primers Clin Transl Gastroenterol, 2019.PMID 31166201
- [3]Löhr JM, Dominguez-Munoz E, Rosendahl J, et al. United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis (HaPanEU) United European Gastroenterol J, 2017.PMID 28344786
- [4]Schneider A, Löhr JM, Singer MV The M-ANNHEIM classification of chronic pancreatitis: introduction of a unifying classification system based on a review of previous classifications of the disease J Gastroenterol, 2007.PMID 17351799
- [5]Ewald N, Hardt PD Diagnosis and treatment of diabetes mellitus in chronic pancreatitis World J Gastroenterol, 2013.PMID 24259958
- [6]Ewald N, Bretzel RG Diabetes mellitus secondary to pancreatic diseases (Type 3c)--are we neglecting an important disease? Eur J Intern Med, 2013.PMID 23375619
- [7]Kirkegård J, Mortensen FV, Cronin-Fenton D Chronic Pancreatitis and Pancreatic Cancer Risk: A Systematic Review and Meta-analysis Am J Gastroenterol, 2017.PMID 28762376
- [8]Shimosegawa T, Chari ST, Frulloni L, et al. International consensus diagnostic criteria for autoimmune pancreatitis: guidelines of the International Association of Pancreatology Pancreas, 2011.PMID 21412117
- [9]de la Iglesia-García D, Huang W, Szatmary P, et al. Efficacy of pancreatic enzyme replacement therapy in chronic pancreatitis: systematic review and meta-analysis Gut, 2017.PMID 27941156
- [10]Cahen DL, Gouma DJ, Nio Y, et al. Endoscopic versus surgical drainage of the pancreatic duct in chronic pancreatitis N Engl J Med, 2007.PMID 17301298