Snap Shot Mr. S, a 52-year-old male, with a twenty year history of alchoholism presents in the ER with persistant epigastric pain, constipation, and steatorrhea. His labs are remarkable for mildly elevated amylase and lipase, UA shows glucosuria, and stool demonstrates low fecal elastase. Abdominal radiograph shows a mild ileus. Introduction Caused by chronic inflammation of the pancreas Follows a persistant and recurrent disease course alchoholism is major cause in the United States other causes include anatomic defects (pancreas divisum), cystic fibrosis, medications (valproate, HCTZ, phenacetin, azathioprine, statins, furosamide, steroids, interferon, etc.), autoimmune Type I and Type II, idiopathic (leading cause in India, China, and Japan), hyperparathyroidism, and rarely infectious (HIV, mumps virus, cozsackie virus B, among others). Presentation Symptoms recurrent epigastric pain constipation flatulence steatorrhea because of decreased lipase activity weight loss fat soluble vitamin deficiencies (A, D, E, K) Evaluation Labs mildly elevated amylase (though can be in normal range) mildly elevated lipase (though can be in normal range) glycosuria Imaging CT abdomen with contrast best first imaging modality MRCP or endoscopic ultrasound (EUS) best modalities for interrogating pancreatic parenchyma. ERCP discouraged for diagnosis alone due to high rates of complications in this population (can be as high as 4%). calicifications and mild ileus Pancreatic function tests pancreatic stimulation with secretin and CCK (not routinely used due to invasiveness) stool elastase (< 200 mcg/g) low serum trypsinogen (< 20ng/mL) Treatment Alchohol cessation Low fat diet to avoid pancreatic stimulation Oral pancreatic enzymes lipase before, during, and after meals concurrent administration of histimine antagonist to reduce acidity, or proton pump inhibitors will inactivate enzyme Vitamin supplementation with vitamins A, D, E, K and B12 in those due to alcoholism Analgesia for pain, avoid patient controlled opiods due to high rate of opiod dependece in this population, if possible manage pain with NSAIDs, acetomenophen, tramadol Autoimmune pancreatitis responsive to steroid therapy Pancreatectomy only if intractable pain despite medical therapy Prognosis, Prevention, and Complications Chronic pain with addiction to analgesics May have exocrine and endocrine insufficiency Pancreatic pseudocyst Ductal obstruction Increased risk of pancreatic cancer