Updated: 10/22/2019

Chronic Pancreatitis

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Snapshot
  • A 32-year-old female is brought to the emergency room by her husband for severe abdominal pain. The patient reports that the pain began 4 hours again and is 10/10, sharp, and radiates to her back. She has had multiple similar episodes in the past that have resolved with opioid analgesics. She reports a 6-lbs. weight loss over the past 4 months and stools that are difficult to flush.  A CT scan demonstrastes dystrophic calcifications of the pancreas.
Introduction
  • Clinical definition
    • condition characterized by a long-standing, progressive inflammation of the pancreas leading to permanent alterations in the organ’s normal structure and functions
    • damage of the organ leads to impairment of exocrine and endocrine function 
      • malabsorption leading to fat soluble vitamin (D, E, A, and K) deficiencies 
      • diabetes due to pancreas’ inability to produce insulin
  • Epidemiology
    • demographics
      • alcoholism is the most common cause in the United States
  • Pathogenesis
    • there are various etiologies that can lead to chronic pancreatitis
      • alcohol abuse
      • smoking
      • genetic causes (e.g., cystic fibrosis or hereditary pancreatitis)
      • ductal obstruction (e.g., trauma, pseudocysts, stones, tumors, or pancreas divisum)
      • tropical pancreatitis
      • systemic diseases (e.g., systemic lupus erythematous, hypertriglyceridemia, or hyperparathyroidism)
      • autoimmune pancreatitis
      • idiopathic pancreatitis
    • the pathophysiology of chronic pancreatitis is not fully understood but some theories to its development are as follows
      • proteinaceous ductal plug secondary to increased secretion of pancreatitic proteins
        • plugs acts a nidus for calcification leading to stone formation, ductal lesions, and subsequent inflammatory changes
      • ischemia likely important in exacerbating and facilitating the disease
      • lack of antioxidants (e.g., selenium, vitamin C and E, and methionine) leading to increases in free radicals
      • autoimmune mechanisms, as a number of autoimmune disorders (e.g., autoimmune pancreatitis) have been linked to chronic pancreatitis
  • Associations 
    • increased risk of pancreatic cancer 
Presentation
  • Symptoms
    • abdominal pain
      • often epigastric with radiation to the back relieved by leaning forward
      • worse 15-30 minutes after eating
      • repeated pain attacks
    • nausea
    • vomiting
    • steatorrhea
    • constipation
    • flatulence
  • Physical exam
    • weight loss
Imaging
  • Abdominal computed tomography (CT) with contrast
    • best initial imaging
    • positive findings include calcifications within the pancreas, ductal dilation, enlargement of the pancreas, and fluid collections (e.g., pseudocysts) adjacent to the gland  
  • Magnetic resonance cholangiopancreatography (MRCP)
    • becoming the diagnostic test of choice
    • no radiation risk
    • allows for better detection of calcifications and pancreatic duct obstruction consistent with chronic pancreatitis
  • Endoscopic retrograde cholangiopancreatography
    • indicated in patients with no calcifications on imaging and have the potential need of therapeutic intervention
Studies 
  • Laboratory studies
    • normal to minimally elevated of amylase and/or lipase
      • should not be used for the diagnosis of chronic pancreatitis
    • CBC, electrolytes, and liver functions tests
      • typically normal
      • may see elevations in serum bilirubin and alkaline phosphatase
    • HbA1c levels for evaluation of diabetes
  • Pancreatic function tests
    • secretin pancreatitic function test
      • low levels of bicarbonate concentration following secretin administration indicates exocrine pancreatic insufficiency
    • stool elastase (< 200 mcg/g)
    • low serum trypsinogen (< 20ng/mL)
Differential 
  • Pancreatic cancer
    • differentiating factors
      • lesion will be visible on imaging with further support from ERCP findings if needed
  • Acute pancreatitis
    • differentiating factors
      • clinical presentation (e.g., pain characteristic) and history as well as serum lipase and/or amylase levels
Treatment
  • Lifestyle and dietary modifications 
    • cessation of alcohol and tobacco
    • dietary modifications (eat small meals that are low in fat)
    • acid suppression (e.g.. proton pump inhibitor) along with pancreatic enzyme supplements (e.g., lipase) for pain management and malabsorption
    • oral hypoglycemic agents or insulin therapy if needed
    • vitamin supplementations (e.g., vitamins A, D, E, K, and B12)
  • Pain management 
    • analgesics with opiates and/or nonsteroidal anti-inflammatory agents
      • indicated if pancreatic enzyme therapy fails to control pain
      • can be used with adjuvant pregabalin
    • other approaches for pain management include
      • endoscopic therapy
      • extracorporeal shock wave lithotripsy
      • celiac nerve block
  • Surgery 
    • generally indicated in patients who fail medical therapy
    • approaches include decompression/drainage, pancreatic resections, and denervation procedures
Complications 
  • Chronic pain with addiction to analgesics
  • May have exocrine and endocrine insufficiency
  • Pancreatic pseudocyst
  • Ductal obstruction
  • Increased risk of pancreatic cancer
 

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Questions (2)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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