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