Chronic Pancreatitis ✅

Related Subjects:Acute Cholecystitis |Acute Appendicitis |Chronic Peritonitis |Abdominal Aortic Aneurysm |Ectopic Pregnancy |Acute Cholangitis |Acute Abdominal Pain |Penetrating Abdominal Trauma |Acute Pancreatitis |Acute Diverticulitis

⚠️ Chronic Pancreatitis is a progressive, irreversible inflammatory disease of the pancreas, characterised by fibrosis, scarring and loss of both exocrine and endocrine function. 💡 Patients may develop secondary diabetes and are at high risk of hypoglycaemia due to loss of insulin and glucagon. Complications include malabsorption, chronic pain, pseudocysts, and pancreatic cancer.

📌 About

• Definition: Chronic inflammation of the pancreas causing irreversible structural and functional damage.
• Prevalence: More common in men, typically aged 40–60; alcohol is the most common cause.
• Pathophysiology: Progressive fibrosis → ductal strictures, calcification, loss of islet cells → endocrine and exocrine insufficiency.

🧾 Aetiology

• 🍷 Alcohol misuse: ~70% of cases, usually onset ~40 yrs.
• Idiopathic: ~20% of cases.
• Recurrent acute pancreatitis episodes.
• Metabolic: hypertriglyceridaemia, hyperparathyroidism.
• Genetic/anatomical: PRSS1, SPINK1, CFTR mutations, pancreas divisum, hereditary pancreatitis.
• Autoimmune: IgG4-related pancreatitis.
• Tropical pancreatitis, post-transplant, or post-surgical pancreatitis.

🧬 Pathophysiology

• Fibrosis and calcification → obstruction of pancreatic ducts.
• Loss of endocrine function → diabetes mellitus (high risk of hypoglycaemia due to absent glucagon).
• Loss of exocrine function → malabsorption, steatorrhoea, fat-soluble vitamin deficiencies (A, D, E, K), metabolic bone disease.
• Increased risk of pancreatic ductal adenocarcinoma.

🔎 Types

• Chronic calcifying pancreatitis: Protein plugs → calcification, fibrosis, secondary diabetes. Alcohol abstinence slows progression but may not reverse disease.
• Chronic obstructive pancreatitis: Stones/ductal strictures; endoscopic or surgical interventions may improve outcome.

🤒 Clinical Features

• Recurrent epigastric pain radiating to the back, relieved by sitting forward.
• 💩 Malabsorption → steatorrhoea, bloating, weight loss, malnutrition.
• Cachexia in advanced disease.
• Signs of chronic liver disease may coexist if alcohol-related.

⚠️ Complications

• Secondary diabetes mellitus – high risk of severe hypoglycaemia.
• Malabsorption → fat-soluble vitamin deficiencies.
• Chronic abdominal pain → opiate dependence risk.
• Pancreatic pseudocysts and ductal strictures.
• Pancreatic duct calcification visible on imaging.
• ↑ Risk of pancreatic cancer (ductal adenocarcinoma).

🧪 Investigations

• Bloods: FBC, LFTs, U&E, glucose, HbA1c, IgG4 if autoimmune suspected.
• Amylase/lipase often normal in chronic disease.
• AXR: pancreatic calcifications (~30%).
• CT abdomen: pseudocysts, calcifications, ductal changes.
• MRCP/ERCP: delineates ductal strictures or stones; MRCP preferred due to non-invasiveness.
• Faecal elastase-1: low in exocrine insufficiency.

💊 Management – Chronic Pancreatitis with Secondary Diabetes

• 🏥 Acute admissions: Admit if severe pain, vomiting, dehydration. Start IV fluids, correct electrolytes, keep NBM initially. Monitor vital signs and SIRS features.
• 🚭 Lifestyle: Abstain from alcohol and smoking. Small, frequent low-fat meals, weight management.
• 🍽️ Enzyme replacement: Pancreatic enzymes (e.g., Creon) with meals ± PPI. Monitor for fat-soluble vitamin deficiencies.
• 💉 Diabetes management: Insulin therapy with frequent glucose checks. Educate about hypoglycaemia recognition and dose adjustment.
• 🩺 Pain control: Stepwise: analgesics → opiates → coeliac plexus block for refractory pain. Avoid chronic high-dose opioids without specialist input.
• 🔧 Interventions: ERCP for stones/strictures. Surgery (e.g., lateral pancreaticojejunostomy) for refractory obstruction or strictures.
• 🥗 Nutritional support: Dietitian-guided high-calorie, small meals. Fat-soluble vitamin supplementation.
• 🛌 Emergency stabilisation: Assess ABCs, establish IV access, monitor vitals.
• 💉 Severe hypoglycaemia: Immediate IV dextrose (10–20% glucose). Glucagon often ineffective due to alpha-cell loss. Monitor glucose hourly and watch for seizures, arrhythmias, or altered consciousness.
• 💊 Post-episode insulin adjustment: Reduce basal/bolus doses as counter-regulation is impaired; consider endocrinology review.
• ⚠️ Identify triggers & prevent recurrence: Missed meals, alcohol, illness, excess insulin. Educate patients on hypoglycaemia management and ongoing monitoring.

Key Point: Hypoglycaemia in chronic pancreatitis is more severe and prolonged due to loss of glucagon. Prompt recognition and IV glucose administration are critical to prevent seizures, coma, or death. Long-term management requires a multidisciplinary approach addressing pain, nutrition, endocrine dysfunction, and prevention of recurrent episodes.

Cases – Chronic Pancreatitis

• Case 1 (Alcohol-related): A 47-year-old man with 20-year heavy alcohol use presents with recurrent epigastric pain radiating to the back, steatorrhoea, and weight loss. CT shows pancreatic calcifications and ductal dilatation. Faecal elastase low. Management: Alcohol cessation, pancreatic enzyme replacement, fat-soluble vitamin supplementation, oral analgesia. Outcome: Symptom improvement, pain intermittently persists; abstinence reduces flare frequency.
• Case 2 (Idiopathic/hereditary): A 28-year-old woman with chronic upper abdominal pain and intermittent vomiting. Family history of pancreatitis. MRCP shows ductal strictures and reduced gland size. Endocrine tests reveal impaired glucose tolerance. Management: Pancreatic enzyme replacement, low-fat diet, insulin started, endoscopic therapy for strictures. Genetic counselling provided. Outcome: Symptoms controlled; glucose stabilised; long-term cancer surveillance ongoing.

Teaching Commentary 🧑‍⚕️

Chronic pancreatitis is a progressive fibro-inflammatory disease leading to irreversible pancreatic damage. Key clinical features: chronic pain, malabsorption, diabetes mellitus. Diagnosis relies on clinical assessment, imaging (CT/MRCP), and functional tests (faecal elastase). Management is multidisciplinary: alcohol/smoking cessation, enzyme replacement, nutritional support, analgesia, endoscopic/surgical interventions, and diabetes management. Emergency recognition of hypoglycaemia is critical due to loss of glucagon. Long-term, patients require monitoring for pancreatic cancer and management of complications.

📚 References

• Complications of Chronic Pancreatitis – PubMed
• NICE Guidance: Diabetes in Chronic Pancreatitis
• BSG Guidelines on Chronic Pancreatitis
• UpToDate: Chronic Pancreatitis – Clinical Features and Diagnosis