AKT · Gastroenterology/Pancreatobiliarylow yield

Chronic pancreatitis

Chronic pancreatic inflammation/fibrosis → exocrine + endocrine failure (alcohol commonest)

Overview

Chronic inflammation and irreversible fibrosis of the pancreas — most commonly from chronic ALCOHOL (also genetic, autoimmune, obstructive, hypertriglyceridaemia). Causes chronic epigastric pain, and progressive loss of function: EXOCRINE failure (steatorrhoea, malabsorption, weight loss — low faecal elastase) and ENDOCRINE failure (diabetes). Pancreatic CALCIFICATION on imaging is characteristic. Managed with pain control, pancreatic enzyme replacement, and diabetes treatment.

Recognise

Chronic/recurrent epigastric pain radiating to the back (often relieved by sitting forward), worse after eating/alcohol
EXOCRINE insufficiency: steatorrhoea, weight loss, fat-soluble vitamin deficiency (low faecal elastase); ENDOCRINE: diabetes
Pancreatic CALCIFICATION on AXR/CT; alcohol history; raised pancreatic-cancer risk

Red flags

New/worsening pain + weight loss → exclude pancreatic cancer (chronic pancreatitis raises the risk)
Pseudocyst, biliary/duodenal obstruction, splenic vein thrombosis

Differentials & how to tell them apart

Pancreatic cancerweight loss + painless jaundice / new diabetes — exclude with imaging (the feared mimic/complication)

Peptic ulcer/biliary diseasedifferent pain pattern/tests

Malabsorption from other causescoeliac (normal faecal elastase)

Investigations

Faecal ELASTASE (low — exocrine insufficiency); CT/MRCP (calcification, ductal changes, complications); HbA1c/glucose (diabetes); fat-soluble vitamins; amylase often NORMAL (burnt-out gland).

Management

Alcohol cessation + analgesia + pancreatic enzyme replacement + treat diabetes

1Confirm with faecal elastase (low) and imaging (calcification/ductal change). Stop alcohol and smoking; analgesia; pancreatic enzyme replacement + fat-soluble vitamins; treat diabetes.Gate: New/worsening pain with weight loss must prompt exclusion of PANCREATIC CANCER (chronic pancreatitis raises the risk); amylase is often normal in established disease, so don't rely on it
2Endoscopic/surgical drainage for ductal obstruction/pseudocyst; coeliac plexus block for refractory pain; nutritional and diabetes support.

Alcohol + smoking cessation; analgesia — address the cause; stepwise analgesia (neuropathic agents; coeliac plexus block)

Pancreatic enzyme replacement (CREON) + fat-soluble vitamins — for exocrine insufficiency/steatorrhoea

Manage diabetes — endocrine insufficiency — often brittle

Key points

Chronic epigastric-to-back pain + steatorrhoea (low faecal elastase) + diabetes + pancreatic calcification + alcohol = chronic pancreatitis → enzyme replacement + pain control + treat diabetes. Watch for pancreatic cancer.

Monitor & prognosis

Nutrition/vitamins, glucose, pain; cancer vigilance.

Chronic; complications and cancer risk.

Source: BSG; NICE NG104