Chronic pancreatitis

Epidemiology

Chronic heavy alcohol use (most common, esp. men)
Pancreatic ductal obstruction
Tobacco use
Idiopathic pancreatitis
Hereditary pancreatitis
- PRSS1 gene mutation
- Age of onset < 20 years
- Characterized by a positive family history and the absence of other risk factors
Systemic disease
- Cystic fibrosis
- Severe hypertriglyceridemia (levels > 1,000 mg/dL)

Epigastric abdominal pain (main symptom)
- Pain radiates to the back, is relieved on bending forward, and is exacerbated after eating.
- Often associated with nausea and vomiting
Features of pancreatic insufficiency: late manifestation (after 90% of the pancreatic parenchyma is destroyed)
- Steatorrhea (exocrine enzyme deficiency)
  - Cramping abdominal pain, bloating, diarrhea
  - Can lead to a deficiency of fat-soluble vitamins (A, D, E, and K)
- Malabsorption and weight loss
- Pancreatic diabetes (endocrine hormone deficiency)

Encapsulated collection of pancreatic fluid that develops 4 weeks after an acute attack of pancreatitis (can occur in both acute and chronic pancreatitis)

Pancreatic secretions leak from damaged ducts → inflammatory reaction of surrounding tissue → encapsulation of secretions by granulation tissue

Often asymptomatic
Painless abdominal mass
Pressure effects
- Gastric outlet obstruction (early satiety, nonbilious vomiting, abdominal pain)
- Obstruction of the distal duodenum (bilious vomiting) may result in steatorrhea.
- Bile duct obstruction with jaundice

First line: CT abdomen with contrast
- Findings: Extrapancreatic fluid collection within well-defined wall or capsule with contrast enhancementA large circumscribed fluid collection (green overlay) with an enhancing wall (red overlay) surrounds the pancreas (P).

Serum pancreatic enzyme levels: Lipase (specific) and amylase (nonspecific) are often normal.
Fecal elastase-1 (FE-1): most common test
- Elastase is derived from a zymogen produced by pancreatic acinar cells and activated by trypsin in the duodenum; levels correlate with pancreatic exocrine activity. Therefore, low fecal elastase can help diagnose pancreatic insufficiency and supports a diagnosis of chronic pancreatitis.
Sudan staining (which identifies fecal fat)