Epidemiology

Etiology

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)

Pathology
- Fluid collection rich in enzymes (Amylase, Lipase) and necrotic debris.
- Lined by granulation tissue/fibrosis (NOT epithelium) $\to$ “Pseudo” cyst. t
- Most common cystic lesion of pancreas.
Etiology
- Acute Pancreatitis (complication appearing 4–6 weeks post-onset).
- Chronic Pancreatitis (most common).
- Trauma.
Clinical Features
- Persistent epigastric pain/mass.
- Early satiety or N/V (mass effect on stomach/duodenum).
Diagnostics
- CT Scan: Best initial test.
- Labs: Persistently $↑$ Serum Amylase weeks after acute episode.
Treatment
- Asymptomatic / < 6 cm: Conservative (Observation); spontaneous resolution common.
- Symptomatic / > 6 cm / > 6 weeks: Drainage required (Percutaneous, Endoscopic Cystogastrostomy, or Surgical).

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)

Exocrine Insufficiency (Malabsorption)
- Pancreatic Enzyme Replacement Therapy (PERT) containing lipase, amylase, and protease.
  - Lipase is irreversibly inactivated at pH < 4.0. So use enteric-coated microspheres (delayed release) or PPI. t
- Indicated for steatorrhea and weight loss.