PANCREATITIS, CHRONIC   36A

A 52-year-old man with a 20-year history of alcohol abuse presents to the clinic complaining of recurrent episodes of epigastric and left upper quadrant (LUQ) abdominal pain. Over the past month, his pain has become almost continuous; he requests morphine for pain control. Recently, his stool has been bulky and foul smelling. He has a history of alcohol-related acute pancreatitis. Examination reveals a 10-lb weight loss and mild epigastric tenderness to palpation and guarding. Bowel sounds are decreased. Serum amylase and lipase are mildly elevated. A plain abdominal film shows pancreatic calcifications.

What are the salient features of this patient’s problem? How do you think through his problem?

Salient features: Long-standing alcohol abuse; repeated acute pancreatitis episodes; chronic epigastric abdominal pain; bulky and foul-smelling stool (steatorrhea from pancreatic insufficiency); epigastric tenderness; elevated serum amylase and lipase; pancreatic calcifications

How to think through: Epigastric pain has a broad differential diagnosis, highlighting the importance of the history—the pattern and timing of abdominal pain, alcohol use, prior episodes of acute pain, nausea, and anorexia—and careful physical examination. If the serum amylase and lipase levels were normal, could the patient still have chronic pancreatitis? (Yes. Although these enzymes are often mildly elevated in chronic pancreatitis, their sensitivity and utility are far greater in acute pancreatitis.) How could you confirm your diagnosis? (Diagnosis of steatorrhea and pancreatic calcifications on radiography provide sufficient confirmation. Computed tomography [CT], magnetic resonance cholangiopancreatography [MRCP], and endoscopic retrograde cholangiopancreatography [ERCP] are available, if needed.) Should he be assessed for endocrine dysfunction? (Yes. Such patients can develop impaired glucose tolerance and eventually diabetes mellitus.) What lifestyle modification will improve his symptoms? (Abstinence from alcohol; small meals; low-fat diet.) What medication might help? (Pancreatic enzymes.) Are there procedural interventions that might help his symptoms? (ERCP with stenting of the pancreatic duct; sphincterotomy; celiac plexus nerve block.) What complications might arise for this patient? (Opioid addiction; diabetes; pancreatic pseudocyst, abscess or cancer; bile duct stricture; cholestasis; malnutrition; peptic ulcer.)

PANCREATITIS, CHRONIC   36B

What are the essentials of diagnosis and general considerations regarding chronic pancreatitis?

Essentials of Diagnosis

Epigastric pain, steatorrhea, weight loss, abnormal pancreatic imaging

General Considerations

Chronic pancreatitis occurs most often with alcoholism; the risk increases with the duration and amount of consumption.

Tobacco smoking may accelerate progression of alcoholic chronic pancreatitis.

Pancreatitis develops in about 2% of patients with hyperparathyroidism.

Tropical pancreatitis, related to malnutrition, is a common cause in Africa and Asia.

A stricture, stone, or tumor obstructing the pancreas can lead to obstructive chronic pancreatitis.

Autoimmune pancreatitis is associated with hypergammaglobulinemia.

The pathogenesis may be related to a first episode of acute pancreatitis, which initiates an inflammatory process that results in injury and then fibrosis.

Genetic factors may predispose to chronic pancreatitis in some cases (e.g., CFTR gene mutations).

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