Chronic Pancreatitis

Welcome to our educational podcast! In this episode, we delve into chronic pancreatitis, a complex condition that poses significant challenges in diagnosis and management. We’ll explore the key causes—including alcohol use, genetics, and obesity—and discuss the pathophysiology that underlies this chronic disease.

Join us as we review the clinical presentation, highlighting the symptoms and complications. We’ll also cover diagnostic approaches, including lab tests and imaging techniques, and treatment options, from lifestyle modifications to advanced therapies.

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Transcript

Welcome back to Audioboards! Today, we’re diving into a significant health issue –—chronic pancreatitis. This condition often has a close link to alcoholism; in fact, the longer someone consumes alcohol and the greater the amount, the higher the risk. And let’s not forget about tobacco smoking, which also raises this risk.

Hyperparathyroidism can also cause chronic pancreatitis. In certain regions of Africa and Asia, we see malnutrition causing what's known as tropical pancreatitis. In Western countries, obesity can lead to pancreatic steatosis, disrupting pancreatic function and increasing the risk of pancreatic cancer. Autoimmune pancreatitis is often associated with hypergammaglobulinemia and, importantly, it responds well to corticosteroids. A handy way to remember the causes of chronic pancreatitis is with the mnemonic TIGAR-O. That stands for Toxic which is primarily alcohol and smoking, Idiopathic, Genetic, Autoimmune, and Recurrent or Obstructive causes.

When we consider the pathogenesis, we often refer to the SAPE hypothesis—meaning “Sentinel Acute Pancreatitis Event.” Essentially, that first episode of acute pancreatitis triggers an inflammatory cascade that can lead to significant injury and ultimately to fibrosis.

Moving on to the signs and symptoms, patients typically report persistent or recurrent pain in the epigastric region or the left upper quadrant. This might be accompanied by symptoms like anorexia, nausea, vomiting, constipation, flatulence, and even weight loss. During flare-ups, tenderness over the pancreas can occur, and in more advanced stages, you might see steatorrhea. It's important to highlight the consequences of vitamin deficiencies, particularly regarding fat-soluble vitamins A, D, E, and K. This can even lead to conditions like osteoporosis due to vitamin D deficiency. 

Now, when it comes to lab findings, serum amylase and lipase levels might rise initially but can also appear normal. So, don’t be misled—normal levels don’t rule out chronic pancreatitis! A decreased fecal elastase can confirm if steatorrhea is linked to pancreatic issues. Other markers to keep an eye on include elevated alkaline phosphatase and bilirubin levels, along with increased fecal fat. If autoimmune pancreatitis is suspected, watch for elevated IgG4 levels and specific antibodies. Also, it’s smart to consider genetic testing in younger patients to rule out cystic fibrosis or familial pancreatitis.

Now, let’s talk about imaging. Plain radiographs might show calcifications from pancreatolithiasis, but a CT scan is our most sensitive tool. It can help detect pancreatic duct dilatation and those classic calcifications. Speaking of which, the “Chain of Lakes” appearance is a hallmark of chronic pancreatitis. If there’s any ambiguity with a CT scan, we can also rely on MRI or endoscopic ultrasound. And let's not forget, ERCP remains our gold standard as it can even provide treatment options like duct dilatation.

When it comes to autoimmune pancreatitis, we apply the HISORt criteria—looking at Histology, Imaging, Serology, involvement of Other organs, and, importantly, the response to corticosteroid therapy.

So, how do we treat chronic pancreatitis? First up is a crucial low-fat diet, along with a complete elimination of alcohol and smoking. Pain management is vital too—NSAIDs should be your first line. If stronger pain relief is needed, consider opioids like tramadol or alternatives like Tri-Cyclic Antidepressants, Selective Serotonin Reuptake Inhibitors, gabapentin, or pregabalin. For patients experiencing exocrine pancreatic insufficiency, pancreatic enzyme replacement therapy is crucial. Additionally, using an H2 receptor antagonist, a proton pump inhibitor, or sodium bicarbonate can help reduce the inactivation of lipase by stomach acid. Autoimmune pancreatitis is treated with prednisone 40 mg daily for one to two months, with a gradual taper.

Endoscopic or surgical options may come into play for addressing underlying biliary tract diseases, especially when pain remains a challenge. Procedures such as celiac ganglion blocks or duct dilatation can offer much-needed relief.

Complications include pancreatic pseudocysts that can either rupture or become infected, as well as splenic vein thrombosis. Asymptomatic pseudocysts larger than 5 cm, as well as symptomatic cysts, will usually require intervention.

Finally, let’s talk about prognosis. The chronic pancreatitis prognosis score provides valuable insights based on factors like pain level, HbA1c, CRP, BMI, and platelet count—all of which correlate with hospital admissions and duration of the illness.

That’s all for today’s episode. Thanks for listening to AudioBoards. Stay tuned for more educational content in our next episode!

"The views and opinions expressed on the AudioBoards Podcast do not necessarily reflect those of our employers. This podcast is for educational purposes only and should not be used to diagnose or treat any medical conditions. It is not a substitute for professional medical advice. Always consult a qualified, board-certified healthcare provider for any medical concerns."