Clinical manifestations and diagnosis of chronic pancreatitis in adults
- Steven D Freedman, MD, PhD
Steven D Freedman, MD, PhD
- Professor of Medicine
- Harvard Medical School
Chronic pancreatitis is a syndrome involving progressive inflammatory changes in the pancreas that result in permanent structural damage, which can lead to impairment of exocrine and endocrine function . This disorder contrasts with acute pancreatitis, which is an acute inflammatory response to pancreatic injury and is usually nonprogressive, although the two conditions may overlap. Recurrent episodes of acute pancreatitis may lead to chronic pancreatitis over time.
Chronic and acute pancreatitis can be distinguished by several features.
●Chronic pancreatitis may be asymptomatic over long periods of time, can present with a fibrotic mass, or there may be symptoms of pancreatic insufficiency without pain. Acute pancreatitis is almost always painful.
●The serum amylase and lipase concentrations tend to be normal in patients with chronic pancreatitis, but are almost always elevated with acute disease.
●Morphologically, chronic pancreatitis is a patchy focal disease characterized by a mononuclear infiltrate and fibrosis (picture 1). In contrast, acute pancreatitis diffusely involves a large portion of the entire pancreas with a predominantly neutrophilic inflammatory response.
- Steer ML, Waxman I, Freedman S. Chronic pancreatitis. N Engl J Med 1995; 332:1482.
- Ammann RW, Muellhaupt B. The natural history of pain in alcoholic chronic pancreatitis. Gastroenterology 1999; 116:1132.
- Layer P, Yamamoto H, Kalthoff L, et al. The different courses of early- and late-onset idiopathic and alcoholic chronic pancreatitis. Gastroenterology 1994; 107:1481.
- Clark E. Pancreatitis in acute and chronic alcoholism. Am J Dig Dis 1942; 9:428.
- DiMagno EP, Go VL, Summerskill WH. Relations between pancreatic enzyme ouputs and malabsorption in severe pancreatic insufficiency. N Engl J Med 1973; 288:813.
- Mergener K, Baillie J. Chronic pancreatitis. Lancet 1997; 350:1379.
- Toskes PP, Hansell J, Cerda J, Deren JJ. Vitamin B 12 malabsorption in chronic pancreatic insufficiency. N Engl J Med 1971; 284:627.
- Del Prato S, Tiengo A. Pancreatic diabetes. Diabetes Reviews 1993; 1:260.
- Malka D, Hammel P, Sauvanet A, et al. Risk factors for diabetes mellitus in chronic pancreatitis. Gastroenterology 2000; 119:1324.
- Ammann RW, Akovbiantz A, Largiader F, Schueler G. Course and outcome of chronic pancreatitis. Longitudinal study of a mixed medical-surgical series of 245 patients. Gastroenterology 1984; 86:820.
- Lowenfels AB, Maisonneuve P, Cavallini G, et al. Pancreatitis and the risk of pancreatic cancer. International Pancreatitis Study Group. N Engl J Med 1993; 328:1433.
- Bang UC, Benfield T, Hyldstrup L, et al. Mortality, cancer, and comorbidities associated with chronic pancreatitis: a Danish nationwide matched-cohort study. Gastroenterology 2014; 146:989.
- Shemesh E, Czerniak A, Nass S, Klein E. Role of endoscopic retrograde cholangiopancreatography in differentiating pancreatic cancer coexisting with chronic pancreatitis. Cancer 1990; 65:893.
- Keim V, Teich N, Moessner J. Clinical value of a new fecal elastase test for detection of chronic pancreatitis. Clin Lab 2003; 49:209.
- Walkowiak J, Herzig KH, Strzykala K, et al. Fecal elastase-1 is superior to fecal chymotrypsin in the assessment of pancreatic involvement in cystic fibrosis. Pediatrics 2002; 110:e7.
- Borowitz D, Baker SS, Duffy L, et al. Use of fecal elastase-1 to classify pancreatic status in patients with cystic fibrosis. J Pediatr 2004; 145:322.
- Bolondi L, Li Bassi S, Gaiani S, Barbara L. Sonography of chronic pancreatitis. Radiol Clin North Am 1989; 27:815.
- Luetmer PH, Stephens DH, Ward EM. Chronic pancreatitis: reassessment with current CT. Radiology 1989; 171:353.
- Balakrishnan V, Chatni S, Radhakrishnan L, et al. Groove pancreatitis: a case report and review of literature. JOP 2007; 8:592.
- Blasbalg R, Baroni RH, Costa DN, Machado MC. MRI features of groove pancreatitis. AJR Am J Roentgenol 2007; 189:73.
- Schmidt G. Pancreas. In: Differential diagnosis in ultrasound: A teaching atlas, Georg Thieme Verlag, Stuttgart, Germany 2006. p.146.
- Bozkurt T, Braun U, Leferink S, et al. Comparison of pancreatic morphology and exocrine functional impairment in patients with chronic pancreatitis. Gut 1994; 35:1132.
- Axon AT, Classen M, Cotton PB, et al. Pancreatography in chronic pancreatitis: international definitions. Gut 1984; 25:1107.
- Zuccaro G Jr, Sivak MV Jr. Endoscopic ultrasonography in the diagnosis of chronic pancreatitis. Endoscopy 1992; 24 Suppl 1:347.
- Catalano MF, Lahoti S, Geenen JE, Hogan WJ. Prospective evaluation of endoscopic ultrasonography, endoscopic retrograde pancreatography, and secretin test in the diagnosis of chronic pancreatitis. Gastrointest Endosc 1998; 48:11.
- Wallace MB, Hawes RH, Durkalski V, et al. The reliability of EUS for the diagnosis of chronic pancreatitis: interobserver agreement among experienced endosonographers. Gastrointest Endosc 2001; 53:294.
- Kahl S, Glasbrenner B, Leodolter A, et al. EUS in the diagnosis of early chronic pancreatitis: a prospective follow-up study. Gastrointest Endosc 2002; 55:507.
- Ketwaroo G, Brown A, Young B, et al. Defining the accuracy of secretin pancreatic function testing in patients with suspected early chronic pancreatitis. Am J Gastroenterol 2013; 108:1360.
- Bishop MD, Freedman SD, Zielenski J, et al. The cystic fibrosis transmembrane conductance regulator gene and ion channel function in patients with idiopathic pancreatitis. Hum Genet 2005; 118:372.
- Ooi CY, Gonska T, Durie PR, Freedman SD. Genetic testing in pancreatitis. Gastroenterology 2010; 138:2202.
- Witt H, Luck W, Hennies HC, et al. Mutations in the gene encoding the serine protease inhibitor, Kazal type 1 are associated with chronic pancreatitis. Nat Genet 2000; 25:213.
- CLINICAL MANIFESTATIONS
- Abdominal pain
- Pancreatic insufficiency
- - Fat malabsorption
- - Pancreatic diabetes
- Differential diagnosis
- Laboratory studies
- Imaging studies
- - Plain films
- - CT, MRI, and US
- - ERCP
- - Endoscopic ultrasonography
- Pancreatic function tests
- GENETIC TESTING
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS