Overview
What are the signs and symptoms of chronic pancreatitis?
How is chronic pancreatitis diagnosed?
What is the role of imaging in the diagnosis of chronic pancreatitis?
What is the role of ERCP and MRCP in the diagnosis of chronic pancreatitis?
What are endosonographic findings suggestive of chronic pancreatitis?
How is treatment for chronic pancreatitis directed?
What is the role of pancreatic enzyme supplementation in the treatment of chronic pancreatitis?
What is the role of celiac ganglion blockade the treatment of chronic pancreatitis?
What is the role of endoscopic therapy in the treatment of chronic pancreatitis?
What are the surgical options for treatment of chronic pancreatitis?
What is the appearance of chronic pancreatitis on imaging?
How does chronic pancreatitis differ from acute pancreatitis?
What is the clinical presentation of chronic pancreatitis?
Where can patient education information be found for chronic pancreatitis?
What is the pathophysiology of chronic pancreatitis?
What are the possible mechanisms in the pathogenesis of chronic pancreatitis?
What are the clinical characteristics of autoimmune pancreatitis?
What is the relationship between pancreatic stone formation and chronic pancreatitis?
What is the most common cause of chronic pancreatitis?
What is the role of alcohol in the pathogenesis of chronic pancreatitis?
What is the role of lithostathine in the etiology of chronic pancreatitis?
What is the role of ethanol in the etiology of chronic pancreatitis?
What is the role of genetics in the etiology of chronic pancreatitis?
Which hereditary disorders cause chronic pancreatitis?
What is the role of cystic fibrosis (CF) in the etiology of chronic pancreatitis?
What are possible causes of idiopathic chronic pancreatitis?
What is the role of congenital abnormalities in the etiology of chronic pancreatitis?
What is the cause of acquired obstructive chronic pancreatitis?
What are less common causes of chronic pancreatitis?
What is the incidence of chronic pancreatitis in the US?
What is the global incidence of chronic pancreatitis?
What are the racial predilections for chronic pancreatitis?
How does the incidence of chronic pancreatitis vary by sex?
How does the incidence of chronic pancreatitis vary by age?
What are prognostic factors associated with chronic pancreatitis?
What are the survival and mortality rates for chronic pancreatitis?
What are common complications of chronic pancreatitis?
What is a pseudocyst in chronic pancreatitis?
What causes pseudocysts in chronic pancreatitis?
What causes pseudoaneurysm in chronic pancreatitis?
What causes ascites and pleural effusion in chronic pancreatitis?
What are the indications for drainage of pseudocysts in chronic pancreatitis?
What causes bile and duodenal obstruction in chronic pancreatitis?
What are less common complications of chronic pancreatitis?
Presentation
What is the typical presenting symptom of chronic pancreatitis?
What are the clinical signs of chronic pancreatitis?
What is the natural history of pain in chronic pancreatitis?
Other than pain, what are the symptoms of chronic pancreatitis?
Which physical findings suggest chronic pancreatitis?
What is included in the physical exam for chronic pancreatitis?
DDX
How are cystic neoplasms differentiated from chronic pancreatitis?
What are the differential diagnoses for Chronic Pancreatitis?
Workup
What is included in the workup of chronic pancreatitis?
What is the role of blood tests in the evaluation of chronic pancreatitis?
What is the role of fecal tests in the diagnosis of chronic pancreatitis?
What is the role of pancreatic function tests in the diagnosis of chronic pancreatitis?
What is the role of duodenal aspirates in the diagnosis of chronic pancreatitis?
How is pancreatic juice tested in the evaluation of chronic pancreatitis?
Which noninvasive pancreatic function tests are used in the diagnosis of chronic pancreatitis?
What are the hallmarks of chronic pancreatitis on imaging studies?
What is the role of abdominal radiography in the diagnosis of chronic pancreatitis?
What is the role of CT scanning in the diagnosis of chronic pancreatitis?
What is the role of ERCP in the diagnosis of chronic pancreatitis?
What is the role of pancreatograms in the diagnosis of chronic pancreatitis?
What is the limitation of endoscopic ultrasonography (EUS) in the diagnosis of chronic pancreatitis?
What are the endoscopic ultrasonography (EUS) criteria for diagnosis of chronic pancreatitis?
Which histologic findings are characteristic of the early stages of chronic pancreatitis?
Which histologic changes suggest chronic pancreatitis?
Treatment
What are the goals of medical treatment for chronic pancreatitis?
What are the treatment options in the early stages of chronic pancreatitis?
What determines the need for hospitalization to treat chronic pancreatitis?
What is included in inpatient treatment of mild chronic pancreatitis?
When is ICU treatment indicated for chronic pancreatitis?
What are anatomical complications of chronic pancreatitis?
What are intervention options for the treatment of chronic pancreatitis?
How is percutaneous drainage performed in the treatment of chronic pancreatitis?
Which specialist consultations are needed for the treatment of chronic pancreatitis?
Which lifestyle changes are indicated for the treatments of chronic pancreatitis?
What are sources of pain in chronic pancreatitis?
How is pain managed in chronic pancreatitis?
What is the role of exogenous pancreatic enzymes in the treatment of chronic pancreatitis?
How do exogenous pancreatic enzymes relive pain in chronic pancreatitis?
What are the benefits of the exogenous pancreatic enzymes for treatment of chronic pancreatitis?
What is the role of celiac ganglion blockade in the treatment of chronic pancreatitis?
What is the benefit of a reduced fat intake in the treatment of chronic pancreatitis?
What is the role of triglycerides in the treatment of chronic pancreatitis?
What is the role of enteric-coated agents for the treatment of chronic pancreatitis?
What is the role of vitamin B-12 in the treatment of chronic pancreatitis?
What is the goal of endoscopic therapy for chronic pancreatitis?
What are the benefits of endoscopic treatment of chronic pancreatitis?
What is the efficacy of endoscopic therapy for chronic pancreatitis?
When is endoscopic therapy beneficial in the treatment of chronic pancreatitis?
How is papillary stenosis in chronic pancreatitis?
How are pancreatic duct strictures treated in patients with chronic pancreatitis?
How are pancreatic duct stones treated in patients with chronic pancreatitis?
How are pancreatic pseudocysts treated in patients with chronic pancreatitis?
How are noncommunicating pseudocysts treated in patients with chronic pancreatitis?
What is the basis for selection of surgery in chronic pancreatitis?
How is pancreatic duct drainage performed in the treatment of chronic pancreatitis?
What is the role of pancreatic resection in patients with chronic pancreatitis?
What is the efficacy of total pancreatectomy for the treatment of chronic pancreatitis?
What is the recommended diet for patients with chronic pancreatitis?
Guidelines
What are the guidelines on the diagnosis and management of chronic pancreatitis?
Medications
What is the curative treatment for chronic pancreatitis?
How do exogenous pancreatic enzymes reduce pain in chronic pancreatitis?
Which medications in the drug class Hormones are used in the treatment of Chronic Pancreatitis?
-
This endoscopic retrograde cholangiopancreatography (ERCP) shows advanced chronic pancreatitis. The pancreatogram has blunting of the lateral branches, dilation of the main pancreatic duct, and filling defects consistent with pancreatolithiasis. The cholangiogram also shows a stenosis of the distal bile duct and a dilated biliary tree.
-
Chronic pancreatitis. Abdominal CT scan showing a pancreatic pseudocyst causing distortion of the ductal system.
-
This patient has recurrent abdominal pain. She used alcohol heavily in the past and was involved in a motor vehicle accident. The pancreatogram shows subtle blunting of the side branches consistent with chronic pancreatitis. A stricture also is present in the body of the pancreas where it drapes over the spine, probably resulting from the trauma she sustained in the motor vehicle accident. Air in the stomach makes it difficult to observe that contrast is filling a pseudocyst on the other side of the stricture. These findings are not amenable to endoscopic intervention, and the patient was sent for a distal pancreatectomy.
-
Chronic pancreatitis. This magnetic resonance cholangiopancreatography (MRCP) shows a healthy biliary system. The pancreatic ductal system is not well visualized. A subsequent endoscopic retrograde cholangiopancreatography (ERCP [not pictured]) showed pancreas divisum, with no evidence of a communication with the pseudocyst. The endoscopic features were ideal for an endoscopic transgastric pseudocystogastrostomy.
-
Chronic pancreatitis. CT scans of the abdomen following an endoscopic transgastric pseudocystogastrostomy. Note that 2 stents are placed through the stomach and into the pseudocyst. Before undertaking this type of endoscopic intervention, the endoscopist must be confident that a cystadenoma has not been mistaken for a pseudocyst.
-
Chronic pancreatitis. This patient had a persistent postoperative leak from the site of a distal pancreatectomy. In the mid-1990s, the author sought to facilitate enteric drainage using transpapillary stents placed into the pancreatic duct. While this changed the fluid dynamics in favor of healing the disrupted duct, some patients developed complications from this technique.
-
Chronic pancreatitis. The persistent postoperative leak from the site of a distal pancreatectomy has healed at 1-month follow-up (see the image above). However, after 4 weeks of transpapillary stenting, the pancreatogram now shows a stent-induced stenosis near the surgical genu (arrow). Based on this experience, the author stopped using pancreatic stents in this setting.
-
Chronic pancreatitis. This patient developed abdominal pain several weeks after being accidentally hit with a baseball bat. A CT scan showed a large splenic hematoma, and the patient underwent a splenectomy. His postoperative course was notable for recurrent pain, abdominal distension, and elevation of serum amylase levels over the course of 2-3 months. This repeat CT scan shows postsurgical changes in the left upper quadrant and a large fluid collection.
-
Chronic pancreatitis. The pancreatogram shows a small leak from the tail of the gland.
-
Chronic pancreatitis. A nasopancreatic tube courses through the esophagus, stomach, and duodenum and into the pancreatic duct. Externally, the end of the tube is attached to a suction bulb to decompress the ductal system and monitor its function on a daily basis. In contrast to patients treated with transpapillary stents, none of these patients ever has failed to return for a follow-up appointment. In addition, while stent obstruction and subsequent infection can occur with transpapillary stents, the author has not observed this complication while using nasopancreatic tubes.
-
Chronic pancreatitis. Nine days after placement of a nasopancreatic tube, a pancreatogram obtained via the tube showed that the disruption had healed (see the above image). The tube then was removed.
-
Chronic pancreatitis. This follow-up CT scan (see the above 2 images) shows a percutaneous tube in the left upper quadrant that was used to drain a fluid collection. It was removed after 4 weeks. The patient returned to work, regained his weight, and had no recurrence of abdominal pain or signs of a recurrent pancreatic leak.
-
Chronic pancreatitis. Pancreatogram in a patient with a pancreatic pseudocyst. Note how the pancreatic ducts are extrinsically distorted by a mass lesion.
-
This pancreatogram shows a pseudocyst communicating with the main pancreatic duct in a patient with chronic pancreatitis and recurrent abdominal pain. He was treated endoscopically with a transpapillary stent placed into the pancreatic duct.
-
Four weeks after placement of a transpapillary stent, a patient with a pseudocyst communicating with the main pancreatic duct (chronic pancreatitis with recurrent abdominal pain) had not had a recurrence of pain. The CT scan showed resolution of the cyst, and the follow-up pancreatogram showed marked improvement. Transpapillary stenting of the pancreatic duct should be reserved for patients with established chronic pancreatitis.