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Diagnosis and Management of Chronic PancreatitisA Review

Educational Objective
To review the diagnosis and treatment of patients with chronic pancreatitis.
1 Credit CME
Abstract

Importance  Chronic pancreatitis (CP) is a chronic inflammatory and fibrotic disease of the pancreas with a prevalence of 42 to 73 per 100 000 adults in the United States.

Observations  Both genetic and environmental factors are thought to contribute to the pathogenesis of CP. Environmental factors associated with CP include alcohol abuse (odds ratio [OR], 3.1; 95% CI, 1.87-5.14) for 5 or more drinks per day vs abstainers and light drinkers as well as smoking (OR, 4.59; 95% CI, 2.91-7.25) for more than 35 pack-years in a case-control study involving 971 participants. Between 28% to 80% of patients are classified as having “idiopathic CP.” Up to 50% of these individuals have mutations of the trypsin inhibitor gene (SPINK1) or the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Approximately 1% of people diagnosed with CP may have hereditary pancreatitis, associated with cationic trypsinogen (PRSS1) gene mutations. Approximately 80% of people with CP present with recurrent or chronic upper abdominal pain. Long-term sequelae include diabetes in 38% to 40% and exocrine insufficiency in 30% to 48%. The diagnosis is based on pancreatic calcifications, ductal dilatation, and atrophy visualized by imaging with computed tomography, magnetic resonance imaging, or both. Endoscopic ultrasound can assist in making the diagnosis in patients with a high index of suspicion such as recurrent episodes of acute pancreatitis when imaging is normal or equivocal. The first line of therapy consists of advice to discontinue use of alcohol and smoking and taking analgesic agents (nonsteroidal anti-inflammatory drugs and weak opioids such as tramadol). A trial of pancreatic enzymes and antioxidants (a combination of multivitamins, selenium, and methionine) can control symptoms in up to 50% of patients. Patients with pancreatic ductal obstruction due to stones, stricture, or both may benefit from ductal drainage via endoscopic retrograde cholangiopancreatography (ERCP) or surgical drainage procedures, such as pancreaticojejunostomy with or without pancreatic head resection, which may provide better pain relief among people who do not respond to endoscopic therapy.

Conclusions and Relevance  Chronic pancreatitis often results in chronic abdominal pain and is most commonly caused by excessive alcohol use, smoking, or genetic mutations. Treatment consists primarily of alcohol and smoking cessation, pain control, replacement of pancreatic insufficiency, or mechanical drainage of obstructed pancreatic ducts for some patients.

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Article Information

Corresponding Author: Vikesh K. Singh, MD, MSc, Division of Gastroenterology, Johns Hopkins University School of Medicine, 1830 E Monument St, Room 428, Baltimore, MD 21287 (vsingh1@jhmil.edu).

Accepted for Publication: November 19, 2019.

Author Contributions:  Dr Singh had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Singh, Garg.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Administrative, technical, or material support: Singh.

Supervision: Singh.

Conflict of Interest Disclosures: Dr Singh reports receiving personal fees from Abbvie, Theraly Inc, Cook Medical, Orgenesis, and Ariel Precision Medicine. Dr Yadav is supported by the National Cancer Institute and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) under award UO1 DK 108306. Dr Garg is supported by a grant for the Center for Advanced Research and Excellence in Pancreatic Diseases by the Indian Council of Medical Research.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Additional Contributions: We thank Kajal Jain, PhD, All India Institute of Medical Sciences, New Delhi, and Mahya Faghih, MD, Division of Gastroenterology, Johns Hopkins University School of Medicine, for helping to put together this review.

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