Chronic Pancreatitis

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GI NOTES

Chronic Pancreatitis

Key points

Chronic pancreatitis is irreversible inflammation and fibrosis of the pancreas, leading to pain, exocrine insufficiency and diabetes.
Alcohol and smoking are the main modifiable risks; stopping both is the single most important intervention.
Diagnose with CT or MRI/MRCP first (calcifications, duct changes); use endoscopic ultrasound when imaging is unclear.
Treat exocrine insufficiency with pancreatic enzymes taken with meals; dose by lipase units per meal.
Screen yearly for diabetes, check fat-soluble vitamins and bone density, and remember the higher risk of pancreatic cancer.

1. What it is and who gets it

Repeated or ongoing injury leads to permanent scarring of the gland, duct strictures and stones. Many patients have had recurrent acute pancreatitis first. Risk factors are often grouped with the TIGAR-O system:

Group	Examples
Toxic-metabolic	Alcohol, smoking, hypercalcemia, hypertriglyceridemia, chronic kidney disease
Idiopathic	Early- and late-onset forms; tropical pancreatitis
Genetic	PRSS1, SPINK1, CFTR, CTRC variants
Autoimmune	Type 1 (IgG4-related) and type 2 autoimmune pancreatitis
Recurrent and severe acute pancreatitis	Including post-necrotic disease
Obstructive	Duct stricture, tumor, pancreas divisum (debated), sphincter problems

2. Symptoms and diagnosis

Pain: epigastric, often radiating to the back, worse after meals; constant or episodic. Some patients have little pain.
Exocrine insufficiency: greasy, foul stools, bloating, weight loss, deficiency of vitamins A, D, E and K.
Endocrine insufficiency: type 3c (pancreatogenic) diabetes, prone to hypoglycemia because glucagon is also lost.
Lipase is often normal in established disease; it does not rule chronic pancreatitis in or out.

FIGURE: STEPWISE DIAGNOSIS

Suspected chronic pancreatitis

Step 1: CT or MRI with MRCP

Calcifications or clear duct changes: diagnosis made

Unclear: endoscopic ultrasound (Rosemont criteria)

Still unclear: secretin-enhanced MRCP or pancreatic function testing

Original diagram based on the ACG 2020 chronic pancreatitis guideline.

Fecal elastase below 100 µg/g supports exocrine insufficiency (100 to 200 is indeterminate); watery stool gives false lows.
Consider genetic testing in young patients or those without an obvious cause; check IgG4 when autoimmune disease is possible.

3. Management

Pain

Stop alcohol and smoking; both slow progression and reduce pain.
Start with non-opioid analgesics; neuromodulators such as pregabalin can help. Avoid long-term opioids where possible.
Antioxidants have limited evidence; pancreatic enzymes are not recommended for pain alone.
Obstructive disease (dilated main duct with stones or stricture): endoscopic therapy, including ERCP with stenting and lithotripsy (ESWL).
Surgery (drainage or resection, such as Frey or Puestow procedures) gives more durable pain relief than endoscopy in suitable patients; consider it early. Total pancreatectomy with islet autotransplant is for selected refractory cases.
Celiac plexus block has short-lived benefit.

Exocrine insufficiency (enzyme replacement)

Start at about 40,000 to 50,000 lipase units with each meal and half that with snacks; increase as needed by symptoms and weight.
Take with the first bite of food, not before or after.
If response is poor, add an acid-suppressing drug (PPI) and check for small intestinal bacterial overgrowth.
Do not restrict dietary fat; eat smaller frequent meals and replace vitamins A, D, E and K as needed.

Long-term monitoring

Fasting glucose and HbA1c every year; metformin is usually first-line; watch for hypoglycemia on insulin.
Baseline bone density (DEXA) for osteoporosis and osteopenia; vitamin D levels.
Pancreatic cancer risk is higher, especially in hereditary pancreatitis; new weight loss, jaundice or worsening diabetes should prompt imaging.

4. Complications to know

Pseudocysts: drain only if symptomatic, infected or obstructing; endoscopic drainage is preferred.
Biliary stricture (rising alkaline phosphatase, jaundice) and duodenal obstruction.
Splenic vein thrombosis causing gastric varices; splenectomy if they bleed.
Pseudoaneurysm with sudden bleeding: CT angiography and embolization.

Self-check questions

What is the first imaging test for suspected chronic pancreatitis?
A patient has steatorrhea and fecal elastase of 60 µg/g. What is the starting enzyme dose?
Does a normal lipase rule out chronic pancreatitis?
Which test should be done every year?

Answers: (1) CT or MRI with MRCP. (2) About 40,000 to 50,000 lipase units with each meal, half with snacks. (3) No. (4) Fasting glucose and HbA1c to screen for diabetes.

References

Gardner TB, Adler DG, Forsmark CE, et al. ACG Clinical Guideline: Chronic Pancreatitis. Am J Gastroenterol. 2020;115(3):322-339.
Whitcomb DC, Shimosegawa T, Chari ST, et al. International consensus statements on early chronic pancreatitis. Pancreatology. 2018;18(5):516-527.
Whitcomb DC, Buchner AM, Forsmark CE. AGA Clinical Practice Update on the Epidemiology, Evaluation, and Management of Exocrine Pancreatic Insufficiency. Gastroenterology. 2023;165(5):1292-1301.
Issa Y, Kempeneers MA, Bruno MJ, et al. Effect of Early Surgery vs Endoscopy-First Approach on Pain in Patients With Chronic Pancreatitis (ESCAPE). JAMA. 2020;323(3):237-247.

For educational purposes only. This note does not replace clinical judgment or local protocols. Check doses against current labeling and institutional guidance.