Abstract
Chronic pancreatitis may manifest as recurrent episodes of acute inflammation of the pancreas superimposed on chronic pancreatic dysfunction, or it may be a more constant problem. As the exocrine function of the pancreas deteriorates, malabsorption with steatorrhea and azotorrhea develops. In the United States, chronic pancreatitis is most commonly caused by alcohol consumption, followed by cystic fibrosis and malignant pancreatic tumors. Hereditary causes such as alpha 1 -antitrypsin deficiency are also common. In developing countries, the most common cause of chronic pancreatitis is severe protein-calorie malnutrition. Chronic pancreatitis can also result from acute pancreatitis.
Abdominal pain is a common feature of chronic pancreatitis, and it mimics the pain of acute pancreatitis; it ranges from mild to severe and is characterized by steady, boring epigastric pain that radiates to the flanks and chest. The pain is worse after the consumption of alcohol and fatty meals. Nausea, vomiting, and anorexia are also common features. With chronic pancreatitis, the clinical symptoms are often subject to periods of exacerbation and remission.
Keywords
acute pancreatitis, chronic pancreatitis, abdominal pain, celiac plexus block, Whipple procedure, ultrasound guided procedure, diagnostic sonography, computed tomography, alcohol consumption, hypertriglyceridemia, scorpion venom
ICD-10 CODE K86.1
Keywords
acute pancreatitis, chronic pancreatitis, abdominal pain, celiac plexus block, Whipple procedure, ultrasound guided procedure, diagnostic sonography, computed tomography, alcohol consumption, hypertriglyceridemia, scorpion venom
ICD-10 CODE K86.1
The Clinical Syndrome
Chronic pancreatitis may manifest as recurrent episodes of acute inflammation of the pancreas superimposed on chronic pancreatic dysfunction, or it may be a more constant problem. As the exocrine function of the pancreas deteriorates, malabsorption with steatorrhea and azotorrhea develops. In the United States, chronic pancreatitis is most commonly caused by alcohol consumption, followed by cystic fibrosis and malignant pancreatic tumors ( Box 75.1 ). Hereditary causes such as alpha 1 -antitrypsin deficiency are also common. In developing countries, the most common cause of chronic pancreatitis is severe protein-calorie malnutrition. Chronic pancreatitis can also result from acute pancreatitis.
Abdominal pain is a common feature of chronic pancreatitis, and it mimics the pain of acute pancreatitis; it ranges from mild to severe and is characterized by steady, boring epigastric pain that radiates to the flanks and chest. The pain is worse after the consumption of alcohol and fatty meals. Nausea, vomiting, and anorexia are also common features. With chronic pancreatitis, the clinical symptoms are often subject to periods of exacerbation and remission.
Signs and Symptoms
Patients with chronic pancreatitis present similarly to those with acute pancreatitis but may appear more chronically ill than acutely ill ( Fig. 75.1 ). Tachycardia and hypotension resulting from hypovolemia are much less common in chronic pancreatitis and are ominous prognostic indicators, or they may suggest the presence of another pathologic process, such as perforated peptic ulcer. Diffuse abdominal tenderness with peritoneal signs may be noted if the patient has acute inflammation. A pancreatic mass or pseudocyst secondary to pancreatic edema may be palpable.
Testing
Although serum amylase levels are always elevated in acute pancreatitis, they may be only mildly elevated or even within normal limits in chronic pancreatitis. Serum lipase levels are also attenuated in chronic, compared with acute, pancreatitis, although lipase may remain elevated longer than amylase in this setting and be more indicative of actual disease severity. Because serum amylase may be elevated in other diseases, such as parotitis, amylase isozymes may be necessary to confirm a pancreatic basis for this finding. Plain radiographs of the chest are indicated in all patients with chronic pancreatitis to identify pulmonary complications, including pleural effusion. Given its extrapancreatic manifestations (e.g., acute renal or hepatic failure), serial complete blood counts, serum calcium and glucose levels, liver function tests, and electrolytes are indicated in all patients with chronic pancreatitis. Computed tomography (CT) and ultrasound imaging of the abdomen can identify pancreatic pseudocyst or pancreatic tumor that may have been overlooked, and it may help the clinician gauge the severity and progress of the disease ( Figs. 75.2 and 75.3 ). Gallbladder evaluation with radionuclides is indicated if gallstones are a possible cause of chronic pancreatitis. Arterial blood gas analysis can identify respiratory failure and metabolic acidosis.
