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Chronic pancreatitis 

Chronic pancreatitis

Chapter:
Chronic pancreatitis
Author(s):

Richard A. Schatz

and Phillip P. Toskes

DOI:
10.1093/med/9780199204854.003.152402_update_003

Update:

Management – expanded discussion of endoscopic procedures for refractory pain, main pancreatic and bile duct strictures, main pancreatic duct stones, and coeliac plexus block / neurolysis.

Updated on 30 Jul 2015. The previous version of this content can be found here.
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date: 28 April 2017

Chronic pancreatitis is most commonly due to chronic alcoholism in adults and cystic fibrosis in children, but there are many other causes/associations. Typical presentation is with (1) abdominal pain—but this is not always a feature and when present can vary from being mild to extremely severe; and/or (2) maldigestion—diarrhoea/steatorrhoea and weight loss.

Accurate diagnosis requires a combination of a hormone stimulation test (e.g. secretin–cholecystokinin stimulation of bicarbonate and enzyme secretion) and a structural test, e.g. endoscopic ultrasonography or endoscopic retrograde cholangiopancreatography ERCP). In routine clinical practice common strategy is to evaluate patients suspected of having chronic pancreatitis with a noninvasive test, e.g. faecal elastase (reduced), and initiate treatment if the result is abnormal, reserving invasive tests for cases where diagnostic doubt remains or clinical progress is unsatisfactory.

Management requires use of (1) potent enzyme formulations—protease for pain, lipase for steatorrhoea; given before meals and (if pain is a symptom) before bedtime, (2) acid suppressive therapy—H2 antagonist or proton pump inhibitor; (3) abstinence from alcohol; (4) diet that is moderate in fat (30%), high in protein (24%), and low in carbohydrate (40%); (5) pain control—if required, (a) non-narcotic analgesics are the pain-relieving medications of choice, and (b) lateral pancreaticojejunostomy (Peustow procedure) should be considered if there is dilatation of the main pancreatic duct.

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