Chronic Pancreatitis
Permanent inflammatory scarring of the pancreas leading to intractable pain, malabsorption, and diabetes.
Emergency Management: Rupture of a splenic artery pseudoaneurysm (a complication of adjacent pancreatic inflammation) causing catastrophic intra-abdominal hemorrhage.
A progressive inflammatory disorder of the pancreas characterized by irreversible destruction of exocrine and endocrine parenchyma, replaced by fibrotic tissue and strictures.
Detailed Overview
Unlike acute pancreatitis, chronic pancreatitis results in permanent structural damage. The destruction of acinar cells leads to exocrine insufficiency (malabsorption, steatorrhea), while the destruction of Islets of Langerhans causes endocrine insufficiency (pancreatogenic diabetes or Type 3c diabetes). The hallmark symptom is intractable, debilitating abdominal pain.
Epidemiology & Demographics
Prevalence is 50 per 100,000. Most commonly diagnosed in men aged 30-40. High association with heavy alcohol use.
Etiological Mechanism
Alcohol abuse is the most common cause (TIGAR-O classification: Toxic-metabolic, Idiopathic, Genetic, Autoimmune, Recurrent and Severe Acute, Obstructive).
Primary Causes
Chronic heavy alcohol consumption (60-70% of cases). Genetic mutations (PRSS1, SPINK1, CFTR).
Repeated episodes of acute inflammation or chronic toxic exposure cause acinar cell injury. This activates pancreatic stellate cells, transforming them into myofibroblast-like cells that deposit excessive collagen and extracellular matrix. Pancreatic juice becomes rich in protein and low in bicarbonate, leading to the precipitation of protein plugs in the ducts. These plugs calcify, causing ductal obstruction, upstream ductal dilation, and increased tissue pressure, which causes severe ischemic and perineural pain.
Diagnostic Criteria & Guidelines
Diagnosed via imaging showing characteristic pancreatic calcifications, ductal dilation, and parenchymal atrophy, combined with clinical signs of pancreatic insufficiency.
Pain management (NSAIDs, Acetaminophen, Pregabalin 75 mg BID). Pancreatic Enzyme Replacement Therapy (PERT) to treat steatorrhea and reduce pain: Creon/Zenpep (minimally 40,000-50,000 units of lipase per meal, half that per snack).
Second-Line & Adjunctive Therapy
Endoscopic stenting of ductal strictures or lithotripsy for ductal stones. Opiates (e.g., Tramadol 50 mg QDS) if pain is refractory, though risk of addiction is high.
Surgical & Procedural Management
Lateral pancreaticojejunostomy (Puestow procedure) to decompress a dilated main pancreatic duct (>5 mm). Total pancreatectomy with islet auto-transplantation (TPIAT) for severe intractable pain.
Patient Counseling & Advice
Counsel on strict adherence to PERT (must take enzymes WITH the first bite of food, not after). Warn about the symptoms of hypoglycemia due to loss of glucagon.
Follow-Up & Monitoring Schedule
Annual fasting glucose/HbA1c to screen for diabetes. DEXA scan every 2 years due to Vitamin D malabsorption risk.
Preventive Strategies
Limit alcohol intake and stop smoking.
Significantly reduced quality of life due to chronic pain. High risk of mortality from cardiovascular events, infections, and malnutrition. 4% lifetime risk of developing pancreatic cancer.