Chronic Pancreatitis: Diagnosis and Treatment

 

Am Fam Physician. 2018 Mar 15;97(6):385-393.

  Patient information: A handout on pancreatitis is available.

Author disclosure: No relevant financial affiliations.

Chronic pancreatitis is an irreversible and progressive disorder of the pancreas characterized by inflammation, fibrosis, and scarring. Exocrine and endocrine functions are lost, often leading to chronic pain. The etiology is multifactorial, although alcoholism is the most significant risk factor in adults. The average age at diagnosis is 35 to 55 years. If chronic pancreatitis is suspected, contrast-enhanced computed tomography is the best imaging modality for diagnosis. Computed tomography may be inconclusive in early stages of the disease, so other modalities such as magnetic resonance imaging, magnetic resonance cholangiopancreatography, or endoscopic ultrasonography with or without biopsy may be used. Recommended lifestyle modifications include cessation of alcohol and tobacco use and eating small, frequent, low-fat meals. Although narcotics and antidepressants provide the most pain relief, one-half of patients eventually require surgery. Therapeutic endoscopy is indicated to treat symptomatic strictures, stones, and pseudocysts. Decompressive surgical procedures, such as lateral pancreaticojejunostomy, are indicated for large duct disease (pancreatic ductal dilation of 7 mm or more). Resection procedures, such as the Whipple procedure, are indicated for small duct disease or pancreatic head enlargement. The risk of pancreatic cancer is increased in patients with chronic pancreatitis, especially hereditary pancreatitis. Although it is not known if screening improves outcomes, clinicians should counsel patients on this increased risk and evaluate patients with weight loss or jaundice for neoplasm.

Chronic pancreatitis is a permanent, progressive destruction of pancreatic tissue and function. Clinical manifestations include disabling abdominal pain, steatorrhea, and diabetes mellitus.13 Incidence and prevalence remain low and, despite advances in medical imaging, definitive diagnosis remains challenging.3 Primary care physicians should be familiar with presenting clinical features, as well as treatment options and long-term complications.

WHAT IS NEW ON THIS TOPIC

A meta-analysis of 43 studies that included more than 3,400 patients concluded that computed tomography, magnetic resonance imaging, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography have comparably high diagnostic accuracy for chronic pancreatitis; therefore, a stepwise approach based on cost, invasiveness, and availability is recommended.

A Cochrane review of 10 trials involving 361 participants suggested that pancreatic enzyme replacement does not reduce pain from chronic pancreatitis.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Contrast-enhanced computed tomography is the recommended initial imaging study in patients with suspected chronic pancreatitis.

C

3, 10, 2224

Endoscopic ultrasonography is favored over endoscopic retrograde cholangiopancreatography for the endoscopic diagnosis of chronic pancreatitis because of its increased safety and ability to evaluate the pancreatic parenchyma and duct system.

C

3

Antioxidant therapy does not improve pain control or mortality outcomes in patients with chronic pancreatitis.

B

10, 35

Pancreatic enzyme replacement is indicated for steatorrhea and malabsorption and may help relieve pain in patients with chronic pancreatitis.

B

3842

Endoscopic drainage of pseudocysts results in a similar rate of pain relief as surgery, with equivalent or lower mortality.

B

25, 4447, 53, 54

Pancreatoduodenectomy (Whipple procedure, pylorus-preserving, or duodenum-preserving) is indicated in the treatment of chronic pancreatitis with pancreatic head enlargement and typically results in significant pain relief.

B

8, 49, 55


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Contrast-enhanced computed tomography is the recommended initial imaging study in patients with suspected chronic pancreatitis.

C

3, 10, 2224

Endoscopic ultrasonography is favored over endoscopic retrograde cholangiopancreatography for the endoscopic diagnosis of chronic pancreatitis because of its increased safety and ability to evaluate the pancreatic parenchyma and duct system.

C

3

Antioxidant therapy does not improve pain control or mortality outcomes in patients with chronic pancreatitis.

B

10, 35

Pancreatic enzyme replacement is indicated for steatorrhea and malabsorption and may help relieve pain in patients with chronic pancreatitis.

B

3842

Endoscopic drainage of pseudocysts results in a similar rate of pain relief as surgery, with equivalent or lower mo

The Author

KATHLEEN BARRY, MD, is an assistant professor in the Department of Family and Community Medicine at the University of Texas Health Science Center at Houston. When this article was written, she was an assistant professor at the University of Virginia in Charlottesville.

Address correspondence to Kathleen Barry, MD, 6410 Fannin St., Houston, TX 77030 (e-mail: kathleen.anne.barry@gmail.com). Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

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