Table of contents
Chronic pancreatitis
What's new
Updated 2024 ASGE guidelines for endoscopic management in chronic pancreatitis.
Background
Overview
Definition
Chronic pancreatitis is a clinical syndrome involving inflammation, fibrosis, and loss of acinar and islet cells of the pancreas.
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Pathophysiology
The pathogenesis of chronic pancreatitis typically involves multiple risk modifiers that interact to produce pancreatic disease, including bile duct obstruction (pancreatic tumors, chronic strictures), exogenous toxins (alcohol, smoking), metabolic disturbances (hyperlipidemia, hypercalcemia), as well as autoimmune disease and genetic disease.
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Epidemiology
The incidence of chronic pancreatitis ranges from 5 to 12 cases per 100,000 person-years, while its prevalence is estimated at 50 persons per 100,000 population.
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Disease course
Destruction of normal pancreatic tissue leads to the clinical manifestations of chronic abdominal pain, exocrine insufficiency (compromised digestion, absorption, and metabolism of nutrients), and endocrine insufficiency (pancreatogenic diabetes).
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Prognosis and risk of recurrence
Patients with chronic pancreatitis have increased mortality as compared with age and sex-matched controls (HR 5.0, 95% CI 4.8-5.2).
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of chronic pancreatitis are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2025), the American Society for Gastrointestinal Endoscopy (ASGE 2024), the American Gastroenterological Association (AGA 2023), the United European Gastroenterology (UEG/ESPEN 2023), the Japanese Society of Gastroenterology (JSG 2022), the American College of Gastroenterology ...
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Screening and diagnosis
Definitions: as per APA 2014 guidelines, chronic pancreatitis is characterized by atrophy and fibrosis of the exocrine tissue, with or without chronic inflammation.
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Epidemiology
Risk factors
Clinical presentation
Differential diagnosis
Diagnostic investigations
Clinical assessment
As per ACG 2020 guidelines:
Obtain a comprehensive review of all risk factors in patients with clinical features of chronic pancreatitis to provide information on the underlying mechanisms, identify both fixed and modifiable risk factors, identify potential targets for therapies, and provide clinically relevant prognostic information.
E
Recognize that the development of diabetes mellitus in chronic pancreatitis is most likely related to the disease duration, although other etiologic factors such as BMI and smoking status may incur an increased risk.
E
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Cross-sectional imaging
MRCP
Pancreatic function testing
Genetic testing
Medical management
General principles
As per APA/EPC/IAP/JPS 2017 guidelines:
Refer all patients with presumed or established diagnosis of chronic pancreatitis to specialist pancreatic centers for investigation and treatment.
B
Follow the principles of the "pain relief ladder" provided by the WHO for analgesic therapy, adjusted to the pain characteristics of chronic pancreatitis.
B
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Opioids
Antioxidants
Pancreatic enzyme replacement therapy
Protease inhibitors
Management of pancreatogenic diabetes
Experimental treatment
Nonpharmacologic interventions
Dietary modifications: as per AGA 2023 guidelines, initiate routine supplementation and obtain monitoring of fat-soluble vitamin levels. Advise dietary modifications, including a low-moderate fat diet with frequent smaller meals and avoiding very low-fat diets.
E
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Alcohol cessation
Smoking cessation
Behavioral interventions
Therapeutic procedures
General principles
As per ASGE 2024 guidelines:
Consider obtaining surgical evaluation before initiation of endoscopic management in patients with painful chronic pancreatitis and an obstructed main pancreatic duct with no contraindications to surgery.
C
Consider performing endoscopic management as the initial approach in patients with contraindications to surgery or preferring a less invasive modality.
C
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Endoscopic therapy
Neurolysis
Surgical interventions
Indications for surgery
As per JSG 2022 guidelines:
Decide on surgical indications and procedures after a thorough evaluation of symptoms and complications given that early surgery after the onset of chronic pancreatitis can delay progression.
B
Consider offering surgery if adequate doses of NSAIDs or weak opioids are ineffective for pain relief.
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Offer surgical treatment if endoscopic treatment has been ineffective for pain relief. B
Specific circumstances
Pediatric patients: as per ESPGHAN/NASPGHAN 2018 guidelines, advise maintaining a regular diet in pediatric patients with chronic pancreatitis, with or without EPI.
B
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Patients with obesity
Follow-up and surveillance
Assessment of treatment response
As per AGA 2023 guidelines:
Obtain a baseline assessment of nutritional status (BMI, quality-of-life measure, and fat-soluble vitamin levels) and monitor thereafter to assess treatment response. Obtain a baseline DEXA and repeat every 1-2 years.
E
Use the following measures to denote successful treatment with pancreatic enzyme replacement therapy:
reduction in steatorrhea and associated gastrointestinal symptoms
gain of weight, muscle mass, and muscle function
improvement in fat-soluble vitamin levels
E
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Management of relapse
Long-term surveillance