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Chronic pancreatitis

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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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 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 (ACG 2020), the European Society of Gastrointestinal Endoscopy (ESGE 2019), the Japan Pancreas Society (JPS/EPC/IAP/APA 2018; 2017), the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN/NASPGHAN 2018), and the American Pancreatic Association (APA 2014).
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Guidelines

1.Screening and diagnosis

Definitions: 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

2.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.
B
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.
B

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  • Cross-sectional imaging

  • MRCP

  • Pancreatic function testing

  • Genetic testing

3.Diagnostic procedures

Endoscopic retrograde cholangiopancreatography: recognize that ERCP is seldom used for diagnostic purposes.
B

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  • EUS

  • Histology

4.Medical management

General principles
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

5.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.
B

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  • Alcohol cessation

  • Smoking cessation

  • Behavioral interventions

6.Therapeutic procedures

General principles: be cautious when performing elective interventional procedures in patients actively using alcohol. Ensure separate considerations for interventional procedures in patients requiring urgent or emergent procedures for complications of chronic pancreatitis.
B

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  • Endoscopic therapy

  • Neurolysis

7.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.
Offer surgical treatment if endoscopic treatment has been ineffective for pain relief.
B

8.Specific circumstances

Pediatric patients: advise maintaining a regular diet in pediatric patients with chronic pancreatitis, with or without exocrine pancreatic insufficiency.
B
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  • Patients with obesity

9.Follow-up and surveillance

Assessment of treatment response
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.
B
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
B

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  • Management of relapse

  • Long-term surveillance