Chronic Pancreatitis

Patient Guideline Summary

Publication Date: February 1, 2020

Last Updated: March 3, 2023

Objective

This patient summary discusses key recommendations from the American College of Gastroenterology (ACG) for chronic pancreatitis. It is limited to adults 18 years of age and older and should not be used as a reference for children.

Overview

We will use the abbreviation CP throughout this summary to refer to chronic pancreatitis.

CP is a continuing inflammatory disease of the pancreas, characterized by irreversible morphological (shape) change, and typically causing pain and/or permanent loss of function.

The etiology (cause) is unclear, but there are many risk factors involved including alcohol, smoking, and certain genes.

Symptoms include characteristic pain, bad digestion, and weight loss.

This patient summary focuses on the etiology, diagnosis, and management of CP.

Diagnosis

The diagnosis of CP has been difficult because of the debate over a gold-standard test.

ACG recommends computed tomography (CT) or magnetic resonance imaging (MRI) as the first-line diagnosis of CP. Endoscopic ultrasonography (EUS) [a medical procedure in which endoscopy is combined with ultrasound to get images of the internal organs] should be used only if the diagnosis is in question after cross-sectional imaging is performed, because EUS is more invasive.

ACG suggests secretin-enhanced magnetic resonance cholangiopancreatography (s-MRCP) when the diagnosis of CP after cross-sectional imaging or EUS is not confirmed and the clinical suspicion remains high. Because s-MRCP allows for better visualization of the main- and side-branch ducts of the pancreas, it helps determine the severity of CP. Given its expense, s-MRCP should be used only when the diagnosis is not confirmed with first-line testing.

ACG suggests histological (microscopic) examination as the gold standard to diagnose CP in high-risk patients when the clinical and functional evidence of CP is strong, but imaging is inconclusive. With the recent widespread use of EUS-guided fine-needle biopsy techniques, the ability to get pancreatic tissue is becoming safer and easier.

Etiology (cause)

The TIGAR-O system helps categorize the etiology (cause) of CP. The acronym stands for T (Toxic-Metabolic), I (Idiopathic [unknown]), G (Genetic), A (Autoimmune), R (Recurrent acute or severe pancreatitis), and O (Obstructive).

The M-ANNHEIM is another system. The acronym stands for A (Alcohol), N (Nicotine), N (Nutritional factors), H (Hereditary [traits or diseases that are passed down in families] factors), E (Efferent duct factors), I (Immunological factors), M (Miscellaneous and rare metabolic factors).

Because there are so many possible causes, the initial approach if you have suspected pancreatitis-related disorders including CP is a thorough history and physical examination along with biomarker tests. The history may include previous dates and number of episodes of acute pancreatitis, dates of onset of diabetes mellitus (DM), if present, bad digestion/malnutrition, weight loss, bone health (e.g., fractures), kidney disease, and diseases in organs associated with cystic fibrosis. The family history may extend to at least third-degree relatives.

Conditions like CP include autoimmune inflammation, inflammation and fibrosis arising from the pancreatic islet cells (which is related to long-standing DM), kidney disease causing secondary effects in the pancreas, medications that change the immune system (e.g., cyclosporine), age-related atrophy or fibrosis, neoplasms, and other disorders.

ACG recommends genetic testing if you have clinical evidence of a pancreatitis-associated disorder or possible CP with unclear etiology, especially if you are young.

Genetic testing is of limited value if you have end-stage CP because the underlying inflammation has already irreversibly destroyed the pancreas. Still, this test may help identify genes associated with familial disorders and thus help family members make clinical decisions.

Natural history and clinical symptoms

Your doctor will probably recommend avoiding alcohol and smoking.

Management of pain

If you have pain from CP, it may be due to pancreatic duct obstruction. Duct obstruction can occur because of pancreatic duct stones, pancreatic duct strictures (abnormal narrowing), or a combination.

If first-line endoscopic approaches to relieving pancreatic duct obstruction have been unsuccessful, ACG recommends surgical intervention over endoscopic therapy for the long-term relief of pain.

Your doctor may suggest antioxidant therapy, although the pain reduction achieved is likely limited.

ACG does not suggest the use of pancreatic enzyme supplements to improve pain in CP.

Your doctor may suggest celiac plexus block. It is an injection of medicine into and/or around the region of the celiac ganglia (a collection of nerves in the abdomen). The most common ingredients in a celiac plexus injection are a local anesthetic and a steroid (cortisone).
- It can be performed through endoscopy, interventional radiology, or surgery.
- Its advantage is that a single treatment can provide pain reduction or relief for 3–6 months.
- Its disadvantages include the risks of the procedure itself (bleeding, allergy, etc.) and the risks of, and need for, sedation during the injection.

Management of EPI in CP

To improve the complications of malnutrition due to CP and exocrine pancreatic insufficiency (EPI), ACG suggests pancreatic enzyme replacement therapy (PERT). EPI is a condition where your pancreas does not supply the necessary enzymes to digest foods.

Abbreviations

ACG: American College Of Gastroenterology
CT: Computed Tomography
DM: Diabetes Mellitus
EPI: Exocrine Pancreatic Insufficiency
EUS: Endoscopic Ultrasonography
MRI: Magnetic Resonance Imaging
PERT: Pancreatic Enzyme Replacement Therapy
s-MRCP: Secretin-enhanced Magnetic Resonance Cholangiopancreatography

Source Citation

Gardner, Timothy B. MD, MS, FACG; Adler, Douglas G. MD, FACG; Forsmark, Chris E. MD, FACG; Sauer, Bryan G. MD, MSc (Clin Res), FACG (GRADE Methodologist); Taylor, Jason R. MD; Whitcomb, David C. MD, PhD, FACG. ACG Clinical Guideline, The American Journal of Gastroenterology: March 2020 - Volume 115 - Issue 3 - p 322-339 doi: 10.14309/ajg.0000000000000535

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.