Chronic pancreatitis: Clinical sciences

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A 48-year-old woman presents to the primary care clinic for routine follow-up. The patient developed chronic pancreatitis 5 years ago. The patient previously had heavy alcohol use but has been in recovery for the past year. She smokes 1 pack of cigarettes per day. Current medications include naproxen (as needed) and pancreatic enzyme replacement therapy. Laboratory studies today are notable for fasting blood glucose of 190 mg/dL and hemoglobin A1c of 8.5%. Which of the following is the best next step in management?  

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Chronic pancreatitis refers to persistent, chronic inflammation of the pancreas that’s associated with irreversible changes, such as fibrosis, calcifications, and atrophy. This eventually decreases the function of the exocrine pancreas, subsequently causing difficulties with digestion and absorption of nutrients, as well as abdominal pain that’s worse with eating, steatorrhea, and unintentional weight loss. Additionally, the destruction of the endocrine pancreas can lead to difficulties in producing hormones, such as insulin. Now, there’s a variety of conditions that can cause chronic pancreatitis, including toxins like chronic alcohol consumption, and metabolic conditions; genetic and autoimmune conditions; as well as recurrent acute pancreatitis and ductal obstruction. An important thing to remember is that tobacco smoking may not be a direct cause, but it is a strong risk factor.

Now, if you suspect chronic pancreatitis, first perform an ABCDE assessment to determine if your patient is unstable or stable. If unstable, stabilize the patient’s airway, breathing, and circulation. Next, obtain IV access and, if needed, start IV fluids. Finally, put your patient on continuous vital sign monitoring.

Ok, now let’s go back to the ABCDE assessment and take a look at stable individuals. If the patient is stable, obtain a focused history and physical examination. These patients typically report upper abdominal pain that can range from constant and dull, to acute and stabbing. Sometimes, the pain might radiate to the back and can be relieved by leaning forward. Other important history findings include nausea, vomiting, and diarrhea. Also, they might report fatty stools that are difficult to flush, abdominal bloating, and unexplained weight loss.

Moreover, these findings typically occur due to progressive loss of acinar cells that eventually result in decreased production of digestive enzymes and subsequent malabsorption. This condition is called Pancreatic Exocrine Insufficiency, or PEI for short.

On the other hand, physical exam findings typically include tenderness to palpation in the upper abdomen.

At this point, you should suspect chronic pancreatitis. Your next step is to order labs, such as lipase, amylase, fecal elastase-1, trypsinogen, and trypsin. Additionally, don’t forget to order imaging, primarily CT or MRI, but in some cases you may also get an endoscopic ultrasonography or EUS, as well as a secretin-stimulated magnetic resonance cholangiopancreatography or s-MRCP. Rarely, you may want to get a biopsy of the pancreas.

Sources

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