QuestionSBA
QuestionChoice
Cholangiocarcinoma is less likely given the age of the patient and lack of risk factors
32430
c
Cholangiocarcinoma
QuestionChoice
Pancreatic cancer is unlikely given the age of the patient. It is also more common for pancreatic cancer to present without pain
32429
b
Pancreatic cancer
QuestionChoice
Choledocholithiasis refers to gallstone disease in the common bile duct. Although this is often associated with pain and cholestatic liver function tests, the post-prandial vomiting would be unusual and is more suggestive of gastric outlet obstruction
32431
d
Choledocholithiasis
QuestionChoice
PBC is less likely as it would not explain the symptoms of gastric outlet obstruction. Also, there is no pruritus (present in around 70% of cases of PBC)
32432
e
Primary biliary cholangitis (PBC)
QuestionChoice
Pancreatic pseudocysts are a common complication of acute or chronic pancreatitis. They occur due to damage to the pancreatic ducts, which leads to cystic accumulation of pancreatic juices. Pseudocysts can be asymptomatic or present with signs of biliary obstruction (abdominal pain, jaundice) or gastric outlet obstruction (post-prandial vomiting) due to mass effect of an enlarging pseudocyst on adjacent structures. There is also the risk of secondary infection
32428
a
Pancreatic pseudocyst
QuestionComment
No fever?
27652
User
subscriber
Vitamin Yellow
QuestionComment
Only if it becomes infected - this is then an abscess so will have a fever 
42989
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subscriber
Lung QRS
Concept
Chapter
# Summary

Chronic pancreatitis is a long-term condition characterised by progressive inflammation and fibrosis of the pancreas leading to irreversible destruction of the exocrine and endocrine functions of the pancreas. Common symptoms include epigastric pain, malabsorption, steatorrhoea, and symptoms of diabetes mellitus. Structural and functional investigations are key to diagnosing the condition, which may be caused by a variety of factors, the most common being chronic alcohol excess. Management strategies include lifestyle changes, medication, and in some cases, invasive interventions. 

# Definition

Chronic pancreatitis is a medical condition characterised by persistent inflammation and fibrosis of both the exocrine and endocrine components of the pancreas.

# Epidemiology

Chronic pancreatitis is most commonly caused by chronic alcohol excess, accounting for approximately 80% of cases. Less common causes include genetic factors, obstructive factors, and metabolic factors, while up to 15% of cases are idiopathic.

# Aetiology

The primary cause of chronic pancreatitis is chronic alcohol excess. Other less common causes include:

- Genetic factors such as cystic fibrosis
- Obstructive causes such as pancreatic cancer
- Metabolic causes such as elevated triacylglycerides

# Pathophysiology

Progressive inflammation and the development of fibrotic tissue in the pancreas results in a loss of exocrine function (lipase, amylase) and endocrine function (insulin). This manifests as malabsorption and impaired impaired blood glucose control, respectively.

# Signs and Symptoms

Patients with chronic pancreatitis typically present with the following:

- Epigastric pain which is typically exacerbated after eating fatty food and relieved by sitting forward
	- Usually 15-30 minutes after eating
- Bloating
- Weight loss 
- Symptoms of exocrine dysfunction, such as malabsorption and steatorrhoea
	- Specifically absorption of fat-soluble vitamins (A, D, E and K) is reduced/lost, resulting in vitamin deficiencies and their own complications	
- Symptoms of endocrine dysfunction, such as diabetes mellitus, with symptoms including thirst and polyuria
- Physical examination may reveal epigastric tenderness and signs of chronic liver disease, which could suggest alcohol as a cause

# Differential Diagnosis

Differential diagnoses for chronic pancreatitis include acute pancreatitis, pancreatic cancer, and peptic ulcer disease. The main signs and symptoms of these differentials include:

- Acute pancreatitis: severe acute-onset epigastric pain radiating to the back, nausea, vomiting, and elevated serum amylase and lipase
- Pancreatic cancer: weight loss, jaundice, and abdominal pain
- Peptic ulcer disease: burning abdominal pain, bloating, and heartburn
- Abdominal aortic aneurysm - abdominal/back pain, shock/hypotension, expansile and pulsatile mass palpable in the abdomen

# Investigations

- Bedside - blood glucose, and faecal elastase (low if there is exocrine insufficiency)
- Blood tests - serum amylase and lipase are not typically raised in chronic pancreatitis, unlike in acute pancreatitis
- Imaging - abdominal x-ray (to detect calcifications) and CT scan (to show pancreatic calcification), the latter being more sensitive at detecting calcification


# Management

Management of chronic pancreatitis includes:

- Conservative measures such as abstinence from alcohol and maintaining a healthy diet
- Medical measures including pain control with analgesia, management of endocrine dysfunction with insulin, and management of exocrine dysfunction with pancreatic enzyme replacement therapy (Creon is a common brand name you may come across, containing mixtures of amylase, lipase, and protease).
- Invasive interventions may be considered if the above measures fail, such as coeliac plexus block and pancreatectomy.

# Complications

Complications of chronic pancreatitis can be local (such as pseudocyst or pancreatic cancer) or systemic (endocrine dysfunction leading to diabetes mellitus, or exocrine dysfunction leading to malabsorption and steatorrhoea).

# NICE Guidelines

[Click here to see NICE CKS information on chronic pancreatitis](https://cks.nice.org.uk/topics/pancreatitis-chronic/)
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Pancreatic pseudocysts are common complications of chronic pancreatitis, typically forming as fluid-filled sacs that develop in response to inflammation, necrosis, or ductal obstruction, and can lead to symptoms such as abdominal pain, nausea, and potential rupture or infection if left untreated.
A 35-year-old woman with a history of chronic pancreatitis presents with post-prandial vomiting and abdominal pain. She denies weight loss, fevers, pruritus and any family history of malignancy.

Her blood tests are significant for a cholestatic pattern of liver function tests.

Which of the following is the most likely diagnosis?
a