Update on diagnosis and management of chronic pancreatitis

Abstract

Chronic pancreatitis should be considered in all patients with unexplained abdominal pain. The importance of small duct disease without obvious radiographic abnormalities is an important new concept. It is meaningful for the clinician to define whether the patient with chronic pancreatitis has small duct or large duct disease. Diagnostic evaluations should begin with a simple, noninvasive, inexpensive test such as serum trypsinogen, to be followed by more complicated testing such as the secretin stimulation test, particularly in those patients with small duct disease. Non-enteric-coated pancreatic enzyme preparations are preferred for the treatment of pain whereas enteric-coated pancreatic enzyme preparations are the drugs of choice for treating steatorrhea. Octreotide may become an important therapy for treating abdominal pain unresponsive to pancreatic enzyme therapy. Endoscopic treatment of the pain of chronic pancreatitis should be used only in highly selected patients and may cause damage to the pancreas. Surgical ductal decompression is appropriate in selected patients.

Defining the Accuracy of Secretin Pancreatic Function Testing in Patients With Suspected Early Chronic Pancreatitis

“…This is the first study to analyze the long-term follow-up data of patients who have been investigated for chronic pancreatitis using the SPFT. This is particularly important, given that a positive SPFT is considered by many to be either suggestive of early chronic pancreatitis or a gold standard for diagnosing chronic pancreatitis (1,20). …”

“…Chronic pancreatitis refers to ongoing inflammation and irreversible destruction of pancreatic tissue (1). This may ultimately manifest with abdominal pain and symptoms of exocrine and endocrine pancreatic insufficiency (2–6).…”

“…In its earliest stage, the diagnosis of chronic pancreatitis can be difficult, as morphologic changes may be minimal (1,7,8). Consequently, imaging modalities such as computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP) have reduced sensitivity for detecting early or minimal-change disease (9–11).…”

“…Direct hormone-stimulated tests, using cholcystekinin or secretin, are considered the most sensitive and specific tests of pancreatic insufficiency and have been advocated for use in diagnosing early chronic pancreatitis (1). In these tests, the duodenal aspirate is collected at different time points after stimulation by cholcystekinin or secretin or both.…”

Dermatology spot diagnosis

“…Furthermore, in elderly patients these changes can be seen and are thought to be related to aging. 15 16 Our institutional experience is that secretin testing becomes positive when there is about 60% damage to the exocrine pancreas and ERCP findings suggestive of the disease occur with about 75% damage. Occasionally, the converse may be seen and patients may be found to have normal pancreatic stimulation testing and an abnormal pancreaticogram at the time of ERCP.…”