Pancreatitis, chronic diagnosis

The major exocrine pancreatic disorders presenting in adult life are acute pancreatitis, chronic pancreatitis, and carcinoma of the pancreas. The use of enzyme tests in the diagnosis of acute pancreatitis is discussed in Chapter 21. The etiologies of pancreatitis are given in Box 48-6. 

Differentiating an episode of acute pancreatitis from chronic pancreatitis maybe difficult because the clinical presentations can be similar. The diagnosis of chronic pancreatitis is made by looking for the effects of chronic pancreatic inflammation and scarring on the pancreas and the patient as a whole. Computed tomography or ERCP will allow visualization of chronic calcified lesions in the pancreas when present.37... 

Hamori J, Arkosy P, Lenkey A, Sapy P, The role of different tumor markers in the early diagnosis and prognosis of pancreatic carcinoma and chronic pancreatitis, Acta. Chir. Hung., 36 125-127, 1997. 

Pancreatic exocrine insufficiency with nutrient maldigestion as described in the case report is both a classical complication and a defining leading symptom of chronic pancreatitis. Therefore, taking a careful history provides the key for the diagnosis. 

It is important to keep in mind, however, that not all patients with chronic pancreatitis develop clinical pancreatic exocrine insufficiency approximately 25% of patients still have sufficient exocrine function after 25 years of disease. On the other hand, it is also important to note that 10%-15% of patients with chronic pancreatitis have primary painless disease in these patients, pancreatic exocrine insufficiency may be the first (and possibly only) clinical manifestation. Thus, the absence of pain or a history of pancreatitis does not exclude the diagnosis (DiMagno et al., 1993). 

Direct tests of secretory function such as fecal chymotrypsin and elastase 1 are the tests of first choice if the main diagnostic goal consists of noninvasive confirmation of chronic pancreatitis. Indirect tests may be preferred, however, if the main goal is to verify maldigestion (which needs not be due to loss of pancreatic secretory capacity) or to optimize enzyme treatment. For patients for whom noninvasive direct or indirect tests are negative or equivocal and diagnosis or exclusion of pancreatic exocrine insufficiency appears relevant, the invasive secretin-cerulein (SC) test should be considered. 

El measurement in stool is the most reliable and sensitive noninvasive procedure for the diagnosis of chronic pancreatic insufficiency. However, such a test does not consistently separate mild to moderate insufficiency cases from healthy controls (see Table 48-15). Unlike fecal CHY, El provides no information helpful to the therapeutic management of the patient. 

A number of laboratory tests are available to measure exocrine function in the investigation of pancreatic insufficiency (most commonly caused by cystic fibrosis in children and chronic pancreatitis in adults). Tests fall into two categories, invasive and noninvasive. Invasive tests require GI, intubation to collect pancreatic samples noninvasive tests (or tubeless tests ) were developed to avoid intubation, which is uncomfortable for the patient, time-consuming, and therefore expensive. Noninvasive tests are simpler and cheaper to perform, but in general they lack the sensitivity and specificity of the invasive tests, particularly for the diagnosis of mild pancreatic insufficiency. It is important to recognize that biochemical tests have a limited clinical application in the diagnosis of pancreatic disease because of either the complexity of the invasive tests or the inadequate... 

Niederau C, Grendell JH. Diagnosis of chronic pancreatitis. Gastroenterology 1985 88 1973-95. 

Patients with alcoholic CP usually present with an initial acute attack followed by successive attacks that are slower to resolve. Continued alcohol use leads to chronic abdominal pain and progressive exocrine and endocrine insufficiency. In about 50% of patients, the pain diminishes 5 to 10 years after the onset of symptoms. Steatorrhea, calcification, and diabetes usually develop after 10 to 20 years of heavy ethanol ingestion. Most patients present with varying degrees of pain, malnutrition, and glucose intolerance. The mortality rate of CP is approximately 50% within 20 to 25 years of the diagnosis. About 15% to 20% actually die of complications associated with acute attacks. Most deaths occur as a consequence of malnutrition, infection, or ethanol, narcotic, and tobacco nse. The clinical course of idiopathic CP is more favorable than that of alcoholic pancreatitis. ... 

Etemad B, Whitcomb DC. Chronic pancreatitis Diagnosis, classification and new genetic developments. Gastroenterology 2001 120 682-707. 

Toskes PR Update on diagnosis and management of chronic pancreatitis. 37. 

Whatever the causes, the final result in type 1 DM is an extensive and selective loss of pancreatic /3 cells and a state of absolute insulin deficiency. In type 2 DM, fi-cell mass is generally reduced by -50%. At diagnosis, virtually all persons with type 2 DM have a profound defect in first-phase insulin secretion in response to an intravenous glucose challenge, although some of these fi-cell abnormalities may be secondary to desensitization by chronic hyperglycemia. 

Al Martini s serum levels of pancreatic amylase (which digests dietary starch) and pancreatic lipase were elevated, a finding consistent with a diagnosis of acute and possibly chronic pancreatitis. The elevated levels of these enzymes in the blood are the result of their escape from the inflamed exocrine cells of the pancreas into the surrounding pancreatic veins. The cause of this inflammatory pancreatic process in this case was related to the toxic effect of acute and chronic excessive alcohol ingestion. 

CT of the abdomen is the standard imaging modality for evaluating acute and chronic pancreatitis and their complications. In addition, CT can be used as a prognostic indicator of the severity of acute pancreatitis, mainly because it allows a complete visualization of the pancreas and retroperitoneum. As well as in the study of other pancreatic disease, imaging reformation is useful and often applied in the evaluation of acute and chronic pancreatitis, not only for diagnosis, but also for the study of possible complications. 

As mentioned, the most important differential diagnosis of a main-duct-type IPMT is chronic pancreatitis. The typical CT features indicative of IPMT are the bulging papilla, diffuse pancreatic duct dilatation without stricture, no circumscribed pancreatic duct stones, and solid contrast-enhanced nodules. Pancreatic gland atrophy may be present in IPMT and chronic pancreatitis as well, but pancreatic parenchyma classifications are almost always absent in IPMT. 

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