Chronic pancreatitis

2020 ◽  
pp. 3218-3227
Author(s):  
Marco J. Bruno ◽  
Djuna L. Cahen
Keyword(s):  
Diabetes Mellitus ◽  
Chronic Pancreatitis ◽  
Pancreatic Enzyme ◽  
Exocrine Insufficiency ◽  
Endocrine Insufficiency ◽  
Diabetes Mellitus Diagnosis ◽  
Permanent Loss ◽  
Stimulation Tests ◽  
Enteric Coated ◽  
Pancreatic Duct Stricture

Chronic pancreatitis is a major source of morbidity, loss in quality of life, and healthcare expenditure. It is most commonly caused by chronic alcoholism in adults and cystic fibrosis in children, but there are many other causes. Patients typically present with severe abdominal pain, but this may vary and even be absent. Exo- and endocrine insufficiency usually occur late in the disease course and reflect permanent loss of pancreatic parenchyma due to ongoing inflammation and fibrosis, exocrine insufficiency manifesting as steatorrhea and weight loss due to fat maldigestion and endocrine insufficiency as diabetes mellitus. Diagnosis is confirmed by imaging investigations such as CT, MRI, and endoscopic ultrasonography. Endoscopic retrograde cholangiopancreatography to diagnose chronic pancreatitis is obsolete. Hormone stimulation tests (e.g. secretin–cholecystokinin stimulation test) to diagnose exocrine insufficiency are largely abandoned because of their complexity and burden to patients. They are replaced by faecal elastase testing, even though this test is less sensitive. Management focuses on the treatment of pain using a stepwise approach. Initially, nonopioid analgesics are prescribed. Next, when feasible, endoscopic therapy is initiated, including pancreatic stone fragmentation by extracorporeal shock-wave lithotripsy, endotherapy to remove stone fragments, and placement of plastic stents to dilate any concomitant pancreatic duct stricture. If that fails or when, for example, the pancreatic head is enlarged, surgical intervention is indicated. Medical management includes enteric-coated pancreatic enzyme preparations and treatment of diabetes mellitus, usually by means of insulin. Abstinence from alcohol and smoking cessation are important predictors of disease and treatment outcome.

scholarly journals Chronic pancreatitis: review and update of etiology, risk factors, and management

F1000Research ◽  
2018 ◽  
Vol 7 ◽  
pp. 607 ◽  
Author(s):  
Angela Pham ◽  
Christopher Forsmark
Keyword(s):  
Chronic Pancreatitis ◽  
Islet Cells ◽  
Pancreatic Insufficiency ◽  
Pancreatic Enzyme ◽  
Exocrine Insufficiency ◽  
Disease Etiology ◽  
Enzyme Replacement ◽  
Endocrine Insufficiency ◽  
Pancreatic Enzyme Replacement Therapy ◽  
Pancreatic Exocrine

Chronic pancreatitis is a syndrome involving inflammation, fibrosis, and loss of acinar and islet cells which can manifest in unrelenting abdominal pain, malnutrition, and exocrine and endocrine insufficiency. The Toxic-Metabolic, Idiopathic, Genetic, Autoimmune, Recurrent and Severe Acute Pancreatitis, Obstructive (TIGAR-O) classification system categorizes known causes and factors that contribute to chronic pancreatitis. Although determining disease etiology provides a framework for focused and specific treatments, chronic pancreatitis remains a challenging condition to treat owing to the often refractory, centrally mediated pain and the lack of consensus regarding when endoscopic therapy and surgery are indicated. Further complications incurred include both exocrine and endocrine pancreatic insufficiency, pseudocyst formation, bile duct obstruction, and pancreatic cancer. Medical treatment of chronic pancreatitis involves controlling pain, addressing malnutrition via the treatment of vitamin and mineral deficiencies and recognizing the risk of osteoporosis, and administering appropriate pancreatic enzyme supplementation and diabetic agents. Cornerstones in treatment include the recognition of pancreatic exocrine insufficiency and administration of pancreatic enzyme replacement therapy, support to cease smoking and alcohol consumption, consultation with a dietitian, and a systematic follow-up to assure optimal treatment effect.

scholarly journals Management of Pain, Exocrine and Endocrine Insufficiency in Chronic Pancreatitis

2020 ◽  
Vol 25 (1) ◽  
pp. 5-10
Author(s):  
Tae Joo Jeon
Keyword(s):  
Diabetes Mellitus ◽  
Chronic Pancreatitis ◽  
Medical Treatment ◽  
Pancreatic Enzyme ◽  
World Health ◽  
Severe Malnutrition ◽  
Enzyme Replacement ◽  
First Choice ◽  
Endocrine Insufficiency ◽  
Life Style Changes

Chronic pancreatitis is the progressive and inflammatory disease which will result in the irreversible destruction and fibrosis of the pancreas. These processes cause chronic pain and pancreatic dysfunctions such as exocrine and endocrine insufficiency. Medical treatment for chronic pancreatitis would be reviewed in this article. Abdominal pain should be accessed by using multidimensional approach including pain intensity, pattern, impact on daily function and quality of life. Abstinence from alcohol and smoking should be strong recommendation. The guideline for analgesic therapy follows the principles of the “pain relief ladder” by World Health Organization. The pancreatic enzyme replacement should be considered when exocrine insufficiency is suspected. Enteric-coated microspheres or mini-microspheres of <2 mm in size with a minimum lipase dose of 40,000–50,000 United States Pharmacopeia are the recommended preparations. These preparations should be taken with main meals. Increasing the oral enzyme dose and the addition of a proton pump inhibitor could be considered in cases of unsatisfactory clinical response. Diabetes mellitus secondary to chronic pancreatitis is classified as Type IIIc diabetes mellitus. Optimal pharmacological treatment has not been established yet but should promote life-style changes, which may improve glucose control and avoid hypoglycemia. In patients with severe malnutrition, insulin therapy is recommended as a first choice. Treatment for chronic pancreatitis can include medication, therapeutic endoscopy, interventional radiology, and surgery. Among them, medical treatment is the most important and should be well understood.

scholarly journals Clinical and pharmacological approaches to the management of exocrine pancreatic insufficiency in chronic pancreatitis

2021 ◽  
pp. 58-67
Author(s):  
V. N. Drozdov ◽  
E. V. Shikh ◽  
A. A. Astapovskiy ◽  
Yu. V. Kotlyachkova ◽  
L. E. Dobrovolskaya ◽  
...  
Keyword(s):  
Chronic Pancreatitis ◽  
Enzyme Replacement Therapy ◽  
Replacement Therapy ◽  
Pancreatic Insufficiency ◽  
Fibrous Tissue ◽  
Pancreatic Enzyme ◽  
The United States ◽  
Exocrine Insufficiency ◽  
Enzyme Replacement ◽  
Endocrine Insufficiency

Chronic pancreatitis is a multifactorial disease in which repeated episodes of inflammation of the pancreas contribute to the development of fibrous tissue, leading to chronic pain, as well as exocrine and endocrine insufficiency. The incidence and prevalence of chronic pancreatitis in the world are growing, as evidenced by current statistics. In addition, the annual costs associated with the treatment of exocrine and endocrine insufficiency are also increasing. In the United States alone, the annual cost of treating these complications is $ 75.1 million. Exocrine insufficiency is one of the most frequent complications, which is characterized by a deficiency of pancreatic enzymes, leading to the development of malabsorption syndrome (impaired absorption of nutrients, vitamins and minerals). Due to the increased incidence and deterioration of the quality of life associated with this condition, the goal of treatment is to compensate for the deficiency of exocrine enzymes with oral pancreatic enzyme replacement therapy. The core of this therapy is to deliver activated, unbroken enzymes directly to the small intestine during a meal. Many studies have shown that prescribing enzyme replacement therapy improves symptoms associated with exocrine insufficiency, reduces the progression of osteopenia, and improves survival in such patients. The use of pancreatin contributes to the correction of exocrine insufficiency in patients with chronic pancreatitis. The data presented in the article indicate that the drug is a safe and effective agent, meets all modern standards and requirements, and can be used to correct enzymatic pancreatic insufficiency.

Increased postprandial responses of GLP-1 and GIP in patients with chronic pancreatitis and steatorrhea following pancreatic enzyme substitution

2007 ◽  
Vol 292 (1) ◽  
pp. E324-E330 ◽  
Author(s):  
Filip K. Knop ◽  
Tina Vilsbøll ◽  
Steen Larsen ◽  
Patricia V. Højberg ◽  
Aage Vølund ◽  
...  
Keyword(s):  
Insulin Secretion ◽  
Chronic Pancreatitis ◽  
Pancreatic Enzyme ◽  
Control Group ◽  
Β Cell ◽  
Exocrine Insufficiency ◽  
Liquid Meal ◽  
Postprandial Plasma Glucose ◽  
Glucagon Like Peptide 1 ◽  
Pancreatic Enzyme Substitution

We aimed to investigate how assimilation of nutrients affects the postprandial responses of glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) and to evaluate the effect of pancreatic enzyme substitution (PES) on insulin secretion in patients with chronic pancreatitis (CP) and pancreatic exocrine insufficiency (PEI). Eight male patients with CP and PEI were studied. Blood was sampled frequently on two separate days after ingestion of a liquid meal with and without PES, respectively. Eight healthy male subjects served as a control group. β-Cell responsiveness was estimated as changes in insulin secretion rates in response to changes in postprandial plasma glucose (PG). There was no difference in the PG incremental area under curve (AUC) for patients with and without PES [406 ± 100 vs. 425 ± 80 mM·4 h (mean ± SE), P = 0.8]. The response of total GLP-1 was higher after PES (AUC: 7.8 ± 1.2 vs. 5.3 ± 0.6 nM·4 h, P = 0.01), as was the response of total GIP (AUC: 32.7 ± 7.5 vs. 21.1 ± 8.3 nM·4 h, P = 0.01). Concurrently, both plasma insulin, plasma C-peptide, and total insulin secretion increased after PES (AUC: 17.7 ± 4.2 vs. 13.6 ± 2.9 nM·4 h, P = 0.02; 237 ± 31.4 vs. 200 ± 27.4 nM·4 h, P = 0.005; and 595 ± 82 vs. 497 ± 80 pmol·kg−1·4 h, P = 0.01, respectively). β-Cell responsiveness to glucose was not significantly different on the two study days for patients with CP. These results suggest that the secretion of GLP-1 and GIP is under influence of the digestion and absorption of nutrients in the small intestine and that PES increases insulin secretion.

scholarly journals Pancreatic Enzyme Supplements Are Not Effective for Relieving Abdominal Pain in Patients with Chronic Pancreatitis: Meta-Analysis and Systematic Review of Randomized Controlled Trials

2016 ◽  
Vol 2016 ◽  
pp. 1-6 ◽  
Author(s):  
Mohammad Yaghoobi ◽  
Julia McNabb-Baltar ◽  
Raheleh Bijarchi ◽  
Peter B. Cotton
Keyword(s):  
Systematic Review ◽  
Abdominal Pain ◽  
Chronic Pancreatitis ◽  
Pain Score ◽  
Meta Analysis ◽  
Pancreatic Enzyme ◽  
Analgesic Consumption ◽  
Randomized Controlled ◽  
Enzyme Supplementation ◽  
Enteric Coated

Background. Pancreatic enzyme supplementation is widely used to treat pain in patients with chronic pancreatitis, despite little evidence for efficacy. We performed a systematic review of the literature and a meta-analysis to investigate its effectiveness.Methods. All randomized controlled parallel or crossover trials in patients with chronic pancreatitis comparing pancreatic enzyme supplementation to placebo were included. The main outcome was improvement in pain score or reduced analgesic consumption. Two independent reviewers extracted data. Mantel-Haenszel random effect model meta-analysis was used whenever methodologically appropriate.Results. Five out of 434 retrieved studies were included in the systematic review. All studies used relatively similar methodology. Four studies using enteric-coated pancreatic enzyme supplementation failed to show any improvement in pain as compared to placebo. The only study using non-enteric-coated enzymes did show reduction in the pain score. There was significant heterogeneity among studies in both analyses. Random model meta-analysis of three studies showed no significant difference in the mean of daily pain score (mean difference: 0.09 (1.57–1.39),p=0.91) or average weekly analgesic consumption (mean difference: −0.30 (−2.37–1.77),p=0.77) between the periods of administering pancreatic enzyme supplementation versus placebo.Conclusion. Pancreatic enzyme supplements do not seem to relieve abdominal pain in patients with chronic pancreatitis and should not be prescribed solely for this purpose, given their significant cost and potential side effects.

Antroduodenal motility in chronic pancreatitis: are abnormalities related to exocrine insufficiency?

2000 ◽  
Vol 278 (3) ◽  
pp. G458-G466 ◽  
Author(s):  
M. K. Vu ◽  
J. Vecht ◽  
E. H. Eddes ◽  
I. Biemond ◽  
C. B. H. W. Lamers ◽  
...  
Keyword(s):  
Chronic Pancreatitis ◽  
Pancreatic Insufficiency ◽  
Motor Pattern ◽  
Pancreatic Enzyme ◽  
Gastrointestinal Hormone ◽  
Hormone Release ◽  
Exocrine Insufficiency ◽  
Liquid Meal ◽  
Gut Hormone ◽  
Antroduodenal Motility

In patients with chronic pancreatitis (CP) the relation among exocrine pancreatic secretion, gastrointestinal hormone release, and motility is disturbed. We studied digestive and interdigestive antroduodenal motility and postprandial gut hormone release in 26 patients with CP. Fifteen of these patients had pancreatic insufficiency (PI) established by urinary para-aminobenzoic acid test and fecal fat excretion. Antroduodenal motility was recorded after ingestion of a mixed liquid meal. The effect of pancreatic enzyme supplementation was studied in 8 of the 15 CP patients with PI. The duration of the postprandial antroduodenal motor pattern was significantly ( P < 0.01) prolonged in CP patients (324 ± 20 min) compared with controls (215 ± 19 min). Antral motility indexes in the first hour after meal ingestion were significantly reduced in CP patients. The interdigestive migrating motor complex cycle length was significantly ( P < 0.01) shorter in CP patients (90 ± 8 min) compared with controls (129 ± 8 min). These abnormalities were more pronounced in CP patients with exocrine PI. After supplementation of pancreatic enzymes, these alterations in motility reverted toward normal. Digestive and interdigestive antroduodenal motility are abnormal in patients with CP but significantly different from controls only in those with exocrine PI. These abnormalities in antroduodenal motility in CP are related to maldigestion.

M1368 Prescription and Response to Pancreatic Enzyme Therapy in Exocrine Insufficiency Due to Chronic Pancreatitis; a Dutch National Survey

2010 ◽  
Vol 138 (5) ◽  
pp. S-390
Author(s):  
Edmée C. Sikkens ◽  
Djuna L. Cahen ◽  
Casper H. van Eijck ◽  
Ernst J. Kuipers ◽  
Marco J. Bruno
Keyword(s):  
Chronic Pancreatitis ◽  
National Survey ◽  
Pancreatic Enzyme ◽  
Enzyme Therapy ◽  
Exocrine Insufficiency

scholarly journals A prospective study of prognostic factors predicting outcome of surgery in chronic pancreatitis at a tertiary care centre in India

2021 ◽  
Vol 11 (2) ◽  
pp. 182-186
Author(s):  
Satya Prasad Samantaray ◽  
Tanmay Dutta
Keyword(s):  
Chronic Pancreatitis ◽  
Pain Relief ◽  
Pain Score ◽  
Scoring System ◽  
Tertiary Care ◽  
Insulin Requirement ◽  
Tertiary Care Centre ◽  
Exocrine Insufficiency ◽  
Endocrine Insufficiency ◽  
Outcome Of Surgery

Identification of factors predicting the outcome of surgery for chronic pancreatitis and preparation of a scoring system to predict the outcome following surgery. A total number of 76 patients who had undergone surgery for chronic pancreatitis were prospectively followed at Department of General Surgery, S.C.B. Medical College, Cuttack during the period from 2010-2013. Data on demographic details, pain score, opioid addiction, exocrine and endocrine insufficiency, insulin requirement and morphology of pancreas on imaging were recorded. On follow up, improvement in pain score and exocrine and endocrine insufficiency were recorded. Factors affecting surgical outcome were determined and a scoring system was done. The mean age of patients was 39.7±7.9 years (range 18-58 years). Chronic alcohol intake was the predominant cause accounting for 56% (n=34) cases. Mean pain score at admission on Visual Analogue Scale (VAS) was 5.98. Twenty-six patients (43.3%) were found to have endocrine insufficiency and 22 (36.6%) patients had exocrine insufficiency. Forty-two patients underwent Partington-Rochelle procedure, and 18 patients underwent Frey’s procedure. Eighty percent of patients (n=48) had significant pain relief. On logistic regression, preoperative VAS score, number of previous admissions, opioid dependence, main pancreatic duct (MPD) diameter, number and site of calcifications were found to be significant in predicting pain relief. Cohort of patients with chronic pancreatitis likely to get benefit from surgery can be predicted preoperatively.

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