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Practice Clinical Update

Chronic pancreatitis

BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2126 (Published 07 June 2018) Cite this as: BMJ 2018;361:k2126
  1. Anand Gupte, assistant professor of medicine1,
  2. Dianne Goede, assistant professor of medicine2,
  3. Robert Tuite, Florida Chapter Chair3,
  4. Chris E Forsmark, professor of medicine1
  1. 1Department of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL, USA
  2. 2Division of General Internal Medicine, University of Florida, Gainesville, FL, USA
  3. 3Florida Chapter Chair, National Pancreas Foundation, FL, USA
  1. Correspondence to chris.forsmark{at}medicine.ufl.edu

What you need to know

  • Although alcohol consumption is the most common cause of chronic pancreatitis, smoking and genetic mutations are also risk factors

  • Older people, those with diabetes, and those who smoke or drink to excess can have changes on imaging that mimic pancreatitis

  • Pancreatic insufficiency typically takes 10 years to develop and is best managed with replacement therapy

  • If abdominal pain is disproportionate, consider whether there is a complication such as a pseudocyst, obstruction, malignancy, or hyperalgesia

  • Monitor for the development of secondary diabetes

Although chronic pancreatitis is commonly attributed to alcohol consumption, it is now clear that newly discovered genetic mutations and smoking are also important risk factors, and idiopathic chronic pancreatitis is much more common than appreciated. The diagnosis rests on cross-sectional imaging, or endoscopic ultrasound, but these tests might be non-diagnostic early in the clinical course. Avoiding further exposure to toxins like alcohol and tobacco can moderate the disease course and reduce the risk of secondary pancreatic cancer and other non-pancreatic complications. Abdominal pain remains difficult to manage, but a good patient-doctor relationship allows reasonable goals to be set. Malabsorption—exocrine insufficiency—can occur, and requires appropriate dosage of pancreatic enzyme replacement therapy (PERT) and monitoring for osteoporosis. Secondary diabetes—endocrine insufficiency—can occur and can be difficult to manage, requiring an understanding of the unique mechanisms of diabetes in patients with chronic pancreatitis. Effective collaboration between primary care doctors and specialists in pain management, diabetes, gastroenterology, surgery, and radiology is important and often essential in these complex patients.

In this article, we review the causes, consequences, and management of chronic pancreatitis and its complications. The available therapeutic options, with very few exceptions, are not supported by randomised trials or high quality evidence, but are instead supported by guidelines1 and expert opinion.

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