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{{Chronic-pancreatitis}}
{{Chronic pancreatitis}}
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==Overview==
==Overview==
Patients with chronic pancreatitis usually present with persistent [[abdominal pain]] with episodic flares that may or may not be associated with food intake, [[steatorrhea]], [[pancreatic]] [[diabetes]], [[nausea]] and [[weight loss]]. According to M-ANNHEIM clinical staging of chronic pancreatitis, it can be classified into [[asymptomatic]] and [[symptomatic]] chronic pancreatitis. M-ANNHEIM scoring system for the grading of clinical features of chronic pancreatitis include features such as [[pain]] control, [[Surgery|surgical]] intervention, [[exocrine]] insufficiency, [[endocrine]] insufficiency, morphologic status on [[pancreatic]] imaging and severe organ complications.


==History==
==History and Symptoms==


==Symptoms==
=== History ===
History findings in patient suffering from chronic pancreatitis depends upon dysfunction in any one of the following:
Patients with chronic pancreatitis usually present with:
* [[Biliary tract]] obstruction; presenting as a history of [[jaundice]]
* Persistent [[abdominal pain]]
* [[Exocrine]] dysfunction; presenting as a history of [[malabsorption]] ([[fatty stools]])
* [[Steatorrhea]] resulting from malabsorption of the fats in food (typically very bad-smelling and equally hard on the patient)
* [[Endocrine]] dysfunction; presenting as a history of [[diabetes]]
* Severe [[nausea]]
 
=== Symptoms ===
Patients with chronic pancreatitis usually present with:<ref name="pmid26516493">{{cite journal |vauthors=Goulden MR |title=The pain of chronic pancreatitis: a persistent clinical challenge |journal=Br J Pain |volume=7 |issue=1 |pages=8–22 |year=2013 |pmid=26516493 |pmc=4590150 |doi=10.1177/2049463713479230 |url=}}</ref>
* Persistent [[abdominal pain]] with episodic flares may or may not be associated with food intake<ref name="pmid6706066">{{cite journal |vauthors=Ammann RW, Akovbiantz A, Largiader F, Schueler G |title=Course and outcome of chronic pancreatitis. Longitudinal study of a mixed medical-surgical series of 245 patients |journal=Gastroenterology |volume=86 |issue=5 Pt 1 |pages=820–8 |year=1984 |pmid=6706066 |doi= |url=}}</ref><ref name="pmid7792289">{{cite journal |vauthors=Lankisch PG, Seidensticker F, Löhr-Happe A, Otto J, Creutzfeldt W |title=The course of pain is the same in alcohol- and nonalcohol-induced chronic pancreatitis |journal=Pancreas |volume=10 |issue=4 |pages=338–41 |year=1995 |pmid=7792289 |doi= |url=}}</ref><ref name="pmid6706079">{{cite journal |vauthors=Warshaw AL |title=Pain in chronic pancreatitis. Patients, patience, and the impatient surgeon |journal=Gastroenterology |volume=86 |issue=5 Pt 1 |pages=987–9 |year=1984 |pmid=6706079 |doi= |url=}}</ref><ref name="pmid7926511">{{cite journal |vauthors=Layer P, Yamamoto H, Kalthoff L, Clain JE, Bakken LJ, DiMagno EP |title=The different courses of early- and late-onset idiopathic and alcoholic chronic pancreatitis |journal=Gastroenterology |volume=107 |issue=5 |pages=1481–7 |year=1994 |pmid=7926511 |doi= |url=}}</ref>. Typical features of [[pain]] associated with chronic pancreatitis are:
** Located in the  [[epigastrium]]
** Radiating to the back
** May be associated with nausea and [[Nausea and vomiting|vomiting]]
** Usually worse 15-30min after meal
** Initially it occurs in discrete episodes but as the disease progresses, it may change to persistent [[abdominal pain]]
* [[Steatorrhea]] resulting from [[malabsorption]] of the fat in food (greasy, loose, foul smelling stools that are difficult to flush- due to decreased pancreatic lipase activity; deficiency of fat soluble vitamins, for example vitamins A, D, E and K correlates with the severity of [[steatorrhea]]<ref name="pmid4693931">{{cite journal |vauthors=DiMagno EP, Go VL, Summerskill WH |title=Relations between pancreatic enzyme outputs and malabsorption in severe pancreatic insufficiency |journal=N. Engl. J. Med. |volume=288 |issue=16 |pages=813–5 |year=1973 |pmid=4693931 |doi=10.1056/NEJM197304192881603 |url=}}</ref><ref name="pmid9365465">{{cite journal |vauthors=Mergener K, Baillie J |title=Chronic pancreatitis |journal=Lancet |volume=350 |issue=9088 |pages=1379–85 |year=1997 |pmid=9365465 |doi=10.1016/S0140-6736(97)07332-7 |url=}}</ref><ref name="pmid5547614">{{cite journal |vauthors=Toskes PP, Hansell J, Cerda J, Deren JJ |title=Vitamin B 12 malabsorption in chronic pancreatic insufficiency |journal=N. Engl. J. Med. |volume=284 |issue=12 |pages=627–32 |year=1971 |pmid=5547614 |doi=10.1056/NEJM197103252841202 |url=}}</ref><ref name="pmid24259957">{{cite journal |vauthors=Rasmussen HH, Irtun O, Olesen SS, Drewes AM, Holst M |title=Nutrition in chronic pancreatitis |journal=World J. Gastroenterol. |volume=19 |issue=42 |pages=7267–75 |year=2013 |pmid=24259957 |pmc=3831208 |doi=10.3748/wjg.v19.i42.7267 |url=}}</ref>
*Pancreatic [[diabetes]]<ref name="pmid4693931">{{cite journal |vauthors=DiMagno EP, Go VL, Summerskill WH |title=Relations between pancreatic enzyme outputs and malabsorption in severe pancreatic insufficiency |journal=N. Engl. J. Med. |volume=288 |issue=16 |pages=813–5 |year=1973 |pmid=4693931 |doi=10.1056/NEJM197304192881603 |url=}}</ref><ref name="pmid11054391">{{cite journal |vauthors=Malka D, Hammel P, Sauvanet A, Rufat P, O'Toole D, Bardet P, Belghiti J, Bernades P, Ruszniewski P, Lévy P |title=Risk factors for diabetes mellitus in chronic pancreatitis |journal=Gastroenterology |volume=119 |issue=5 |pages=1324–32 |year=2000 |pmid=11054391 |doi= |url=}}</ref><ref name="pmid9365465">{{cite journal |vauthors=Mergener K, Baillie J |title=Chronic pancreatitis |journal=Lancet |volume=350 |issue=9088 |pages=1379–85 |year=1997 |pmid=9365465 |doi=10.1016/S0140-6736(97)07332-7 |url=}}</ref>
*[[Nausea]]
* [[Weight loss]]
* [[Weight loss]]
* [[Pseudocyst]]
* [[Pancreatic cancer]]
== M-ANNHEIM clinical staging for Chronic pancreatitis ==
{| class="wikitable"
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Chronic pancreatitis
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Stage
!
|-
| rowspan="4" |Asymptomatic
|0
|Stage of subclinical chronic pancreatitis
|-
|a
|Period without symptoms (determination by chance, e.g., autopsy)
|-
|b
|Acute pancreatitis—single episode (possible onset of chronic pancreatitis)
|-
|c
|Acute pancreatitis with severe complications
|-
| rowspan="14" |Symptomatic
|I
|Stage without pancreatic insufficiency
|-
|a
|(Recurrent) acute pancreatitis (no pain between episodes of acute pancreatitis)
|-
|b
|Recurrent or chronic abdominal pain (including pain between episodes of acute pancreatitis)
|-
|c
|I a/b with severe complications
|-
|II
|Stage of partial pancreatic insufficiency
|-
|a
|Isolated exocrine (or endocrine) pancreatic insufficiency (without pain)
|-
|b
|Isolated exocrine (or endocrine) pancreatic insufficiency (with pain)
|-
|c
|II a/b with severe complications
|-
|III
|Stage of painful complete pancreatic insufficiency
|-
|a
|Exocrine and endocrine insufficiency (with pain, e.g., requiring pain medication)
|-
|b
|III a with severe complications
|-
|IV
|Stage of secondary painless disease (burnout)
|-
|a
|Exocrine and endocrine insufficiency without pain and without severe complications
|-
|b
|Exocrine and endocrine insufficiency without pain and with severe complications
|}
== M-ANNHEIM scoring system for the grading of clinical features of chronic pancreatitis ==
{| class="wikitable"
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Clinical feature
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Comments
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Score
|-
| rowspan="5" |Pain
|No pain without therapy
|0
|-
|Recurrent acute pancreatitis
|1
|-
|No pain with therapy
|2
|-
|Intermittent pain
|3
|-
|Continuous pain
|4
|-
| rowspan="3" |Pain control
|No medication
|0
|-
|Use of nonopioid drugs or use of mild opioids (WHO step 1 or 2)
|1
|-
|Use of potent opioids (WHO step 3) or endoscopic intervention
|2
|-
|Surgical intervention
|Pancreatic surgical intervention for any reason
|4
|-
| rowspan="3" |Exocrine insufficiency
|Absence of exocrine insufficiency
|0
|-
|Presence of mild, moderate, or unproven exocrine insufficiency not requiring enzyme supplementation (including patient reports of intermittent diarrhea)
|1
|-
|Presence of proven exocrine insufficiency (according to exocrine function tests) or presence of marked exocrine insufficiency defined as steatorrhea (>7 g fat/24 h), normalized or markedly reduced by enzyme supplementation
|2
|-
| rowspan="2" |Endocrine insufficiency
|Absence of diabetes mellitus
|0
|-
|Presence of diabetes mellitus
|4
|-
| rowspan="5" |Morphologic status on pancreatic imaging (according to the Cambridge classification)
|Normal
|0
|-
|Equivocal
|1
|-
|Mild
|2
|-
|Moderate
|3
|-
|Marked
|4
|-
| rowspan="3" |Severe organ complications
|Absence of complications
|0
|-
|Presence of possibly reversible complications
|2
|-
|Presence of irreversible complications
|4
|}


The patient may also complain about pain related to their food intake, especially those meals containing a high percentage of fats and protein.
=== M-ANNHEIM severity index of chronic pancreatitis: ===
{| class="wikitable"
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Severity index
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Severity level
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Point range
|-
|M-ANNHEIM A
|Minor
|0–5 points
|-
|M-ANNHEIM B
|Increased
|6–10 points
|-
|M-ANNHEIM C
|Advanced
|11–15 points
|-
|M-ANNHEIM D
|Marked
|16–20 points
|-
|M-ANNHEIM E
|Exacerbated
|>20 points
|}


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


{{WH}}
[[Category:Gastroenterology]]
{{WS}}
[[Category:Emergency medicine]]
[[Category:Surgery]]
 
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Latest revision as of 21:37, 3 February 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2]

Overview

Patients with chronic pancreatitis usually present with persistent abdominal pain with episodic flares that may or may not be associated with food intake, steatorrhea, pancreatic diabetes, nausea and weight loss. According to M-ANNHEIM clinical staging of chronic pancreatitis, it can be classified into asymptomatic and symptomatic chronic pancreatitis. M-ANNHEIM scoring system for the grading of clinical features of chronic pancreatitis include features such as pain control, surgical intervention, exocrine insufficiency, endocrine insufficiency, morphologic status on pancreatic imaging and severe organ complications.

History and Symptoms

History

History findings in patient suffering from chronic pancreatitis depends upon dysfunction in any one of the following:

Symptoms

Patients with chronic pancreatitis usually present with:[1]

M-ANNHEIM clinical staging for Chronic pancreatitis

Chronic pancreatitis Stage
Asymptomatic 0 Stage of subclinical chronic pancreatitis
a Period without symptoms (determination by chance, e.g., autopsy)
b Acute pancreatitis—single episode (possible onset of chronic pancreatitis)
c Acute pancreatitis with severe complications
Symptomatic I Stage without pancreatic insufficiency
a (Recurrent) acute pancreatitis (no pain between episodes of acute pancreatitis)
b Recurrent or chronic abdominal pain (including pain between episodes of acute pancreatitis)
c I a/b with severe complications
II Stage of partial pancreatic insufficiency
a Isolated exocrine (or endocrine) pancreatic insufficiency (without pain)
b Isolated exocrine (or endocrine) pancreatic insufficiency (with pain)
c II a/b with severe complications
III Stage of painful complete pancreatic insufficiency
a Exocrine and endocrine insufficiency (with pain, e.g., requiring pain medication)
b III a with severe complications
IV Stage of secondary painless disease (burnout)
a Exocrine and endocrine insufficiency without pain and without severe complications
b Exocrine and endocrine insufficiency without pain and with severe complications

M-ANNHEIM scoring system for the grading of clinical features of chronic pancreatitis

Clinical feature Comments Score
Pain No pain without therapy 0
Recurrent acute pancreatitis 1
No pain with therapy 2
Intermittent pain 3
Continuous pain 4
Pain control No medication 0
Use of nonopioid drugs or use of mild opioids (WHO step 1 or 2) 1
Use of potent opioids (WHO step 3) or endoscopic intervention 2
Surgical intervention Pancreatic surgical intervention for any reason 4
Exocrine insufficiency Absence of exocrine insufficiency 0
Presence of mild, moderate, or unproven exocrine insufficiency not requiring enzyme supplementation (including patient reports of intermittent diarrhea) 1
Presence of proven exocrine insufficiency (according to exocrine function tests) or presence of marked exocrine insufficiency defined as steatorrhea (>7 g fat/24 h), normalized or markedly reduced by enzyme supplementation 2
Endocrine insufficiency Absence of diabetes mellitus 0
Presence of diabetes mellitus 4
Morphologic status on pancreatic imaging (according to the Cambridge classification) Normal 0
Equivocal 1
Mild 2
Moderate 3
Marked 4
Severe organ complications Absence of complications 0
Presence of possibly reversible complications 2
Presence of irreversible complications 4

M-ANNHEIM severity index of chronic pancreatitis:

Severity index Severity level Point range
M-ANNHEIM A Minor 0–5 points
M-ANNHEIM B Increased 6–10 points
M-ANNHEIM C Advanced 11–15 points
M-ANNHEIM D Marked 16–20 points
M-ANNHEIM E Exacerbated >20 points

References

  1. ↑ Goulden MR (2013). "The pain of chronic pancreatitis: a persistent clinical challenge". Br J Pain. 7 (1): 8–22. doi:10.1177/2049463713479230. PMC 4590150. PMID 26516493.
  2. ↑ Ammann RW, Akovbiantz A, Largiader F, Schueler G (1984). "Course and outcome of chronic pancreatitis. Longitudinal study of a mixed medical-surgical series of 245 patients". Gastroenterology. 86 (5 Pt 1): 820–8. PMID 6706066.
  3. ↑ Lankisch PG, Seidensticker F, Löhr-Happe A, Otto J, Creutzfeldt W (1995). "The course of pain is the same in alcohol- and nonalcohol-induced chronic pancreatitis". Pancreas. 10 (4): 338–41. PMID 7792289.
  4. ↑ Warshaw AL (1984). "Pain in chronic pancreatitis. Patients, patience, and the impatient surgeon". Gastroenterology. 86 (5 Pt 1): 987–9. PMID 6706079.
  5. ↑ Layer P, Yamamoto H, Kalthoff L, Clain JE, Bakken LJ, DiMagno EP (1994). "The different courses of early- and late-onset idiopathic and alcoholic chronic pancreatitis". Gastroenterology. 107 (5): 1481–7. PMID 7926511.
  6. ↑ 6.0 6.1 DiMagno EP, Go VL, Summerskill WH (1973). "Relations between pancreatic enzyme outputs and malabsorption in severe pancreatic insufficiency". N. Engl. J. Med. 288 (16): 813–5. doi:10.1056/NEJM197304192881603. PMID 4693931.
  7. ↑ 7.0 7.1 Mergener K, Baillie J (1997). "Chronic pancreatitis". Lancet. 350 (9088): 1379–85. doi:10.1016/S0140-6736(97)07332-7. PMID 9365465.
  8. ↑ Toskes PP, Hansell J, Cerda J, Deren JJ (1971). "Vitamin B 12 malabsorption in chronic pancreatic insufficiency". N. Engl. J. Med. 284 (12): 627–32. doi:10.1056/NEJM197103252841202. PMID 5547614.
  9. ↑ Rasmussen HH, Irtun O, Olesen SS, Drewes AM, Holst M (2013). "Nutrition in chronic pancreatitis". World J. Gastroenterol. 19 (42): 7267–75. doi:10.3748/wjg.v19.i42.7267. PMC 3831208. PMID 24259957.
  10. ↑ Malka D, Hammel P, Sauvanet A, Rufat P, O'Toole D, Bardet P, Belghiti J, Bernades P, Ruszniewski P, Lévy P (2000). "Risk factors for diabetes mellitus in chronic pancreatitis". Gastroenterology. 119 (5): 1324–32. PMID 11054391.


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