Chronic Pancreatitis with Case

00:01 Let's move on to our next case.

00:04 A 68-year-old woman with a history of alcohol use disorder is seen in clinic for two years of chronic diarrhea.

00:11 She has two to three loose, foul smelling bowel movements daily and intermittent epigastric pain after eating.

00:19 She has lost 10 kg in the past year.

00:22 She quit drinking two years ago, smokes one pack per day and is not on any medications.

00:27 Vitals are normal.

00:29 On exam, she has temporal wasting and mild epigastric tenderness without rebound or guarding.

00:35 There is no hepatosplenomegaly and no jaundice.

00:38 Labs show a serum lipase of 33.

00:42 And abdominal ultrasound shows pancreatic calcifications but no masses.

00:47 So we are asked, what is the best next step in management? So let's point out some key features.

00:54 She has chronic diarrhea with epigastric pain which would prompt you to think of perhaps a malabsorption syndrome.

01:01 In addition, she does have heavy alcohol use and a history of smoking.

01:07 And on exam, she has exam findings that support malnutrition.

01:13 Her normal lipase and pancreatic calcifications may also be helpful in our diagnosis.

01:20 So, let's now talk about chronic pancreatitis.

01:25 To understand how chronic pancreatitis forms, we have to go back to the physiology of the pancreas and what its role is in digesting food.

01:34 So the pancreas has two functions.

01:36 It has an endocrine function and it has an exocrine gland function.

01:40 The endocrine gland function involves secreting insulin, glucagon and somatostatin to aid in the regulation of blood sugar.

01:48 On the other hand, the exocrine function involves producing pancreatic enzymes like protease, lipase and amylase that all help with digestion of food.

01:59 So, in chronic pancreatitis, patients have multiple bouts of inflammation that then leads to irreversible injury and then fibrosis of the pancreas.

02:11 So symptoms include, having intermittent abdominal pain often radiating to the back.

02:16 They may present with diarrhea and steatorrhea, so fatty stools, and they may have weight loss.

02:24 And all of this is related to the inability to process the food that we -- that ordinarily the pancreas would allow us to digest.

02:32 So patients may often present also with diabetes due to the loss of the endocrine function of the pancreas.

02:40 And because they're unable to process fats, they may also have fat soluble vitamin deficiencies.

02:47 Common causes of chronic pancreatitis include alcohol use and anything that causes recurrent bouts of pancreatitis.

02:57 The diagnosis can be quite difficult to make.

03:01 This is because on labs, amylase and lipase are often normal.

03:06 In addition, on imaging, you might find pancreatic calcifications as shown here on the CT scan showing bright white calcifications within the pancreas.

03:18 However, you may not see this finding, so you cannot base your diagnosis on this.

03:24 MRCP or endoscopic ultrasound may help you look for abnormalities in the pancreatic duct.

03:31 But again, not always done.

03:33 And if you suspect malabsorption, you could do 72 hour fecal fat testing.

03:39 In the end, it is mostly a clinical diagnosis and we manage it with pain control, reducing any triggers that are known to cause pancreatitis.

03:51 So, cutting back on alcohol and smoking cessation and replacing the pancreatic enzymes that the person can no longer secrete. So now let's go back to our case.

04:04 We had a 68-year-old woman with chronic diarrhea and epigastric pain.

04:09 She has a history of heavy alcohol use and smoking which are both risk factors for chronic pancreatitis.

04:17 She has evidence of malnutrition and now we know that a normal lipase can be found in chronic pancreatitis as are the pancreatic calcifications seen on her imaging.

04:27 So, the best next step in management would be to screen for fat soluble vitamin deficiencies since she is at high risk for this, offering pain control.

04:37 And of course, counseling her on smoking cessation and replacing her pancreatic enzymes.