Chronic pancreatitis and pancreatic insufficiency

Chronic pancreatitis is an under-recognized condition. It is important to confirm the diagnosis and identify exocrine insufficiency; this is straightforward in advanced disease, using CT scanning and measurement of faecal elastase, but at earlier stages it may require more sensitive investigation such as endoscopic ultrasound and functional breath tests. The aetiology should be sought, and abstinence from alcohol or specific treatment instituted as appropriate. Low fat diets are no longer recommended. Abdominal pain is common but often due to treatable co-morbidities such as gastroparesis, constipation, stones or biliary obstruction. Simple analgesia and gabapentinoids should be used first line, and endoscopic intervention should be considered before regular narcotics. Dependence or narcotic bowel syndrome are both common in this patient population. Management of exocrine insufficiency involves treatment of symptoms as well as normalization of nutritional deficiencies; the addition of a proton pump inhibitor or increases in pancreatic enzyme dosage may be necessary. Sudden changes in symptoms may indicate complications such as pseudocysts, duodenal obstruction or pancreatic cancer.