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SOURCE

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Source: Bolesta S, Montgomery PA. Pancreatitis. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146059813. Accessed April 18, 2017.

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DEFINITION

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  • Progressive disease characterized by long-standing pancreatic inflammation that eventually leads to loss of pancreatic exocrine and endocrine function.

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ETIOLOGY

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  • 70–80% of cases due to chronic alcohol consumption.

  • 20% of cases idiopathic.

  • 10% of cases due to rare causes, for example:

    • Autoimmune.

    • Hereditary.

    • Tropical pancreatitis.

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PATHOPHYSIOLOGY

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  • Long-standing pancreatic inflammation leads to destruction of pancreatic tissue with fibrin deposition with loss of exocrine and endocrine function.

  • Abdominal pain may be caused by increased pancreatic parenchymal pressure from obstruction, inflammation, and necrosis.

  • Malabsorption of protein and fat occurs when capacity for enzyme secretion reduced by 90%.

  • Complications may include pancreatic pseudocyst, abscess, and ascites or common bile duct obstruction leading to cholangitis or secondary biliary cirrhosis.

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EPIDEMIOLOGY

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  • Occurs in 6 per 100,000 population, with peak incidence between ages 35 and 54.

  • About 85% of cases occur in men.

  • Prevalence varies widely based on geographic location.

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PREVENTION AND SCREENING

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  • Avoidance of known risk factors.

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RISK FACTORS

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  • Increased or excessive alcohol consumption.

  • Cigarette smoking.

  • High fat and protein diet.

  • Hypertriglyceridemia.

  • Hereditary or familial pancreatitis.

  • Possible gene mutations.

  • Pancreatic duct obstruction.

  • Chronic kidney disease

  • Medications.

  • Toxins.

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CLINICAL PRESENTATION

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SIGNS AND SYMPTOMS
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  • Deep, penetrating epigastric or abdominal pain that may radiate to the back.

  • Pain often occurs with meals and at night, and may be associated with nausea and vomiting.

  • Steatorrhea, azotorrhea, diarrhea, bloating, and weight loss may occur.

  • Pancreatic diabetes a late manifestation associated with pancreatic calcification.

  • Jaundice occurs in ~10% of patients.

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DIAGNOSIS

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MEANS OF CONFIRMATION AND DIAGNOSIS
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  • Clinical presentation and imaging or pancreatic function studies.

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LABORATORY TESTS
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  • Serum amylase and lipase usually normal or only slightly elevated but may be increased in acute exacerbations.

  • Total bilirubin, alkaline phosphatase, and hepatic transaminases may be elevated with ductal obstruction.

  • Serum albumin and calcium may be low with malnutrition.

  • Pancreatic function tests include:

    • Serum trypsinogen (<20 ng/mL abnormal)

    • Fecal elastase (<200 mcg/g of stool abnormal)

    • 72-hour fecal fat estimation (>7 g/day abnormal)

    • Secretin stimulation (evaluates duodenal bicarbonate secretion)

    • 13C-mixed triglyceride breath test.

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IMAGING
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  • Abdominal ultrasound.

  • Computed tomography (CT)

  • Magnetic resonance cholangiopancreatography (MRCP)

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DIAGNOSTIC PROCEDURES
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  • Endoscopic ultrasonography (EUS)

  • Endoscopic retrograde cholangiopancreatography (ERCP)

  • Histology generally not recommended.

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DIFFERENTIAL DIAGNOSIS
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  • Cholelithiasis.

  • Diabetes mellitus

  • Malabsorption from other causes.

  • Intractable duodenal ulcer.

  • Pancreatic cancer.

  • Irritable bowel syndrome.

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