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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. 8th ed. http://accesspharmacy.com/content.aspx?aid=7979530. Accessed July 22, 2012.

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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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  • 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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  • 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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  • 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 basedon geographic location.

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  • Avoidance of known 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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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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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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  • Relieve abdominal pain.
  • Treat complications of malabsorption and glucose intolerance.
  • Improve quality of life.

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  • Abstinence from alcohol and smoking cessation
  • Smaller, more frequent meals and reduced dietary fat intake to reduce steatorrhea
  • Consider whole protein or peptide-based oral nutritional supplements for patients who do not consume adequate dietary calories.
  • Consider invasive procedures and surgery for uncontrolled pain and complications.

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  • Initial pain management with nonopioid analgesics (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]) given on ...

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