Chronic pancreatitis history and symptoms
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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:
- Biliary tract obstruction; presenting as a history of jaundice
- Exocrine dysfunction; presenting as a history of malabsorption (fatty stools)
- Endocrine dysfunction; presenting as a history of diabetes
Symptoms
Patients with chronic pancreatitis usually present with:[1]
- Persistent abdominal pain with episodic flares may or may not be associated with food intake[2][3][4][5]. Typical features of pain associated with chronic pancreatitis are:
- Located in the epigastrium
- Radiating to the back
- May be associated with nausea and 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[6][7][8][9]
- Pancreatic diabetes[6][10][7]
- Nausea
- Weight loss
- Pseudocyst
- Pancreatic cancer
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
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Warshaw AL (1984). "Pain in chronic pancreatitis. Patients, patience, and the impatient surgeon". Gastroenterology. 86 (5 Pt 1): 987–9. PMID 6706079.
- ↑ 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.
- ↑ 6.0 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.
- ↑ 7.0 7.1 Mergener K, Baillie J (1997). "Chronic pancreatitis". Lancet. 350 (9088): 1379–85. doi:10.1016/S0140-6736(97)07332-7. PMID 9365465.
- ↑ 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.
- ↑ 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.
- ↑ 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.