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{{Chronic pancreatitis}}
{{Chronic pancreatitis}}
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==Overview==
==Overview==
Chronic pancreatitis may be divided based upon underlying [[morphology]] into large-duct type or small-duct type with or without [[calcification]]. The classification systems that have been used for chronic pancreatitis include Marseille, Marseille-Rome system, Cambridge system, TIGAR-O system, ABC grading system and Manchester system.


==Classification==
==Classification==
Chronic pancreatitis may be divided based on underlying morphology into:  
 
=== Classification based upon morphology ===
Chronic pancreatitis may be divided based on underlying [[morphology]] into:  
*Large-duct type
*Large-duct type
*Small-duct type  
*Small-duct type  
**With calcification
**With [[calcification]]
**Without calcification.
**Without [[calcification]]
{| class="wikitable"
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Classification system for chronic pancreatitis
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Year
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Key features
|-
|Clinical description
|1946
|
* Description of the [[clinical]] presentation of chronic pancreatitis and its association with increased [[alcohol]] consumption
|-
|Marseille
|1963
|
* Description of [[Morphology|morphologic]] characteristics and [[Etiology|etiological]] factors of the disease
* No discussion of the correlation between [[anatomic]] and functional changes
* No categorization according to disease severity or [[clinical]] presentation
* No inclusion of [[pancreatic]] imaging findings
|-
|Marseille
|1984
|
* Further description and subclassification of [[Morphology|morphological]] changes
* “Obstructive chronic pancreatitis” listed as distinct form
* No discussion of the correlation between [[anatomic]] and functional changes
* No categorization according to disease severity or [[clinical]] presentation
* No inclusion of [[pancreatic]] imaging findings
|-
|Marseille-Rome
|1988
|
* Description of “chronic calcifying” and “chronic [[inflammatory]]” pancreatitis as distinct forms
* Description of [[Etiology|etiological]] factors
* No further elaboration of clinical, functional or imaging criteria
|-
|Cambridge
|1984
|
* Classification of disease severity based on [[pancreatic]] imaging criteria ([[Ultrasound]], [[CT scanning]], [[endoscopic retrograde cholangiopancreatography]])
* Further discussion of [[Etiology|etiological]] factors, [[pancreatic]] function, and testing for [[pancreatic insufficiency]]
* [[Morphology|Morphologic]] characteristics not clearly defined
|-
|Clinical stages
|1994
|
* Detailed subclassification of chronic pancreatitis with correlation of [[Etiology|etiological]] factors with different [[Morphology|morphological]] forms of the disease
* Differentiation of [[clinical]] stages of the disease
* Linkage of [[pancreatic]] imaging findings and functional testing with stages of the disease
|-
|Japan Pancreas Society
|1997
|
* Description of clinical presentation and classification of disease in “definite” and “probable” chronic pancreatitis according to imaging findings, functional testing, and [[Histology|histological examination]]
|-
|Zürich Workshop
|1997
|
* Description of clinical presentation and classification of disease in “definite” and “probable” chronic pancreatitis according to imaging findings, functional testing, and [[Histology|histological examination]]
|-
|TIGAR-O
|2001
|
* Detailed categorization of [[Etiology|etiological]] risk factors
|-
|ABC grading system
|2002
|
* Disease grading according to clinical criteria, but limited separation of different disease severities
* Not all clinical presentations can be categorized
|-
|Manchester system
|2006
|
* Disease grading according to clinical criteria, but limited separation of different disease severities
* Not all clinical presentations can be categorized
|}
 
=== Classification of pancreatitis based upon area of involvement and etiology ===
There are various forms of chronic pancreatitis based upon the area of involvement and etiology are as follows:


==== Groove pancreatitis: ====
==== Groove pancreatitis: ====
Groove pancreatitis is a form of segmental pancreatitis that involves confinement of the inflammation process to the groove between the duodenum, common bile duct, and head of the pancreas without any involvement of the head of pancreas.<ref name="pmid20551662">{{cite journal |vauthors=Tezuka K, Makino T, Hirai I, Kimura W |title=Groove pancreatitis |journal=Dig Surg |volume=27 |issue=2 |pages=149–52 |year=2010 |pmid=20551662 |doi=10.1159/000289099 |url=}}</ref>
Groove pancreatitis is a form of segmental [[pancreatitis]] that involves confinement of the [[inflammation]] process to the groove between the [[duodenum]], [[common bile duct]], and head of the pancreas without any involvement of the head of pancreas.<ref name="pmid20551662">{{cite journal |vauthors=Tezuka K, Makino T, Hirai I, Kimura W |title=Groove pancreatitis |journal=Dig Surg |volume=27 |issue=2 |pages=149–52 |year=2010 |pmid=20551662 |doi=10.1159/000289099 |url=}}</ref>


==== Hereditary pancreatitis: ====
==== Hereditary pancreatitis: ====
*Hereditary pancreatitis is a subtype of chronic pancreatitis.  
*[[Hereditary pancreatitis]] is a subtype of chronic pancreatitis.  
*It is an autosomal dominant inheritance with 80% of penetrance rate. <ref name="pmid9219780">{{cite journal |vauthors=Sossenheimer MJ, Aston CE, Preston RA, Gates LK, Ulrich CD, Martin SP, Zhang Y, Gorry MC, Ehrlich GD, Whitcomb DC |title=Clinical characteristics of hereditary pancreatitis in a large family, based on high-risk haplotype. The Midwest Multicenter Pancreatic Study Group (MMPSG) |journal=Am. J. Gastroenterol. |volume=92 |issue=7 |pages=1113–6 |year=1997 |pmid=9219780 |doi= |url=}}</ref>
*It is an [[autosomal dominant]] [[inheritance]] with 80% of [[Penetrance|penetrance rate]]. <ref name="pmid9219780">{{cite journal |vauthors=Sossenheimer MJ, Aston CE, Preston RA, Gates LK, Ulrich CD, Martin SP, Zhang Y, Gorry MC, Ehrlich GD, Whitcomb DC |title=Clinical characteristics of hereditary pancreatitis in a large family, based on high-risk haplotype. The Midwest Multicenter Pancreatic Study Group (MMPSG) |journal=Am. J. Gastroenterol. |volume=92 |issue=7 |pages=1113–6 |year=1997 |pmid=9219780 |doi= |url=}}</ref>
*It usually involves mutation in cationic trypsinogen gene (PRSS1) resulting in  loss of autoregulation of activated trypsin.
*It usually involves [[mutation]] in cationic trypsinogen gene (PRSS1) resulting in  loss of [[autoregulation]] of activated [[trypsin]].
*Symptoms usually develop <20 year of age and often <5yr age.
*Symptoms usually develop <20 year of age and often <5yr age.
*It is associated with an increased risk of pancreatic adenocarcinoma.
*It is associated with an increased risk of [[pancreatic adenocarcinoma]].
*The management is similar to the other causes of chronic pancreatitis.
*The management is similar to the other causes of chronic pancreatitis.


==== Autoimmune pancreatitis (AIP): ====
==== Autoimmune pancreatitis (AIP): ====
* Autoimmune pancreatitis may be seen on the continuum of IgG4 related sclerosing diseases.
* [[Autoimmune pancreatitis]] may be seen on the continuum of [[IgG4-related systemic disease|IgG4]] related sclerosing diseases.
* It usually presents as obstructive jaundice or acute recurrent pancreatitis.
* It usually presents as [[obstructive jaundice]] or acute recurrent [[pancreatitis]].
* The underlying pathology involves  bile duct or pancreatic duct compression due to pancreatic swelling and ductal strictures leading to obstructive jaundice or acute recurrent pancreatitis presentation.
* The underlying pathology involves  [[bile duct]] or [[pancreatic duct]] compression due to [[pancreatic]] swelling and ductal [[strictures]] leading to [[obstructive jaundice]] or acute recurrent [[pancreatitis]] presentation.
* Elevated immunoglobulin IgG4 levels are usually seen on lab analysis.
* Elevated [[IgG4-related systemic disease|immunoglobulin IgG4]] levels are usually seen on lab analysis.
* Imaging findings include:
* Imaging findings include:
** Focal or diffuse pancreatic enlargement
** Focal or diffuse [[pancreatic]] enlargement
** Narrowed pancreatic duct
** Narrowed [[pancreatic duct]]


* Corticosteroid therapy results in rapid and marked improvement in clinical and radiographic features.
* [[Corticosteroid]] [[therapy]] results in rapid and marked improvement in [[clinical]] and [[radiographic]] features.


==== Tropical pancreatitis: ====
==== Tropical pancreatitis: ====
*It is one of the most common causes of chronic pancreatitis in tropical areas including south India.
*Tropical pancreatitis is one of the most common causes of chronic pancreatitis in tropical areas including south India.
*It was thought to be caused by cassava fruit but no longer associated with it and has no clear etiology.<ref name="pmid8200268">{{cite journal |vauthors=Sarles H, Augustine P, Laugier R, Mathew S, Dupuy P |title=Pancreatic lesions and modifications of pancreatic juice in tropical chronic pancreatitis (tropical calcific diabetes) |journal=Dig. Dis. Sci. |volume=39 |issue=6 |pages=1337–44 |year=1994 |pmid=8200268 |doi= |url=}}</ref>
*It was thought to be caused by cassava fruit but no longer associated with it and has no clear etiology.<ref name="pmid8200268">{{cite journal |vauthors=Sarles H, Augustine P, Laugier R, Mathew S, Dupuy P |title=Pancreatic lesions and modifications of pancreatic juice in tropical chronic pancreatitis (tropical calcific diabetes) |journal=Dig. Dis. Sci. |volume=39 |issue=6 |pages=1337–44 |year=1994 |pmid=8200268 |doi= |url=}}</ref>
*It usually affects children leading to early adulthood death due to endocrine and exocrine dysfunction.
*It usually affects children leading to early adulthood death due to [[endocrine]] and [[exocrine]] dysfunction.
*Serine protease inhibitor SPINK1 mutations are identified in some of the patients.<ref name="pmid12360463">{{cite journal |vauthors=Bhatia E, Choudhuri G, Sikora SS, Landt O, Kage A, Becker M, Witt H |title=Tropical calcific pancreatitis: strong association with SPINK1 trypsin inhibitor mutations |journal=Gastroenterology |volume=123 |issue=4 |pages=1020–5 |year=2002 |pmid=12360463 |doi= |url=}}</ref><ref name="pmid12360464">{{cite journal |vauthors=Schneider A, Suman A, Rossi L, Barmada MM, Beglinger C, Parvin S, Sattar S, Ali L, Khan AK, Gyr N, Whitcomb DC |title=SPINK1/PSTI mutations are associated with tropical pancreatitis and type II diabetes mellitus in Bangladesh |journal=Gastroenterology |volume=123 |issue=4 |pages=1026–30 |year=2002 |pmid=12360464 |doi= |url=}}</ref>
*[[Serine protease inhibitor]] SPINK1 [[mutations]] are identified in some of the patients.<ref name="pmid12360463">{{cite journal |vauthors=Bhatia E, Choudhuri G, Sikora SS, Landt O, Kage A, Becker M, Witt H |title=Tropical calcific pancreatitis: strong association with SPINK1 trypsin inhibitor mutations |journal=Gastroenterology |volume=123 |issue=4 |pages=1020–5 |year=2002 |pmid=12360463 |doi= |url=}}</ref><ref name="pmid12360464">{{cite journal |vauthors=Schneider A, Suman A, Rossi L, Barmada MM, Beglinger C, Parvin S, Sattar S, Ali L, Khan AK, Gyr N, Whitcomb DC |title=SPINK1/PSTI mutations are associated with tropical pancreatitis and type II diabetes mellitus in Bangladesh |journal=Gastroenterology |volume=123 |issue=4 |pages=1026–30 |year=2002 |pmid=12360464 |doi= |url=}}</ref>


==== Idiopathic pancreatitis: ====
==== Idiopathic pancreatitis: ====
*Idiopathic pancreatitis usually includes the non-alcohol induced cases of chronic pancreatitis
*[[Idiopathic pancreatitis]] usually includes the non-alcohol induced cases of chronic pancreatitis.
*Usually accounts for 30% of cases
*It usually accounts for 30% of cases of pancreatitis.
*It may be classified into early onset and late-onset forms.
*It can be divided into early onset and late-onset forms.
*Contributing factors may include:
*Contributing factors towards idiopathic pancreatitis may include:
**Concealed alcohol intake
**Concealed alcohol intake
**Hypersensitivity to alcohol
**[[Hypersensitivity]] to alcohol
**Unreported pancreatic trauma
**Unreported [[pancreatic trauma]]
**Mutations in the cationic trypsinogen gene and the cystic fibrosis gene
**[[Mutations]] in the cationic [[trypsinogen]] [[gene]] and the [[cystic fibrosis]] [[gene]]


==References==
==References==

Latest revision as of 17:58, 30 January 2018

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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

Chronic pancreatitis may be divided based upon underlying morphology into large-duct type or small-duct type with or without calcification. The classification systems that have been used for chronic pancreatitis include Marseille, Marseille-Rome system, Cambridge system, TIGAR-O system, ABC grading system and Manchester system.

Classification

Classification based upon morphology

Chronic pancreatitis may be divided based on underlying morphology into:

Classification system for chronic pancreatitis Year Key features
Clinical description 1946
  • Description of the clinical presentation of chronic pancreatitis and its association with increased alcohol consumption
Marseille 1963
  • Description of morphologic characteristics and etiological factors of the disease
  • No discussion of the correlation between anatomic and functional changes
  • No categorization according to disease severity or clinical presentation
  • No inclusion of pancreatic imaging findings
Marseille 1984
  • Further description and subclassification of morphological changes
  • “Obstructive chronic pancreatitis” listed as distinct form
  • No discussion of the correlation between anatomic and functional changes
  • No categorization according to disease severity or clinical presentation
  • No inclusion of pancreatic imaging findings
Marseille-Rome 1988
  • Description of “chronic calcifying” and “chronic inflammatory” pancreatitis as distinct forms
  • Description of etiological factors
  • No further elaboration of clinical, functional or imaging criteria
Cambridge 1984
Clinical stages 1994
  • Detailed subclassification of chronic pancreatitis with correlation of etiological factors with different morphological forms of the disease
  • Differentiation of clinical stages of the disease
  • Linkage of pancreatic imaging findings and functional testing with stages of the disease
Japan Pancreas Society 1997
  • Description of clinical presentation and classification of disease in “definite” and “probable” chronic pancreatitis according to imaging findings, functional testing, and histological examination
Zürich Workshop 1997
  • Description of clinical presentation and classification of disease in “definite” and “probable” chronic pancreatitis according to imaging findings, functional testing, and histological examination
TIGAR-O 2001
ABC grading system 2002
  • Disease grading according to clinical criteria, but limited separation of different disease severities
  • Not all clinical presentations can be categorized
Manchester system 2006
  • Disease grading according to clinical criteria, but limited separation of different disease severities
  • Not all clinical presentations can be categorized

Classification of pancreatitis based upon area of involvement and etiology

There are various forms of chronic pancreatitis based upon the area of involvement and etiology are as follows:

Groove pancreatitis:

Groove pancreatitis is a form of segmental pancreatitis that involves confinement of the inflammation process to the groove between the duodenum, common bile duct, and head of the pancreas without any involvement of the head of pancreas.[1]

Hereditary pancreatitis:

Autoimmune pancreatitis (AIP):

Tropical pancreatitis:

  • Tropical pancreatitis is one of the most common causes of chronic pancreatitis in tropical areas including south India.
  • It was thought to be caused by cassava fruit but no longer associated with it and has no clear etiology.[3]
  • It usually affects children leading to early adulthood death due to endocrine and exocrine dysfunction.
  • Serine protease inhibitor SPINK1 mutations are identified in some of the patients.[4][5]

Idiopathic pancreatitis:

References

  1. ↑ Tezuka K, Makino T, Hirai I, Kimura W (2010). "Groove pancreatitis". Dig Surg. 27 (2): 149–52. doi:10.1159/000289099. PMID 20551662.
  2. ↑ Sossenheimer MJ, Aston CE, Preston RA, Gates LK, Ulrich CD, Martin SP, Zhang Y, Gorry MC, Ehrlich GD, Whitcomb DC (1997). "Clinical characteristics of hereditary pancreatitis in a large family, based on high-risk haplotype. The Midwest Multicenter Pancreatic Study Group (MMPSG)". Am. J. Gastroenterol. 92 (7): 1113–6. PMID 9219780.
  3. ↑ Sarles H, Augustine P, Laugier R, Mathew S, Dupuy P (1994). "Pancreatic lesions and modifications of pancreatic juice in tropical chronic pancreatitis (tropical calcific diabetes)". Dig. Dis. Sci. 39 (6): 1337–44. PMID 8200268.
  4. ↑ Bhatia E, Choudhuri G, Sikora SS, Landt O, Kage A, Becker M, Witt H (2002). "Tropical calcific pancreatitis: strong association with SPINK1 trypsin inhibitor mutations". Gastroenterology. 123 (4): 1020–5. PMID 12360463.
  5. ↑ Schneider A, Suman A, Rossi L, Barmada MM, Beglinger C, Parvin S, Sattar S, Ali L, Khan AK, Gyr N, Whitcomb DC (2002). "SPINK1/PSTI mutations are associated with tropical pancreatitis and type II diabetes mellitus in Bangladesh". Gastroenterology. 123 (4): 1026–30. PMID 12360464.

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