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Chronic pancreatitis occurs most often in patients with alcoholism, hereditary pancreatitis, severe malnutrition or untreated hyperparathyroidism, or it may be idiopathic. Progressive fibrosis and destruction of functioning glandular tissue occur as a result. Pancreaticolithiasis and obstruction of the duodenal end of the pancreatic duct are often present. (Acute pancreatitis recurring after cholecystectomy for cholelithiasis should raise the suspicion of a retained or newly developed common duct stone.)

Differentiation of chronic from recurrent pancreatitis is important in that recurrent pancreatitis is initiated by a specific event (e.g. alcoholic binge, passage of a stone), whereas chronic pancreatitis is a self-perpetuating disease characterized by pain and ultimately by pancreatic exocrine or endocrine insufficiency.

Clinical findings

Symptoms and signs

Persistent or recurrent episodes of epigastric and left upper quadrant pain with referral to the upper left lumbar region are typical. Anorexia, nausea, vomiting, constipation, flatulence, and weight loss are common. Abdominal signs during attacks consist chiefly of tenderness over the pancreas, mild muscle guarding, and paralytic ileus. Attacks may last only a few hours or as long as 2 weeks; pain may eventually be almost continuous. Steatorrhea (as indicated by bulky, foul, fatty stools) may occur late in the course.

Laboratory findings

Serum amylase and lipase may be elevated during acute attacks; normal amylase does not exclude the diagnosis, however. Serum alkaline phosphatase and bilirubin may be elevated owing to compression of the common duct. Glycosuria may be present. Excess fecal fat may be demonstrated on chemical analysis of the stool; pancreatic insufficiency may be confirmed by response to therapy with pancreatic enzyme supplements or by a bentiromide (NBT-PABA) test or secretin stimulation test.