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How to diagnose chronic pancreatitis

Chronic pancreatitis is best diagnosed with tests that can evaluate the structure of the pancreas via radiography (x-ray exams)—blood tests are generally not helpful for making the diagnosis of chronic pancreatitis. As with acute pancreatitis, a doctor will conduct a thorough medical history and physical examination. Physicians have a variety of diagnostic tests to choose from:

Transabdominal ultrasound

Sound waves are sent toward the pancreas via a handheld device that a technician glides over the abdomen. The sound waves bounce off the pancreas, gallbladder, liver, and other organs, and their echoes generate electrical impulses that create an image—called a sonogram—on a video monitor. If gallstones are causing inflammation, the sound waves will also bounce off of them, showing their location.

Endoscopic ultrasound

After spraying a solution to numb the patient’s throat, the doctor inserts an endoscope—a thin, flexible, lighted tube—down the throat, through the stomach, and into the small intestine. They then turn on an ultrasound attachment to the endoscope, which produces sound waves to create visual images of the pancreas and bile ducts. To read more about endoscopic ultrasounds, please click here.

Magnetic resonance cholangiopancreatography (MRCP)

MRCP uses magnetic resonance imaging (MRI), a noninvasive procedure that produces cross-section images of parts of the body. After being lightly sedated, the patient lies in a cylinder-like tube. The technician injects dye into the patient’s veins, which helps show the pancreas, gallbladder, and pancreatic and bile ducts.

Computerized tomography (CT)

A CT scan is a noninvasive radiograph (x-ray) that produces 3-dimensional images of parts of the body. The patient lies on a table that slides into a donut-shaped machine. The test can show gallstones and the extent of damage to the pancreas.

Occasionally, blood tests, such as a test for IgG4 to assess for autoimmune pancreatitis, can be used to help diagnose the cause of chronic pancreatitis. However, blood tests are not typically used to make the diagnosis of chronic pancreatitis.

Affiliation

  • 1 Department of Gastroenterology, Hepatology and Infectious Disease, Otto-von-Guericke University, Magdeburg, Germany.
  • PMID: 10829520
  • Search in PubMed
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Authors

Affiliation

  • 1 Department of Gastroenterology, Hepatology and Infectious Disease, Otto-von-Guericke University, Magdeburg, Germany.
  • PMID: 10829520

Abstract

Chronic pancreatitis is a dynamic disease characterized on one side by a progressive destruction of the pancreatic parenchyma and change in the architecture of the gland and on the other by the impairment of its function. Diagnosis of chronic pancreatitis may be a quite easy or a very difficult attempt according to the severity and evolutive stage of disease. In fact, while most patients presents with a typical history of alcohol abuse, recurrent abdominal pain and steatorrhea, in the late stage of disease it is not rare to see patients with symptoms and signs which may be not typical for pancreatitis. A large number of morphological and functional methods has been developed to allow an easy and early diagnosis of disease. However, while in the advanced stages of disease, where pancreatic insufficiency, calcifications, or pseudocysts are present, diagnosis is easy and most of the procedures show high sensitivity and specificity, in the early disease the degree of pancreatic dysfunction and structural change are too small to be detected by current methods. The present article aims to evaluate the different morphological and functional methods with their advantages and shortcomings, as well as to establish their role in the diagnostic assessment of chronic pancreatitis.

Affiliation

  • 1 University of Texas Health Science Center at Houston, Houston, TX, USA.
  • PMID: 29671537

Free article

  • Search in PubMed
  • Search in NLM Catalog
  • Add to Search

Author

Affiliation

  • 1 University of Texas Health Science Center at Houston, Houston, TX, USA.
  • PMID: 29671537

Abstract

Chronic pancreatitis is an irreversible and progressive disorder of the pancreas characterized by inflammation, fibrosis, and scarring. Exocrine and endocrine functions are lost, often leading to chronic pain. The etiology is multifactorial, although alcoholism is the most significant risk factor in adults. The average age at diagnosis is 35 to 55 years. If chronic pancreatitis is suspected, contrast-enhanced computed tomography is the best imaging modality for diagnosis. Computed tomography may be inconclusive in early stages of the disease, so other modalities such as magnetic resonance imaging, magnetic resonance cholangiopancreatography, or endoscopic ultrasonography with or without biopsy may be used. Recommended lifestyle modifications include cessation of alcohol and tobacco use and eating small, frequent, low-fat meals. Although narcotics and antidepressants provide the most pain relief, one-half of patients eventually require surgery. Therapeutic endoscopy is indicated to treat symptomatic strictures, stones, and pseudocysts. Decompressive surgical procedures, such as lateral pancreaticojejunostomy, are indicated for large duct disease (pancreatic ductal dilation of 7 mm or more). Resection procedures, such as the Whipple procedure, are indicated for small duct disease or pancreatic head enlargement. The risk of pancreatic cancer is increased in patients with chronic pancreatitis, especially hereditary pancreatitis. Although it is not known if screening improves outcomes, clinicians should counsel patients on this increased risk and evaluate patients with weight loss or jaundice for neoplasm.

Inflammation of the pancreas is called pancreatitis. But in order to reliably establish a diagnosis, differential diagnosis should be performed. Pancreatitis can be acute or chronic. It is important to know its characteristic signs, in order to distinguish it from other gastrointestinal diseases.

Similar diseases

– peptic ulcer (perforated ulcers);

Determine which particular problem is caused by those or other symptoms, you can, as a rule, only in the hospital. Doctors should know the characteristics of all diseases in order to establish the diagnosis accurately.

Differential diagnostics

Distinguish from perforated ulcer pancreatitis can be on the behavior of the patient. In the first case, he will try to take one position and not move. With pancreatitis, patients are restless. In addition to pain, they experience vomiting.

To understand what exactly bothers a person, you can use ultrasound. This study makes it possible to diagnose cholecystitis. With this disease, patients complain of pain on the right side, which passes into the appropriate shoulder. On ultrasound with cholecystitis seen inflammatory process.

Intestinal obstruction is manifested in the same way as pancreatitis. You can distinguish these diseases by blood tests. For this purpose, the diagnosis of pancreatitis is carried out. Analyzes will show diastases and an elevated level of chlorides in inflammation of the pancreas.

Classification of pancreatitis

To understand how inflammation of the pancreas manifests itself, it must be understood that it can be acute or chronic. In the first case, the symptoms are pronounced, the doctor can easily understand that the patient has acute pancreatitis. Diagnosis is mandatory, and only after confirmation of the assumptions of the doctor (with the help of ultrasound and analysis) is prescribed treatment.

Chronic pancreatitis is characterized by alternating periods of slight improvement / deterioration. Thus the inflammatory process goes sluggishly. But it leads to atrophy of the gland tissues.

Characteristics of acute inflammation

In the severe form of acute inflammatory process in the pancreas, pronounced disorders in various organs and tissues are observed. In addition, severe form can be accompanied by such complications:

  • Pancreatic abscess (in pancreas or surrounding tissues pus accumulates);
  • Acute spurious cyst – occurs 4 or more weeks after an attack of pancreatitis, characterized by the accumulation of pancreatic juice ;
  • Pancreatic necrosis (possibly also infection of tissues);
  • Acute fluid accumulation in the pancreatic space or in the gland itself.

This should be taken into account when the diagnosis is carried out. Pancreatitis, in which necrosis of tissues began , can lead to death. This happens, as a rule, with the development of a purulent form of the disease.

Chronic forms of inflammation

With this disease, inflammation can then decrease, then begin to develop with renewed vigor. But it’s not as harmless as it might seem at first glance. A competent diagnosis of chronic pancreatitis is necessary, because with it tissue atrophy can begin, the pancreas eventually calcifies, its normal tissues are replaced by scars.

Symptoms of acute pancreatitis

To understand, when it is necessary to address to the doctor, it is possible, if to know signs of the beginning of the active inflammatory process. These include a pronounced pain symptom. Most patients indicate the epigastric region (left hypochondrium). Pain surrounding, she can give to the area of the left scapula. In the supine position on the back, it only intensifies. Deterioration is observed after taking alcohol, fatty, fried or spicy food.

In addition to pain, there are other signs that suggest that acute pancreatitis has started. Diagnosis and treatment should be carried out in a hospital hospital. This will make it possible to establish the diagnosis as precisely as possible and to shorten the time necessary for restoring health. Symptoms of this disease are:

– vomiting, which does not bring relief (can be indomitable);

– Moderate icterus sclera, in some patients the skin may appear yellowish;

– hemorrhages in the navel, cyanotic stains on the body;

Also, the disorder is indicated by a violation of the stool, the appearance of excessive fatigue, a decrease in pressure, pallor of the skin and increased sweating. Patients often complain of dry mouth, while seeing a white coating on the tongue.

Signs of chronic inflammation

The development of chronic pancreatitis is evidenced by:

– Periodic pain localized in the left hypochondrium, they often give back to the area of the back;

– a periodic feeling of nausea;

– diarrhea, which produces a characteristic odor;

– a sharp weight loss;

– deterioration of health after consumption of fatty, fried, smoked food.

If pancreatitis is not treated, then the patient has weakness, dizziness. Some can even develop type 2 diabetes, memory impairment becomes noticeable, breathing problems appear.

Methods of laboratory diagnostics

With inflammation of the pancreas, the level of alpha-amylase, lipase increases, the activity of the C-reactive protein sharply increases. If the disease is accompanied by a malfunction in the kidneys, then the blood level of urea increases. Simultaneously, one can see a decrease in the number of proteins, including albumin. Also significantly decreases the amount of insulin, because of which the glucose level begins to increase.

Water and electrolytic analysis allows you to determine how much the composition of the blood has changed. Reducing the level of fluid can lead to blood clots and clogging of small vessels. Also this analysis allows to determine the concentration of minerals: potassium, sodium, calcium. They are responsible for the normal functioning of the heart and blood vessels.

A general blood test gives an idea of the nature of the disease. Pay attention to the level of leukocytes and erythrocytes. Without this survey, a full diagnosis can not be carried out.

Pancreatitis is also established by the analysis of urine. In this disease, the level of alpha-amylase deviates significantly from the norm. But this is observed only at the initial stages of the disease. With the progression of pancreatitis in the urine can detect red blood cells, white blood cells and other components.

Instrumental diagnostics

Methods for diagnosing pancreatitis are quite diverse. In addition to researching biological fluids, the doctor needs to see how the pancreas has changed. It is also necessary to establish whether its inflammation affected the surrounding organs and tissues.

Laparoscopy allows you to simultaneously diagnose and treat pancreatitis. In some cases during this mini-operation it is possible to minimize the negative effect of inflammation on other organs. But laparoscopy is used only in extremely difficult cases.

With the help of computed tomography, diagnostics can also be performed. Pancreatitis can be established by characteristic signs: the increased size of the pancreas, the presence of inflammatory processes and dead tissue.

Endoscopy allows you to see all the changes in the pancreas and in the duodenum. To do this, the endoscope with the chamber mounted on it is inserted into the esophagus.

Duke one of few centers to offer endoscopic pancreatic function testing

How to diagnose chronic pancreatitis

Chronic pancreatitis can mimic peptic ulcer disease, gastritis, and other gastrointestinal conditions, making it difficult to diagnose. However, an endoscopic pancreatic function test that Duke is one of only a few medical centers in the country to offer can help to better identify the indolent inflammatory condition.

Darshan Kothari, MD, a gastroenterologist who specializes in pancreatic disorders, says patients often suffer from either recurrent or persistent abdominal pain without a clear diagnosis. “It’s common for patients to initially be given the wrong diagnosis or a catch-all diagnosis, such as functional abdominal pain. Conversely, patients can also be given an incorrect diagnosis of chronic pancreatitis when in fact they do not have it,” he explains.

Typically, the inflammatory condition is diagnosed when patients present with abdominal pain and have some form of imaging. However, even after a CT scan, MRI, and endoscopic ultrasound, the findings may not confirm a diagnosis.

How the test works

The most sensitive test for the diagnosis of chronic pancreatitis is the secretin pancreatic function test. Traditionally, patients undergo an upper endoscopy in which a tube is placed into the duodenum. After receiving an intravenous form of the hormone secretin, patients recover for an hour with a tube in their mouth. During this hour, the fluid secreted from the pancreas into the small intestine is aspirated and analyzed to determine what concentration of bicarbonate the pancreas is producing. Kothari explains that if the peak bicarbonate is below the 80 mEq threshold, it indicates a diagnosis of chronic pancreatitis; importantly, though, a normal test has a 97% negative predicted value, virtually ruling out chronic pancreatitis.

“While many centers choose to use endoscopic ultrasound as a means of diagnosing chronic pancreatitis, the benefit we provide our patients at Duke is that even for those patients in whom those findings are indeterminate but the suspicion remains high, this pancreatic function testing provides those patients some comfort to confirm or rule out a diagnosis based on their symptoms,” Kothari says.

Why the test is important

“Patients come to Duke wanting to know a diagnosis, and with this test, we’re able to give them a relatively dichotomized answer,” Kothari says. For the 15 in 100,000 people who develop chronic pancreatitis, “It’s important to have a diagnosis because it helps patients deal with this disease in a more positive way,” he adds. “It’s also important because we are able to administer therapy that they may not otherwise have received without this diagnosis due to insurance coverage.”

Kothari adds that while treatment for a patient’s symptoms may not differ based on the results of an endoscopic ultrasound versus the endoscopic pancreatic function testing, “it helps us properly advise our patients on what to do next. There is a real risk—albeit small—for pancreatic cancer in patients who have chronic pancreatitis, and we have to keep an eye on that risk for these patients.”

It is a paradox when the failure of the pancreas has medical term-chronic pancreatitis. You may open any textbook for doctors or medical articles and read symptoms of chronic pancreatitis.

  • Pain in the upper abdomen
  • Chronic Diarrhea
  • Fatty, oily stools, which are loose, pale, and do not flush away easily
  • Nausea and vomiting
  • Excessive thirst and fatigue
  • Weight loss
  • Clay-colored or pale stools

These symptoms demonstrate complete shutdown of the pancreas.

Let us explain. All chronic diseases have three stages: functional, structural and the final stage; failure of the organ. Pancreas is a core of the digestion. Without good quality and a proper amount of the pancreatic digestive enzymes (amylase, protease, lipase) human being cannot digest carbohydrates, proteins, and fats. The weak function of the pancreas and bile leads to the myriad of the digestive symptoms and malfunction of the nervous, immune, cardiovascular, pulmonary and hormonal systems. A person can follow the healthiest diet in the world, without pancreatic enzymes they will starve and have many health problems.

The staff of the Biotherapy Clinic, Peter Melamed, Ph.D. and Felix Melamed, MS offer Biotherapy Functional Clinical Classification of Exocrine Pancreatic Disorders subdivides all digestive disorders and diseases into three groups.

  1. Acidic pancreas and bile- fictional stage
  2. Pancreatic deficiency-structural stage
  3. Pancreatic failure

We describe it in detail in the part I of our EBook “Healthy Pancreas, Healthy You.”

And in the Short Review of Our Work – “Chronic Metabolic Acidosis Destroys Pancreas” with Focus on the Functional Exocrine Pancreatic Disorders that published in the European magazine “Journal of the Pancreas”

You may ask why has the functional stage been called as the acidic pancreas and bile? Because acidity is a primary culprit for pancreas and bile disorders. Acidity kills the pancreas.

Sorry to say, conventional medicine does not focus on the functional stage because there are not the general lab and imaging tests, and pharmaceutical treatment for this stage. When the healthy alkaline bile and the pancreatic juice are getting acidic, it disrupts the normal processes of digestion, causing numerous symptoms. It includes gas, bloating, heartburn, belching, abdominal pain, nausea, food intolerance, diarrhea, or constipation, flatulence, weight gain, and more. People can suffer from a hidden pancreatic deficiency and do not even know that a deficiency of the pancreatic digestive enzymes can also increase inflammation, body’s pain, and a lack of energy, hindering the body’s ability to heal the wounds and traumas.

A crowd of patients with these symptoms fills up the doctors’ offices, get symptomatic therapy, have useless tests, medications, and surgeries. Some of them receive psych label and are treated accordingly.

  • Correction of the acid-alkaline balance
  • Improving the quality and quality of the bile and pancreatic juice
  • Avoiding harmful for pancreas substances.’
  • Improvement of the balance of the beneficial intestinal bacteria
  • Replacement of the essential nutrients
  • Acceptance of the proper eating habits
  • Reducing abdominal pain without medications
  • Withdrawal from the alcohol and painkillers

Without these actions, functional stage proceeds to the next step-structural changes in the pancreas, gallbladder, sphincter of Oddi, stomach, and small and large intestines. It is accompanied by a more reduction of pancreatic function and biliary problems. The digestive symptoms are getting worse; some lab and imaging tests may show pancreatic and biliary system structural damages. Now it is a clinical picture of chronic pancreatitis with the pancreatic deficiency. In the pancreatic deficiency-structural stage, health and destiny of the sick person also depend upon the healing actions, which are described above.

Unfortunately, the progression of the disease deteriorates the exocrine pancreatic function causing many vicious circles. However, when a functional capacity of the pancreas depletes to 10%, the pancreatic failure occurs with steatorrhea (indigestion of fats), and malabsorption syndrome, resulting in a total crush of the digestive system and consequently of the whole human organism.

The low pancreatic function is more common than formerly believed both in diabetic and nondiabetic individuals. For instance, autopsy studies indicate pancreatic involvement in 13% of a “normal” population. Some clinical studies find the relation between functional digestive diseases and low pancreatic function. In almost all chronic diseases of the gastrointestinal tract, an exocrine pancreatic function is diminished.

In the Biotherapy Clinic, we developed the healing program for any stages of chronic pancreatitis and customized it for the situation and the person’s needs.

To obtain the benefits from the Biotherapy Clinic from healing chronic Pancreatitis, one can select from the following options:

  • Telephone consultation (415) 409-3939 or (650) 365-3640
  • Office consultation