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{{Chronic-pancreatitis}}
{{Chronic pancreatitis}}
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==Overview==
The diagnosis of chronic pancreatitis is typically based on tests on [[pancreatic]] structure and function. Serum [[amylase]] and [[lipase]] are usually normal but may be slightly elevated. Serum [[calcium]] and [[triglyceride]] levels may be elevated in [[hypertriglyceridemia]] induced pancreatitis. A [[secretin]] stimulation test is considered the gold standard functional test for diagnosis of chronic pancreatitis. Fecal tests may include sudan staining of feces, 72-hour quantitative fecal fat (Gold standard), and faecal elastase measurement (test of choice).


==Laboratory Findings==
==Laboratory Findings==
* The diagnosis of chronic pancreatitis is typically based on tests on pancreatic structure and function, as direct biopsy of the pancreas is considered excessively risky.
* Serum [[amylase]] and [[lipase]] are usually normal but may be slightly elevated (neither diagnostic nor prognostic).
* Serum bilirubin and alkaline phosphatase levels may be elevated in case of intra-pancreatic biliary duct obstruction.
* Serum calcium and triglyceride levels may be elevated in hypertriglyceridemia induced pancreatitis.
* The following lab tests are usually normal:
** CBC
** LFTs
** Electrolytes


The diagnosis of chronic pancreatitis is typically based on tests on pancreatic structure and function, as direct biopsy of the pancreas is considered excessively risky.
* A [[secretin]] stimulation test is considered the gold standard functional test for diagnosis of chronic pancreatitis. The observation that bi-carbonate production is impaired early in chronic pancreatitis has led to the rationale of use of this test in early stages of disease ([[sensitivity]] of 95%).
* Autoimmune pancreatitis can be diagnosed with elevated levels of:<ref name="pmid17555461">{{cite journal |vauthors=Ghazale A, Chari ST, Smyrk TC, Levy MJ, Topazian MD, Takahashi N, Clain JE, Pearson RK, Pelaez-Luna M, Petersen BT, Vege SS, Farnell MB |title=Value of serum IgG4 in the diagnosis of autoimmune pancreatitis and in distinguishing it from pancreatic cancer |journal=Am. J. Gastroenterol. |volume=102 |issue=8 |pages=1646–53 |year=2007 |pmid=17555461 |doi=10.1111/j.1572-0241.2007.01264.x |url=}}</ref><ref name="pmid11236777">{{cite journal |vauthors=Hamano H, Kawa S, Horiuchi A, Unno H, Furuya N, Akamatsu T, Fukushima M, Nikaido T, Nakayama K, Usuda N, Kiyosawa K |title=High serum IgG4 concentrations in patients with sclerosing pancreatitis |journal=N. Engl. J. Med. |volume=344 |issue=10 |pages=732–8 |year=2001 |pmid=11236777 |doi=10.1056/NEJM200103083441005 |url=}}</ref><ref name="pmid18181673">{{cite journal |vauthors=Raina A, Krasinskas AM, Greer JB, Lamb J, Fink E, Moser AJ, Zeh HJ, Slivka A, Whitcomb DC |title=Serum immunoglobulin G fraction 4 levels in pancreatic cancer: elevations not associated with autoimmune pancreatitis |journal=Arch. Pathol. Lab. Med. |volume=132 |issue=1 |pages=48–53 |year=2008 |pmid=18181673 |doi=10.1043/1543-2165(2008)132[48:SIGFLI]2.0.CO;2 |url=}}</ref>
** [[ESR]]
** IgG4
** [[Rheumatoid factor]]
** [[Anti-nuclear antibody|ANA]]
** Antismooth muscle antibody


Serum [[amylase]] and [[lipase]] may well not be elevated in cases of advanced chronic pancreatitis, but are often used as markers for detecting pancreatic inflammation in acute pancreatitis.
==== Fecal tests: ====


A [[secretin]] stimulation test is considered the gold standard functional test for diagnosis of chronic pancreatitis. The observation that bi-carbonate production is impaired early in chronic pancreatitis has led to the rationale of use of this test in early stages of disease ([[sensitivity]] of 95%).
===== (a) Sudan staining of feces: =====
* A non-specific, qualitative test that is no longer used for the diagnosis of steatorrhea


Other common tests used to determine chronic pancreatitis are faecal elastase measurement in stool, serum trypsinogen.
===== (b) 72-hour quantitative fecal fat (Gold standard): =====
* A quantitaive test that determines fecal fat excretion for over 24hrs.
* Fecal fat excretion of >7g/day is diagnostic of malabsorption.
* Patients with steatorrhea usually have an excretion of >10g of fat per day.


There are other non-specific laboratory studies useful in diagnosis of chronic pancreatitis. Serum bilirubin and alkaline phosphatase can be elevated, indicating stricturing  of the common bile duct due to edema, fibrosis or cancer.  When the chronic pancreatitis is due to an autoimmune process, elevations in [[ESR]], IgG4, [[rheumatoid factor]], [[Anti-nuclear antibody|ANA]] and antismooth muscle antibody may be seen.
===== (c) Faecal elastase measurement (Test of choice): =====
*The most sensitive and specific test for pancreatic exocrine dysfunction.
*It can be done with a single random stool sample.
*The results are independent of pancreatic enzyme replacement therapy.
*A value of less than 200 ug/g indicates pancreatic insufficiency.<ref name="UpTo">{{cite web |author=Freedman SD |url=http://www.uptodate.com/patients/content/topic.do?topicKey=~EzkfCtNwumVrg |title=Clinical manifestations and diagnosis of chronic pancreatitis in adults |format= |work=UpToDate  |accessdate=}}</ref><ref name="pmid15285176">{{cite journal |vauthors=Keim V, Teich N, Moessner J |title=Clinical value of a new fecal elastase test for detection of chronic pancreatitis |journal=Clin. Lab. |volume=49 |issue=5-6 |pages=209–15 |year=2003 |pmid=15285176 |doi= |url=}}</ref><ref name="pmid12093988">{{cite journal |vauthors=Walkowiak J, Herzig KH, Strzykala K, Przyslawski J, Krawczynski M |title=Fecal elastase-1 is superior to fecal chymotrypsin in the assessment of pancreatic involvement in cystic fibrosis |journal=Pediatrics |volume=110 |issue=1 Pt 1 |pages=e7 |year=2002 |pmid=12093988 |doi= |url=}}</ref><ref name="pmid15343184">{{cite journal |vauthors=Borowitz D, Baker SS, Duffy L, Baker RD, Fitzpatrick L, Gyamfi J, Jarembek K |title=Use of fecal elastase-1 to classify pancreatic status in patients with cystic fibrosis |journal=J. Pediatr. |volume=145 |issue=3 |pages=322–6 |year=2004 |pmid=15343184 |doi=10.1016/j.jpeds.2004.04.049 |url=}}</ref>
=== Pancreatic function tests: ===


The common symptom of chronic pancreatits, [[steatorrhea]], can be diagnosed by two different studies: Sudan staining of feces or fecal fat excretion over 24hr on a 100g fat diet.
===== (a) Direct/ Invasive tests: =====
* Direct tests are used to assess pancreatic insufficiency in the early course of disease when patient has clinical symptoms but no radiology findings.
* Direct tests involve pancreatic stimulation via meal or hormonal secretagogues and assessment of pancreatic secretions in the duodenal fluid.
* Direct tests along with radiographic findings (pancreatic calcifications) are stll considered to be the gold standard for the diagnosis of chronic pancreatitis.<ref name="pmid11276375">{{cite journal |vauthors=Boeck WG, Adler G, Gress TM |title=Pancreatic function tests: when to choose, what to use |journal=Curr Gastroenterol Rep |volume=3 |issue=2 |pages=95–100 |year=2001 |pmid=11276375 |doi= |url=}}</ref><ref name="pmid12641496">{{cite journal |vauthors=Chowdhury RS, Forsmark CE |title=Review article: Pancreatic function testing |journal=Aliment. Pharmacol. Ther. |volume=17 |issue=6 |pages=733–50 |year=2003 |pmid=12641496 |doi= |url=}}</ref><ref name="pmid15508057">{{cite journal |vauthors=Siegmund E, Löhr JM, Schuff-Werner P |title=[The diagnostic validity of non-invasive pancreatic function tests--a meta-analysis] |language=German |journal=Z Gastroenterol |volume=42 |issue=10 |pages=1117–28 |year=2004 |pmid=15508057 |doi=10.1055/s-2004-813604 |url=}}</ref><ref name="pmid16633964">{{cite journal |vauthors=Ammann RW |title=Diagnosis and management of chronic pancreatitis: current knowledge |journal=Swiss Med Wkly |volume=136 |issue=11-12 |pages=166–74 |year=2006 |pmid=16633964 |doi=2006/11/smw-11182 |url=}}</ref>
* The limitation of direct tests is that they are costly and cumbersome.<ref name="pmid11276375">{{cite journal |vauthors=Boeck WG, Adler G, Gress TM |title=Pancreatic function tests: when to choose, what to use |journal=Curr Gastroenterol Rep |volume=3 |issue=2 |pages=95–100 |year=2001 |pmid=11276375 |doi= |url=}}</ref><ref name="pmid12641496">{{cite journal |vauthors=Chowdhury RS, Forsmark CE |title=Review article: Pancreatic function testing |journal=Aliment. Pharmacol. Ther. |volume=17 |issue=6 |pages=733–50 |year=2003 |pmid=12641496 |doi= |url=}}</ref><ref name="pmid15508057">{{cite journal |vauthors=Siegmund E, Löhr JM, Schuff-Werner P |title=[The diagnostic validity of non-invasive pancreatic function tests--a meta-analysis] |language=German |journal=Z Gastroenterol |volume=42 |issue=10 |pages=1117–28 |year=2004 |pmid=15508057 |doi=10.1055/s-2004-813604 |url=}}</ref><ref name="pmid16633964">{{cite journal |vauthors=Ammann RW |title=Diagnosis and management of chronic pancreatitis: current knowledge |journal=Swiss Med Wkly |volume=136 |issue=11-12 |pages=166–74 |year=2006 |pmid=16633964 |doi=2006/11/smw-11182 |url=}}</ref>
* Direct tests include:
** [[Secretin]] stimulation test
** Pancreozymin-secretin test
*[[Secretin]] stimulation test is considered the gold standard functional test for diagnosis of chronic pancreatitis.
**The observation that bi-carbonate production is impaired early in chronic pancreatitis has led to the rationale of use of this test in early stages of disease.
***Sensitivity - 82%<ref name="pmid23711627">{{cite journal |vauthors=Ketwaroo G, Brown A, Young B, Kheraj R, Sawhney M, Mortele KJ, Najarian R, Tewani S, Dasilva D, Freedman S, Sheth S |title=Defining the accuracy of secretin pancreatic function testing in patients with suspected early chronic pancreatitis |journal=Am. J. Gastroenterol. |volume=108 |issue=8 |pages=1360–6 |year=2013 |pmid=23711627 |pmc=5388854 |doi=10.1038/ajg.2013.148 |url=}}</ref>
***Specificity- 86%<ref name="pmid23711627">{{cite journal |vauthors=Ketwaroo G, Brown A, Young B, Kheraj R, Sawhney M, Mortele KJ, Najarian R, Tewani S, Dasilva D, Freedman S, Sheth S |title=Defining the accuracy of secretin pancreatic function testing in patients with suspected early chronic pancreatitis |journal=Am. J. Gastroenterol. |volume=108 |issue=8 |pages=1360–6 |year=2013 |pmid=23711627 |pmc=5388854 |doi=10.1038/ajg.2013.148 |url=}}</ref>


To check for pancreatic exocrine dysfunction, the most sensitive and specific test is the measurement of fecal elastase, which can be done with a single stool sample, and a value of less than 200 ug/g indicates pancreatic insufficiency.<ref name=UpTo>{{cite web |author=Freedman SD |url=http://www.uptodate.com/patients/content/topic.do?topicKey=~EzkfCtNwumVrg |title=Clinical manifestations and diagnosis of chronic pancreatitis in adults |format= |work=UpToDate  |accessdate=}}</ref>[[abdominal pain]].
===== (b) Indirect/ Non-invasive tests: =====
* Indirect tests are used to assess the complications of chronic pancreatitis.
* Indirect tests include:
** Faecal chymotrypsin, PABA-, pancreolauryl-
** Faecal elastase test
* Indirect tests are not sensitive to assess pancreatic insufficiency in the early course of disease.<ref name="pmid16633964">{{cite journal |vauthors=Ammann RW |title=Diagnosis and management of chronic pancreatitis: current knowledge |journal=Swiss Med Wkly |volume=136 |issue=11-12 |pages=166–74 |year=2006 |pmid=16633964 |doi=2006/11/smw-11182 |url=}}</ref><ref name="pmid11179244">{{cite journal |vauthors=Etemad B, Whitcomb DC |title=Chronic pancreatitis: diagnosis, classification, and new genetic developments |journal=Gastroenterology |volume=120 |issue=3 |pages=682–707 |year=2001 |pmid=11179244 |doi= |url=}}</ref>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


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Latest revision as of 13:20, 8 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

The diagnosis of chronic pancreatitis is typically based on tests on pancreatic structure and function. Serum amylase and lipase are usually normal but may be slightly elevated. Serum calcium and triglyceride levels may be elevated in hypertriglyceridemia induced pancreatitis. A secretin stimulation test is considered the gold standard functional test for diagnosis of chronic pancreatitis. Fecal tests may include sudan staining of feces, 72-hour quantitative fecal fat (Gold standard), and faecal elastase measurement (test of choice).

Laboratory Findings

  • The diagnosis of chronic pancreatitis is typically based on tests on pancreatic structure and function, as direct biopsy of the pancreas is considered excessively risky.
  • Serum amylase and lipase are usually normal but may be slightly elevated (neither diagnostic nor prognostic).
  • Serum bilirubin and alkaline phosphatase levels may be elevated in case of intra-pancreatic biliary duct obstruction.
  • Serum calcium and triglyceride levels may be elevated in hypertriglyceridemia induced pancreatitis.
  • The following lab tests are usually normal:
    • CBC
    • LFTs
    • Electrolytes
  • A secretin stimulation test is considered the gold standard functional test for diagnosis of chronic pancreatitis. The observation that bi-carbonate production is impaired early in chronic pancreatitis has led to the rationale of use of this test in early stages of disease (sensitivity of 95%).
  • Autoimmune pancreatitis can be diagnosed with elevated levels of:[1][2][3]

Fecal tests:

(a) Sudan staining of feces:
  • A non-specific, qualitative test that is no longer used for the diagnosis of steatorrhea
(b) 72-hour quantitative fecal fat (Gold standard):
  • A quantitaive test that determines fecal fat excretion for over 24hrs.
  • Fecal fat excretion of >7g/day is diagnostic of malabsorption.
  • Patients with steatorrhea usually have an excretion of >10g of fat per day.
(c) Faecal elastase measurement (Test of choice):
  • The most sensitive and specific test for pancreatic exocrine dysfunction.
  • It can be done with a single random stool sample.
  • The results are independent of pancreatic enzyme replacement therapy.
  • A value of less than 200 ug/g indicates pancreatic insufficiency.[4][5][6][7]

Pancreatic function tests:

(a) Direct/ Invasive tests:
  • Direct tests are used to assess pancreatic insufficiency in the early course of disease when patient has clinical symptoms but no radiology findings.
  • Direct tests involve pancreatic stimulation via meal or hormonal secretagogues and assessment of pancreatic secretions in the duodenal fluid.
  • Direct tests along with radiographic findings (pancreatic calcifications) are stll considered to be the gold standard for the diagnosis of chronic pancreatitis.[8][9][10][11]
  • The limitation of direct tests is that they are costly and cumbersome.[8][9][10][11]
  • Direct tests include:
    • Secretin stimulation test
    • Pancreozymin-secretin test
  • Secretin stimulation test is considered the gold standard functional test for diagnosis of chronic pancreatitis.
    • The observation that bi-carbonate production is impaired early in chronic pancreatitis has led to the rationale of use of this test in early stages of disease.
      • Sensitivity - 82%[12]
      • Specificity- 86%[12]
(b) Indirect/ Non-invasive tests:
  • Indirect tests are used to assess the complications of chronic pancreatitis.
  • Indirect tests include:
    • Faecal chymotrypsin, PABA-, pancreolauryl-
    • Faecal elastase test
  • Indirect tests are not sensitive to assess pancreatic insufficiency in the early course of disease.[11][13]

References

  1. ↑ Ghazale A, Chari ST, Smyrk TC, Levy MJ, Topazian MD, Takahashi N, Clain JE, Pearson RK, Pelaez-Luna M, Petersen BT, Vege SS, Farnell MB (2007). "Value of serum IgG4 in the diagnosis of autoimmune pancreatitis and in distinguishing it from pancreatic cancer". Am. J. Gastroenterol. 102 (8): 1646–53. doi:10.1111/j.1572-0241.2007.01264.x. PMID 17555461.
  2. ↑ Hamano H, Kawa S, Horiuchi A, Unno H, Furuya N, Akamatsu T, Fukushima M, Nikaido T, Nakayama K, Usuda N, Kiyosawa K (2001). "High serum IgG4 concentrations in patients with sclerosing pancreatitis". N. Engl. J. Med. 344 (10): 732–8. doi:10.1056/NEJM200103083441005. PMID 11236777.
  3. ↑ Raina A, Krasinskas AM, Greer JB, Lamb J, Fink E, Moser AJ, Zeh HJ, Slivka A, Whitcomb DC (2008). "Serum immunoglobulin G fraction 4 levels in pancreatic cancer: elevations not associated with autoimmune pancreatitis". Arch. Pathol. Lab. Med. 132 (1): 48–53. doi:10.1043/1543-2165(2008)132[48:SIGFLI]2.0.CO;2. PMID 18181673.
  4. ↑ Freedman SD. "Clinical manifestations and diagnosis of chronic pancreatitis in adults". UpToDate.
  5. ↑ Keim V, Teich N, Moessner J (2003). "Clinical value of a new fecal elastase test for detection of chronic pancreatitis". Clin. Lab. 49 (5–6): 209–15. PMID 15285176.
  6. ↑ Walkowiak J, Herzig KH, Strzykala K, Przyslawski J, Krawczynski M (2002). "Fecal elastase-1 is superior to fecal chymotrypsin in the assessment of pancreatic involvement in cystic fibrosis". Pediatrics. 110 (1 Pt 1): e7. PMID 12093988.
  7. ↑ Borowitz D, Baker SS, Duffy L, Baker RD, Fitzpatrick L, Gyamfi J, Jarembek K (2004). "Use of fecal elastase-1 to classify pancreatic status in patients with cystic fibrosis". J. Pediatr. 145 (3): 322–6. doi:10.1016/j.jpeds.2004.04.049. PMID 15343184.
  8. ↑ 8.0 8.1 Boeck WG, Adler G, Gress TM (2001). "Pancreatic function tests: when to choose, what to use". Curr Gastroenterol Rep. 3 (2): 95–100. PMID 11276375.
  9. ↑ 9.0 9.1 Chowdhury RS, Forsmark CE (2003). "Review article: Pancreatic function testing". Aliment. Pharmacol. Ther. 17 (6): 733–50. PMID 12641496.
  10. ↑ 10.0 10.1 Siegmund E, Löhr JM, Schuff-Werner P (2004). "[The diagnostic validity of non-invasive pancreatic function tests--a meta-analysis]". Z Gastroenterol (in German). 42 (10): 1117–28. doi:10.1055/s-2004-813604. PMID 15508057.
  11. ↑ 11.0 11.1 11.2 Ammann RW (2006). "Diagnosis and management of chronic pancreatitis: current knowledge". Swiss Med Wkly. 136 (11–12): 166–74. doi:2006/11/smw-11182 Check |doi= value (help). PMID 16633964.
  12. ↑ 12.0 12.1 Ketwaroo G, Brown A, Young B, Kheraj R, Sawhney M, Mortele KJ, Najarian R, Tewani S, Dasilva D, Freedman S, Sheth S (2013). "Defining the accuracy of secretin pancreatic function testing in patients with suspected early chronic pancreatitis". Am. J. Gastroenterol. 108 (8): 1360–6. doi:10.1038/ajg.2013.148. PMC 5388854. PMID 23711627.
  13. ↑ Etemad B, Whitcomb DC (2001). "Chronic pancreatitis: diagnosis, classification, and new genetic developments". Gastroenterology. 120 (3): 682–707. PMID 11179244.


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