Chronic Pancreatitis - Pancreatic Pathologies by Cincinnati Children's Pancreas Care Center
With Dr. Dr. Maisaabel Haija & Dr. Dr. Andrew Trout · StayCurrentMD
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Chronic pancreatitis is a chronic inflammatory condition where inflammation over time results in damage and destruction of the pancreas with replacement of healthy tissue with fibrosis
Ongoing pancreatic damage affects acinar cells, ductal cells, and islet cells which are responsible for producing insulin
When islet cells are damaged by chronic pancreatitis, it can lead to endocrine issues such as diabetes
Chronic pancreatitis is a progressive inflammatory disorder that results in irreversible loss of pancreatic function
Diagnosis of chronic pancreatitis mostly relies on imaging findings
Diagnosis involves identifying calcifications, ductal obstruction, or dilation combined with one of three criteria: pain consistent with pancreatic origin, exocrine dysfunction, or endocrine dysfunction
For CT imaging, a single phase with portal venous contrast is adequate
MRI has advantages over CT in terms of soft tissue contrast with multiple different sequences, providing the best visualization of both parenchymal and duct changes in chronic pancreatitis
Multiple CT phases including non-contrast, arterial and portal venous phases markedly increase radiation dose in children and do not provide much additional diagnostic information
Non-contrast CT is essentially never needed in a child with pancreatitis because calcifications can be seen on post-contrast phases
Arterial phase imaging is reserved for specific questions about arterial pseudoaneurysms or when characterizing potential masses
Key MRI sequences are 3D MRCP to characterize the duct and its relationship to the bile duct, and T1 weighted sequence to understand parenchymal health
MRI exams can often be performed without IV contrast except for initial characterization when understanding vascular complications or fluid collections
Cincinnati Children's has an in-house 10 gene pancreatitis risk panel to screen for genetic links to pancreatitis
It is advised to work closely with a genetic counselor before sending genetic testing to help the family choose the test and interpret it afterwards
Genetic testing plays a vital role in early diagnosis and prognosis of pancreatic diseases, potentially guiding new preventative and therapeutic interventions
Exocrine and endocrine function need assessment because they can decline over time in chronic pancreatitis
Problems related to chronic pancreatitis include macro and micronutrient deficiencies, growth problems, small intestinal bacterial overgrowth, and risk for tumors in adulthood
Treatment starts with assessing disease stage, finding extent of exocrine or endocrine problems, and correcting nutrient abnormalities and growth issues
For pancreatic enzyme replacement, cystic fibrosis guidelines are followed for dosing
Pancreatic enzyme replacement is reserved only for cases with documented exocrine pancreatic insufficiency
When medical management fails and the patient continues to have symptoms, endoscopic management is considered
Endoscopic therapy relies on two methods: endoscopic ultrasound and endoscopic retrograde cholangiopancreatography (ERCP)
ERCP is an imaging and interventional modality where the endoscopist can evaluate pancreatic or biliary ducts and treat problems with scarring or strictures
Pain management follows a stepwise ladder approach starting with opiate-sparing medications and reserving opiates for severe pain cases
Opiate-sparing chronic pain medications include neuropathic medications like amitriptyline and gabapentin, usually prescribed in partnership with a pain specialist
Multidisciplinary pain management includes a pain specialist, psychologist, and physical therapist to address all aspects of pain's impact on the patient's body
Psychologists assess pain's functional and emotional impact, as chronic pain can significantly affect daily functioning
Cognitive behavioral therapy (CBT) is incorporated in pain management at Cincinnati Children's and has been shown in other chronic conditions to be helpful in managing pain