Clinical Features, Signs, and Symptoms of Chronic Pancreatitis
Chronic pancreatitis presents with a characteristic triad of chronic abdominal pain, steatorrhea from exocrine insufficiency, and eventual diabetes from endocrine failure, reflecting progressive and irreversible destruction of pancreatic tissue. 1, 2
Primary Clinical Manifestations
Abdominal Pain
- Approximately 80% of patients present with recurrent or constant upper abdominal pain as the dominant symptom. 3, 4
- Pain typically occurs in the upper abdomen and may be chronic or recurrent in nature. 1, 3
- The pain syndrome is a hallmark feature that significantly impacts quality of life and often drives patients to seek medical attention. 5, 6
Exocrine Insufficiency (Malabsorption)
- Steatorrhea (fatty diarrhea) develops as pancreatic lipase secretion drops below 10% of normal levels, manifesting as oily, foul-smelling stools. 2
- Exocrine pancreatic insufficiency affects 30% to 48% of patients and occurs earlier in the disease course than endocrine dysfunction. 2, 4
- Additional gastrointestinal symptoms include bloating, abdominal cramping, and eventually azotorrhea (protein malabsorption). 7, 2
- The traditional teaching that more than 90% of the pancreas must be damaged before exocrine insufficiency occurs is not supported by original data. 5, 2
Endocrine Insufficiency (Diabetes)
- Type 3c (pancreatogenic) diabetes develops in 38% to 40% of patients as islet cells are progressively destroyed later in the disease process. 4, 2
- Endocrine cells are diffusely distributed throughout the pancreatic parenchyma, making them more resistant to damage than exocrine tissue. 5, 2
- This diabetes is complicated by concurrent decreased glucagon secretion, creating an increased risk of hypoglycemia that distinguishes it from type 1 and type 2 diabetes. 5
Secondary Clinical Features
Nutritional Complications
- Weight loss occurs from the combination of poor dietary intake (due to intractable pain and gastrointestinal side effects), malabsorption, and often concurrent alcoholism. 5, 1, 2
- Patients are at considerable risk for undernutrition, muscle depletion (sarcopenia), and malnutrition affecting a substantial proportion. 5, 7, 2
- Fat-soluble vitamin deficiencies (vitamins A, D, E, and K) develop from steatorrhea and require monitoring. 5, 7
Bone Disease
- Premature osteoporosis/osteopenia afflicts two-thirds of patients as a consequence of poor dietary intake of calcium and vitamin D, low physical activity, low sunlight exposure, heavy smoking, and chronic low-grade inflammation. 5, 2
- Bone metabolism studies demonstrate abnormally high bone turnover with increased both bone formation and bone resorption. 5
Physical Examination Findings
Advanced Disease Features
- Patients may exhibit signs of malnutrition including muscle wasting and temporal wasting. 2
- Jaundice may occur if intrapancreatic bile duct stricturing develops. 3
- Abdominal tenderness in the epigastric region is common during pain episodes. 3
Important Clinical Caveats
Disease Progression Pattern
- Exocrine insufficiency manifests earlier than endocrine dysfunction because acinar tissue is more vulnerable to injury than islet cells. 2
- The disease is characterized by progressive, irreversible destruction with replacement by fibrous scar tissue throughout the gland. 7, 1
- Gradual atrophy of pancreatic tissue occurs with ductal dilation, strictures, and eventual pancreatic shrinkage and calcification. 7
Diagnostic Challenges
- Early-stage chronic pancreatitis is challenging to diagnose as changes are subtle, ill-defined, and overlap with other disorders. 3
- Later stages show variable fibrosis, calcification of pancreatic parenchyma, ductal dilatation and distortion, pseudocysts, and potential vascular complications. 3