Which laboratory tests should be ordered for an adult being evaluated for chronic pancreatitis?

Laboratory Testing for Chronic Pancreatitis

For adults being evaluated for chronic pancreatitis, order fecal elastase-1 as the primary test for exocrine pancreatic insufficiency, along with comprehensive metabolic panels including fat-soluble vitamins, glucose/HbA1c for diabetes screening, and bone density assessment, as these directly impact the major complications of malnutrition, osteoporosis, and endocrine dysfunction that drive morbidity and mortality in this disease. 1

Initial Diagnostic and Functional Assessment

Exocrine Function Testing

• Fecal elastase-1 is the most frequently used indirect pancreatic function test and should be ordered to assess for exocrine pancreatic insufficiency (EPI), which occurs commonly in chronic pancreatitis and leads to malnutrition, weight loss, and reduced quality of life 1
• For pancreatic-sufficient patients, annual assessment of pancreatic function by fecal pancreatic elastase-1 determination is recommended, with repeat testing when inadequate growth or nutritional status occurs 1
• Direct pancreatic function tests are less frequently used, more invasive, and available only in limited centers 1

Nutritional and Metabolic Screening

• Annual nutritional review with blood tests should include:
  • Complete blood count and iron status 1
  • Fat-soluble vitamin levels (A, D, E, K) - these deficiencies are uniquely prevalent in chronic pancreatitis and should be monitored in all patients regardless of EPI status to avoid associated health effects 1, 2
  • Serum liver function tests 1
  • Electrolyte measurements 1
  • Plasma phospholipids or red blood cell fatty acids if available 1

Endocrine Assessment

• Annual screening for glucose intolerance is mandatory - order fasting glucose and HbA1c for all chronic pancreatitis patients, as type 3c diabetes (pancreatogenic diabetes) is common, characteristically "brittle," and associated with malnutrition and poor outcomes 1
• Screen patients ≥10 years of age annually for glucose tolerance 1

Bone Health Monitoring

Bone Density Assessment

• Order dual-energy X-ray absorptiometry (DXA) for baseline bone mineral density assessment in all patients with chronic pancreatitis, given the substantially elevated fracture risk (4.8% vs 1.1% in healthy controls, comparable to celiac disease and cirrhosis) 1
• DXA should be performed from 8-10 years of age and repeated every 1-5 years depending on patient age, previous scan values, and risk factors 1
• Repeat DXA every 2 years following a diagnosis of osteopenia 1
• Priority groups for DXA include: post-menopausal women, those with previous low-trauma fractures, men over 50 years, and those with malabsorption 1

Bone Health Markers

• Consider measuring serum 25-hydroxyvitamin D, as deficiency is associated with lower bone mineral density and chronic systemic inflammation in chronic pancreatitis 1
• Inflammatory markers (high-sensitivity C-reactive protein and IL-6) show direct association with bone mineral density abnormalities 1

Micronutrient Monitoring

• Assess calcium intake at least annually, as adequate calcium is essential for bone health prevention in this high-risk population 1
• Monitor for deficiencies in vitamins A, E, and K, which may uniquely present in chronic pancreatitis patients even without documented EPI 2

Monitoring Frequency Algorithm

Every 3 Months:

• Weight and BMI for children and adolescents 1
• Assessment for pancreatic enzyme replacement therapy adequacy by monitoring growth, nutritional status, and gastrointestinal symptoms in adolescents 1

Every 6 Months:

• Weight and BMI for adults 1
• Dietary review for adults 1
• Assessment for PERT adequacy in adults 1

Annually:

• Fecal elastase-1 for pancreatic-sufficient patients 1
• Complete nutritional blood panel (CBC, iron, vitamins, liver function, electrolytes) 1
• Glucose tolerance screening 1
• Calcium intake assessment 1

Every 1-5 Years:

• DXA scan for bone mineral density 1

Critical Pitfalls to Avoid

• Do not wait for overt steatorrhea to test for EPI - under-recognized symptoms include diarrhea, abdominal distention, increased flatulence, and unexplained weight loss that warrant testing 1
• Do not assume normal fat-soluble vitamin status without testing - deficiencies occur even in patients without documented EPI and require periodic screening to prevent complications 2
• Do not overlook diabetes screening - type 3c diabetes is frequently misclassified as type 2 diabetes but has distinct metabolic characteristics requiring different management approaches 1
• Do not defer bone density assessment - the fracture risk in chronic pancreatitis is comparable to conditions with well-established osteoporosis screening protocols, yet bone health is often neglected 1