Pancreatic cancer after surgery for chronic pancreatitis

BACKGROUND: Chronic pancreatitis is known to be a risk factor for pancreatic cancer. AIMS: To identify patients who were diagnosed with pancreatic cancer after undergoing surgery for histologically documented chronic pancreatitis. PATIENTS/METHODS: Records of 484 consecutive patients who underwent surgery for chronic pancreatitis from 1976 to 1997 were reviewed. RESULTS: Pancreatic cancer was diagnosed after a mean of 3.4 years (range: 2 months-1 years) in 14 patients (2.9%). In four patients, pancreatic cancer became evident within 12 months of surgery for chronic pancreatitis, suggesting cancer was present at the original surgery. Cancer presented with recurrent or persistent pain, jaundice, and/or weight loss. Pancreatic resection was possible in eight patients, but in the others, the cancer was inoperable. There was one long-term survivor (alive 14 years postoperatively), but for theothers mean survival was 10 months (16 months after resection vs. 4 months for inoperable cancer). CONCLUSION: Pancreatic malignancy should be suspected in patients who have had surgery for chronic pancreatitis when symptoms (such as recurrent pain, jaundice, weight loss, or anorexia) recur. Attempts at curative pancreatic resection are indicated and can offer palliation and the potential for a cure.     

Relation between chronic pancreatitis and pancreatic cancer in the light of surgical management

BACKGROUND/AIMS: Relation between cancer of the exocrine part of the pancreas and chronic pancreatitis has not been clearly defined and the problem of carcinogens based on long-lasting chronic pancreatitis is still a matter of discussion. METHODOLOGY: The aim of the study was analysis of postoperative material of patients who in the years 1999-2003 underwent either drainage procedures (n=49) in the course of chronic pancreatitis or resectional procedures (n=36) for chronic pancreatitis or pancreatic cancer. RESULTS: In the group of patients with drainage procedures pancreatic cancer was histologically detected in postoperative material (specimens collected from the wall of pancreatic pseudocyst or dilated main pancreatic duct) in 3 patients (6.1%). In the group of patients with long-lasting chronic pancreatitis who underwent a resectional procedure pancreatic cancer was postoperatively detected in 4 cases (30.7%). CONCLUSIONS: Analysis of presented material confirms that long-lasting chronic pancreatitis predisposes to cancer of the exocrine part of the pancreas. This indicates that risk of pancreatic cancer should be taken into consideration in each patient with long lasting chronic pancreatitis.     

Lateral pancreatojejunostomy in the surgical management of chronic pancreatitis. Current concepts and future perspectives

Chronic pancreatitis is a medical disease, but surgery will be required for a selected subgroup of patients. Main indications for surgery in chronic pancreatitis are severe truly incapacitating pain refractory to medical therapy, local complications of pancreatitis or suspicion of malignancy. Surgical options include resective and drainage procedures. The choice of operation depends on the structural anatomy of the gland and the adjacent organs. Lateral pancreatojejunostomy is the preferred drainage procedure, because it is safe and effective in relieving the pain, while it preserves whatever pre-surgical pancreatic endocrine/exocrine function exists. It is indicated in large duct chronic pancreatitis (diameter of the main pancreatic duct >7 mm]; however, recently there is an increased interest in defining its role in small duct disease. The main advantage of the lateral pancreatojejunostomy over the resectional procedures is the preservation of the pancreatic parenchyma and endocrine and exocrine pancreatic function and the significantly lower early and late morbidity and mortality     

Endoscopic assay and surgery at chronic pancreatitis]

OBJECTIVE: To assess the possibilities of endoscopic surgeries at the pathology of major duodenal papilla in patients with the painful form of chronic pancreatitis. The study involved 35 patients with the painful form of chronic pancreatitis including 19 subjects with cholecystectomy as a result of cholelithiasis, 8 subjects with alcohol-induced pancreatitis (4 of them had external pancreatic fistulas) and 8 patients with idiopathic pancreatitis. As many as 60 different X-ray and endoscopic procedures were carried out altogether: ERCPG, EPST and dissection of pancreatitis duct entrances as well as nasopancreatic drainage and stenting. ERCPG discovered the pathology of major duodenal papilla in the form of stenosis of the common bile duct entrance and/or main pancreatic duct entrance in 25 (71%) patients. At the same time, the ultrasonic examination discovered the pathology only in 7 patients (20%). EPST was performed in 20 patients of 25. The dissection of the major pancreatitis duct entrance was carried out in 16 of them; the dissection of the additional pancreatic duct was performed in 1 patient; the external pancreatic duct drainage was conducted in 5 patients; the additional pancreatic duct stenting was carried out in 1 patient. Fifteen patients (75%) felt better immediately upon the surgery. Ten patients were followed-up from 2 months to 3 years; steady amelioration was observed in 7 of them. There were complications in the form of acute pancreatitis in 3 patients after ERCPG and in 2 patients after endoscopic surgeries. There were no other complications or fatalities. For patients with the painful form of chronic pancreatitis, ERCPG is an informative and relatively safe technique enabling to discover the stenosis of the common bile duct entrance and/or main pancreatic duct entrance in 71% of cases. Endoscopic surgeries make it possible to produce an immediate positive result in 75% of cases.     

Autoimmune Pancreatitis as a New Clinical Entity (Three Cases of Autoimmune Pancreatitis with Effective Steroid Therapy)

The most common forms of chronic pancreatitisare related to alcohol ingestion, whereas the entity ofnon-alcohol-associated (idiopathic) pancreatitis ispoorly understood. Autoimmunity has been suggested as a possible etiologic factor of idiopathicchronic pancreatitis. A total of 362 Japanese patientsunderwent endoscopic retrograde pancreatography (ERP)for suspected pancreatic disease, and 161 were diagnosed with chronic pancreatitis. Among them, we foundthree cases (1.86% incidence) of unique chronicpancreatitis, in which ERP revealed diffuse narrowing ofthe main pancreatic duct with an irregular wall. We diagnosed these three patients as havingpancreatitis associated with an autoimmune mechanismmorphologically and biochemically and started them onsteroid therapy. The characteristics of the these three patients were as follows:hypergammaglobulinemia, eosinophilia, ultrasonographyshowing hypoehoic diffuse swelling in the pancreas(sausage-like appearance), ERP showing diffuse narrowingof the main pancreatic duct with irregular like thumbprintlike marks,reversible exocrine insufficiency, and positiveanti-carbonic anhydrase II antibody. After one month ofthe treatment with steroids, pancreatitis dramatically improved morphologically and enzymatically.Here we describe these cases of the suspected autoimmunechronic pancreatitis. We must recognize the concept andthe features of autoimmune pancreatitis in order to avoid unnecessary surgery as pancreaticcancer.     

Pain Management in chronic pancreatitis

Opinion statement Painful chronic pancreatitis is difficult to manage. We believe a multidisciplinary approach is the best means of evaluating this complex syndrome. In our opinion, the initial evaluation should aim at firmly establishing the diagnosis of chronic pan-creatitis: calcifications on imaging; duct morphologic changes on pancreatography; parenchymal changes on ultrasound; or evidence of pancreatic dysfunction on secre-tin/ cholecystokinin stimulation tests. In addition, psychological assessment and qual-ity-of-life measurements are recommended. Once the diagnosis of chronic pancreatitis has been made, characterization of the chronic pain syndrome (visceral, non-visceral) with a diagnostic differential nerve block (DNB) is performed. Unlike celiac plexus block, which interrupts visceral afferent impulses traveling through the celiac plexus, a DNB is a meticulous, diagnostic tempo-rary block that localizes the origin of chronic abdominal pain. This pain can be classi-fied as visceral, psychologic/central, somatosensory, or mixed when more than one pain pathway is involved. Treatment modalities are different for these different types of pain syndromes. Chronic pancreatic pain should be visceral in origin if pain is stemming from an inflamed/scarred gland [1]. There is evidence that DNB may be helpful in characterizing abdominal pain in chronic pancreatitis [1]. Furthermore, it allows better selection of patients for treatment of chronic pancreatic pain [2]. Initial treatment in all patients should include pancreatic enzyme therapy, abstinence from alcohol, non-narcotic analgesics, and a low-fat diet. Patients who fail initial therapy should be considered for surgery or enrollment in medical treatment trials. Those identified by DNB as having visceral-type pain should be directed to med-ical and surgical therapy based on pancreatic duct morphology. Visceral-pain patients with dilated ducts or focal disease should undergo pancreatic duct drainage, or surgi-cal resection procedures. Patients with nonciliated ducts should undergo further medi-cal therapy, including celiac plexus blocks, enrollment into treatment trials of endoscopic therapy, or drug trials with new agents such as tramadol, gabapentin, or octreotide, or nutritional supplementation. Finally, those patients with visceral pain unresponsive to all medical therapy and who are not surgical candidates should be enrolled in a trial of thorascopic splanchnicectomy for intractable pain (Fig. 1). Patients identified by DNB as having a non-visceral type of chronic abdominal pain should undergo initial medical therapy as above ( enzymes, cessation of alcohol, diet modifications, analgesics).     

Clinical outcomes in patients who undergo extracorporeal shock wave lithotripsy for chronic calcific pancreatitis

BACKGROUND: There is controversy as to whether extracorporeal shock wave lithotripsy fragmentation and ERCP retrieval of pancreatic stones are associated with relief of chronic pain or relapsing attacks of pancreatitis. Our most recent experience with this technology is reviewed. METHODS: Forty patients with chronic calcific pancreatitis who required extracorporeal shock wave lithotripsy between 1995 and 2000 to facilitate pancreatic duct stone removal were retrospectively reviewed. Data collected included patient presentation, number of lithotripsy and ERCP sessions required, complications, and outcomes measures to include pre- and post-ESWL pain scale, monthly oxycodone (5 mg)-equivalent pills ingested, yearly hospitalizations, and need for subsequent surgery. RESULTS: A single extracorporeal shock wave lithotripsy session was required for 35 patients who underwent a total of 86 ERCPs to achieve complete stone extraction from the main pancreatic duct. Minor complications occurred in 20%. There was one episode of pancreatic sepsis that was treated with antibiotics and removal of an occluded pancreatic prosthesis. At a mean [SD] follow-up of 2.4 (0.6) years, 80% of patients had avoided surgery and there was a statistically significant decrease in pain scores (6.9 [1.3] vs. 2.9 [1.1]; p = 0.001), yearly hospitalizations for pancreatitis (3.9 [1.9] vs. 0.9 [0.9]; p = 0.001), and oxycodone-equivalent narcotic medication ingested monthly (125 [83] vs. 81 [80]; p = 0.03). CONCLUSIONS: Extracorporeal shock wave lithotripsy fragmentation of pancreatic duct calculi in conjunction with endoscopic clearance of the main pancreatic duct is associated with significant improvement in clinical outcomes in most patients with chronic pancreatitis.     

Laparoscopic pancreatic surgery: What now and what next?

In recent years, improved laparoscopic skill sets have expanded surgical management of pancreatic disease to encompass pancreatic resection, tumor enucleation, débridement, and drainage. With the aid of radio-logically guided drainage catheters, necrosectomy for acute pancreatitis can be delayed and accomplished laparoscopically in a select patient population. Pancreatic pseudocysts from chronic pancreatitis can now be approached via minimally invasive strategies, including emerging combined laparoendoscopic procedures and natural orifice transluminal endoscopic surgery. It is clear that laparoscopic pancreaticoduodenectomy is possible in experienced hands; pancreatic neoplasms in the body and tail are more suitable for laparoscopic procedures because distal pancreatic resection requires no reconstruction of the biliary or enteric tract. Laparoscopic staging of pancreatic tumors has decreased as preoperative radiographic imaging becomes more sensitive. Similarly, laparoscopic palliative procedures have decreased because of the emergence of other minimally invasive options for relieving gastric outlet obstruction and biliary obstruction. Nonetheless, major advances in minimally invasive pancreatic surgery will continue as technology and skill sets advance.     

Risk factors for diabetes mellitus in chronic pancreatitis

BACKGROUND & AIMS: The influence of disease progression and pancreatic surgery on the appearance of diabetes mellitus in patients with chronic pancreatitis is unknown. METHODS: A prospective cohort study of 500 consecutive patients with chronic pancreatitis (alcoholics, 85%) followed up over a mean period of 7.0 +/- 6.8 years in a medical-surgical institution between 1973 and 1996 was performed. Multivariate analysis of risk factors for diabetes mellitus was performed after exclusion of 47 patients. Patients who underwent elective pancreatic surgery (n = 231, 51%) were compared with patients who never underwent surgery (n = 222, 49%). RESULTS: The cumulative rate of diabetes mellitus was 83% +/- 4% 25 years after the clinical onset of chronic pancreatitis (insulin requirement, 54% +/- 6%). The prevalence of diabetes mellitus did not increase in the surgical group overall but was higher 5 years after distal pancreatectomy (57% +/- 8%) than after pancreaticoduodenectomy (36% +/- 18%), pancreatic drainage (36% +/- 13%), or cystic, biliary, or digestive drainage (24% +/- 7%) (P = 0. 005), without difference in the latter ones. Pancreatic drainage did not prevent the onset of diabetes mellitus. Distal pancreatectomy (risk ratio, 2.4; 95% confidence interval [CI], 1.6-3.8; P < 0.0001) and early onset of pancreatic calcifications (risk ratio, 3.2; CI, 2. 2-4.7; P < 0.0001) were the only independent risk factors for diabetes mellitus. CONCLUSIONS: The risk of diabetes mellitus is not influenced by elective pancreatic surgical procedures other than distal pancreatectomy in patients with chronic pancreatitis. This risk seems to be largely caused by progression of the disease because it increased by more than 3-fold after the onset of pancreatic calcifications.     

Endoscopic treatment for biliary stricture secondary to chronic pancreatitis

The causes of benign biliary stricture include chronic pancreatitis, primary/immunoglobulin G4-related sclerosing cholangitis and complications of surgical procedures. Biliary stricture due to fibrosis as a result of inflammation is sometimes encountered in patients with chronic pancreatitis. Frey's procedure, which can provide pancreatic duct drainage with decompression of biliary stricture, can be an initial treatment for chronic pancreatitis with pancreatic and bile duct strictures with upstream dilation. When patients are high-risk surgical candidates or hesitate to undergo surgery, endoscopic treatment appears to be a potential second-line therapy. Placement of multiple plastic stents is currently considered to be the best choice as endoscopic treatment for biliary stricture due to chronic pancreatitis. Temporary placement with a fully covered metal stent has become an attractive option due to the lesser number of endoscopic retrograde cholangiopancreatography (ERCP) sessions and its large diameter. Further clinical trials comparing multiple placement of plastic stents with placement of a covered metal stent for biliary stricture secondary to chronic pancreatitis are awaited.     

Surgical options in chronic pancreatitis

Summary Chronic pancreatitis is primarily a medical disease but surgery is indicated to treat complications, rule out malignancy, and ameliorate intractable pain. The ideal operation for chronic pancreatitis would relieve this pain while preserving exocrine and endocrine function. No one procedure achieves these goals in all patients so surgeons must tailor their operations to individual patient needs. In patients with a dilated pancreatic duct, complete ductal decompression with a lateral pancreaticojejunostomy is usually indicated. Pancreatic resection is useful in patients with localized disease, nondialated ducts, or in whom cancer cannot be ruled out. More rigorous documentation of the type and outcome of therapeutic interventions for chronic pancreatitis and the patient populations to whom they are applied is needed. Subjective measurements must be replaced by objective findings so that the true benefits of these procedures can be better assessed and compared.     

Surgical treatment and long-term follow-up in chronic pancreatitis

In the past two decades our knowledge of the pathophysiology and surgical treatment options in chronic pancreatitis have improved substantially. Surgical treatment in chronic pancreatitis has evolved from radical to organ-preserving procedures. The classic Whipple resection is no longer indicated in chronic pancreatitis, and operations like the duodenum-preserving pancreatic head resection and the pylorus-preserving Whipple have replaced it as surgical standards. These procedures allow the preservation of exocrine and endocrine pancreatic function, provide pain relief in up to 90% of patients, and contribute to an improvement in the quality of life.     

Role of differential neuroaxial blockade in the evaluation and management of pain in chronic pancreatitis

OBJECTIVES: Chronic pancreatic pain is difficult to treat. Surgical and medical therapies directed at reducing pain have met with little long-term success. In addition, there are no reliable predictors of response including pancreatic duct diameter. A differential neuroaxial blockade allows characterization of chronic abdominal pain into visceral and nonvisceral pain origins and may be useful as a guide to the treatment. Pain from an inflamed, and scarred pancreas should be visceral in origin. The purpose of our study was to determine the frequency with which patients with chronic pancreatitis have visceral pain and whether our modified differential neuroaxial blockade technique using thoracic epidural analgesia can accurately predict which patients will respond to medical or surgical therapy. METHODS: We retrospectively reviewed the medical records of patients with a firmly established diagnosis of chronic pancreatitis (Cambridge classification, calcifications) who had undergone a differential neuroaxial block for their chronic abdominal pain evaluation. Patient demographics and medical or surgical treatment for pancreatic pain was recorded. Response to therapy was defined by a 50% reduction in pain by verbal response score. RESULTS: A total of 23 patients were identified. Alcohol was the most common etiology for chronic pancreatitis (15 of 23, 55%). Surprisingly, the majority of chronic pancreatitis patients had nonvisceral pain (18 of 23, 78%) and only 22% (5 of 23) had visceral pain by differential neuroaxial block. Four of five patients (80%) with visceral pain responded to therapy, whereas only 5 of 17 (29%) of patients with nonvisceral pain responded. CONCLUSIONS: Surprisingly, patients with chronic pancreatitis commonly have nonvisceral pain. Differential neuroaxial blockade can predict which patients will respond to therapy.     

The role of surgery in acute pancreatitis

Due to the lack of randomized controlled studies comparing medical with surgical therapy, the role of surgery in acute pancreatitis is not clear. This is especially true in critically ill patients who are rapidly deteriorating with hemorrhagic or necrotizing pancreatitis. Surgical intervention may be of benefit in those patients who do not have a clearcut diagnosis of pancreatitis and may have a surgically correctable disorder, who have biliary or pancreatic duct disease, or who have developed a complication such as abscesses or a pseudocyst. The mortality rate of performing a laparotomy on patients with acute pancreatitis is not prohibitive.     

Incidence and characteristics of chronic and lymphoplasmacytic sclerosing pancreatitis in patients scheduled to undergo a pancreatoduodenectomy

Background:

The determination of the exact nature of a pancreatic head mass in a patient scheduled to undergo a pancreatoduodenectomy can be very difficult. This is important as patients who suffer from benign disease such as pancreatitis do not always require surgery. The aim of the present study was to analyse the incidence of pancreatitis and the signs and symptoms associated with these tumours mistaken for pancreatic cancer and the diagnostic procedures performed.

Methods:

A consecutive group of patients who underwent a pancreatoduodenectomy between 1992 and 2005 with histopathologically proven pancreatic adenocarcinoma (PCA) and pancreatitis were analysed.

Results:

The incidence of pancreatitis after pancreatoduodenectomy is 63 out of 639 patients who underwent a pancreaticoduodenectomy (9.9%). Of these patients, 24 patients (38%) had lymphoplasmacytic sclerosing pancreatitis (LPSP) and 31 patients (49%) had focal chronic pancreatitis. Eight patients (13%) had an intermediate form with characteristics of both. Pancreatic adenocarcinoma occurred in 227 patients (36%). The presence of pancreatitis without a discrete mass on endoscopic ultrasonography (EUS) seemed to have clinical relevance with a positive likelihood ratio of 5.1. Mortality after resection was nil in both groups.

Conclusion:

The incidence of pancreatitis is 9.9% for patients scheduled to undergo a pancreatoduodenectomy. Of these patients, 38% had LPSP, 13% had a intermediate form and 49% had focal chronic pancreatitis. The determination of the exact nature of a pancreatic head mass remains difficult.     

Endoscopic ductal drainage may avoid resective surgery in painful chronic pancreatitis without large ductal dilatation

Summary Conclusion. Endoscopic stenting treatment, in cases of chronic pancreatitis unsuitable for decompressive surgery, appears to be safe and efficient. Perfect anatomical results are only obtained if large stents are used after balloon dilatation. Background. Decompressive surgery in cases of painful chronic pancreatitis is only feasible if the main pancreatic duct exceeds approx 8 mm over a sufficient length. When those anatomical changes are not present, surgery must be resective. This study evaluates the results of endoscopic stent drainage and decompression of painful chronic pancreatitis without large dilatation of the main pancreatic duct. Methods. Sixteen of our chronic pancreatitis patients were included in this study. They presented a mean of 5.3 episodes of pain in the 6 mo before treatment. Decompressive surgery was not possible because of a mean pancreatic duct diameter of 5.8 mm. Stents were 7F in eight patients and 12F in the other eight. They were left in the duct after endoscopic dilation for 9.5±1.0 mo. Results. During stenting we observed two early obstructions and seven episodes of pain. All cysts disappeared and stenosis of the duct disappeared anatomically in six cases, was improved in four, but persisted in six. During follow-up, two episodes of mild pain were recorded. No cysts reappeared. Complete disappearance of stenosis was only observed in patients whose pancreatic duct was equipped with a 12F stent (P<0.02).     

Outcome of pancreatic ascites in patients with tropical calcific pancreatitis managed using a uniform treatment protocol

Pancreatic ascites or internal pancreatic fistula is a known complication of chronic pancreatitis. This condition is associated with considerable morbidity and mortality. The management approach of pancreatic ascites in tropical calcific pancreatitis is infrequently reported owing to the low incidence of this condition. Between December 2005 and June 2007, 11 patients with pancreatic ascites with tropical calcific pancreatitis (male:female 7:4, mean age 29.5 [14.2] years) were treated. A retrospective analysis of patients who underwent endotherapy and surgery for this condition based on an institutional protocol was performed. The end point was resolution of pancreatic ascites and relief of symptoms. All patients had pancreatic ascites, and one patient also had pancreatic pleural effusion. Endoscopic transpapillary stenting was possible in nine patients (81%). Identification of site of leak and placement of an endoscopic stent across the PD disruption was possible in five (45%) patients. All these patients had relief of ascites. Mean number of endotherapy sessions required before control of ascites was 1.8. Among the remaining four (36.6%) patients who had ERCP, placement of stent across the leak was unsuccessful; however stenting helped stabilize the general condition and nutritional status. These four patients and two patients who failed ERP underwent lateral pancreatojejunostomy surgery. Morbidity was observed in three patients who underwent surgery and one patient died due to sepsis and hemorrhage. All patients who had surgical drainage had complete relief of ascites and symptoms. In patients with pancreatic ascites in tropical calcific pancreatitis endotherapy and transpapillary stenting helps in resolution of ascites in nearly half of the patients. In the remaining patients preliminary conservative management followed by surgical pancreatic ductal drainage provides good relief of symptoms.     

Pain relief by surgery in chronic pancreatitis? Relationship between pain relief, pancreatic dysfunction, and alcohol withdrawal.

Since 1963, 57 consecutive patients with chronic pancreatitis, 44 of them alcoholics who had been operated upon for recurrent severe pain, have been controlled regularly for an average of 6 years. Thirty-two of them had a cyst drainage procedure (group A), and 25 had a ductal drainage procedure and/or distal pancreatectomy (group B). Ten patients died within 2 years (group A, n = 5). Lasting pain relief by surgery occurred in 19 patients only. Of 28 patients with pain relapses after surgery (group A, n = 15), however, 22 (78.6%) obtained late pain relief 1-8 years after surgery in association with marked increase of pancreatic dysfunction (group A, n = 12). Pain relief was associated with pancreatic calcifications in 71-86% of the alcoholics. Cyst drainage procedures were successful in preventing pain relapses mainly in patients with either advanced pancreatic dysfunction or in non-alcoholic pancreatitis. The data suggest that in chronic pancreatitis lasting pain relief is more often due to marked pancreatic dysfunction than to surgery. Alcohol abstinence after surgery was probably an additional factor for lasting pain relief in some patients.     

Endoscopic manometry of the pancreatic duct and sphincter zone in patients with chronic pancreatitis

A possible mechanism for pain in alcohol-induced chronic pancreatitis is increased pancreatic duct pressure. A study has been done to compare sphincter of Oddi and pancreatic duct pressures in normal controls and patients with alcohol-induced chronic pancreatitis who had recently had pain or who were pain-free. Pressures were measured in the sphincter of Oddi in 10 controls and 33 patients, in the pancreatic duct in six controls and 15 patients, and in the common bile duct in four controls and five patients during station pull-through at the time of an endoscopic retrograde cholangiopancreatogram. There was no significant difference in the mean pressures in the pancreatic duct, sphincter of Oddi (basal and phasic), and frequency of papillary contraction when comparing patients with alcoholic pancreatitis and controls. There was also no difference between patients with or without pain and patients with or without strictures. This study has not confirmed the hypothesis that increased pancreatic duct pressures may be incriminated as a possible mechanism of pain in alcoholic-induced chronic pancreatitis.     

The patient with slightly elevated pancreatic enzymes and abdominal complaints

Abdominal complaints in combination with slightly elevated serum pancreatic enzymes represent a classical clinical challenge. These symptoms may be due to coincidental unrelated harmless disorders, benign pancreatic alterations which are fairly easily treatable such as mild acute pancreatitis or uncomplicated chronic pancreatitis. However, serious, often insidious diseases such as pancreatic tumours may also present with this constellation as their first signs. Diagnostic procedures need to be stratified according to acuteness and severity of symptoms. While patients with acute onset of symptoms and severe complaints need immediate and combined laboratory and imaging investigations to allow adequate therapy, chronic and mild complaints usually justify a stepwise diagnostic approach consecutively using abdominal ultrasound, CT/MRI and endoscopic ultrasound as imaging procedures and reserving ERCP for cases which remain unclear or in which interventional therapy is needed. Diagnosis and follow-up are often particularly demanding in patients with cystic tumours of the pancreas. In chronic pancreatitis patients pain therapy and adequate control of pancreatic exocrine insufficiency may pose major problems. Patients with refractory pain may ultimately require surgical intervention. Another important indication for surgery in chronic pancreatitis is suspicion of cancer that cannot be ruled out by dedicated diagnostic procedures. This also applies to cystic tumours of the pancreas, which have a high risk of malignant transformation or may even already represent pancreatic cancer at the time of diagnosis.