Synopsis
Diagnose irreversible pancreatic disease, treat pain without stigma, replace exocrine function, detect type 3c diabetes and malnutrition, and select duct or cancer pathways safely.
- Chronic pancreatitis is progressive fibro-inflammatory pancreatic damage causing recurrent or persistent upper-abdominal pain, ductal or calcific structural change and eventual exocrine or endocrine failure.
- Do not assume alcohol causation because a person drinks: smoking, genetic variants, autoimmune disease, recurrent acute episodes, obstruction, anatomical factors and metabolic disease require consideration.
- CT demonstrates calcification, atrophy, duct dilatation, stones, pseudocyst and mass; MRI/MRCP and EUS help when early or ductal disease remains uncertain and the result would change care.
- Steatorrhoea, weight loss, sarcopenia, bloating and fat-soluble vitamin deficiency suggest exocrine insufficiency; watery stool can falsely lower faecal elastase and results need clinical interpretation.
- Pancreatic enzyme replacement is taken with every meal and nourishing snack, distributed through eating and titrated to symptoms, weight and nutrition rather than prescribed as a token fixed capsule.
- Type 3c diabetes combines insulin deficiency with impaired glucagon counter-regulation and malabsorption, producing unstable glucose and substantial hypoglycaemia risk that merits specialist review.
- NICE advises exocrine and nutrition assessment at least annually, HbA1c at least every six months and bone-density assessment every two years in adults with chronic pancreatitis.
- New weight loss, jaundice, a changed pain pattern, duct cutoff, worsening diabetes or gastric-outlet symptoms require prompt pancreatic-cancer assessment rather than automatic attribution to chronic disease.
Key red flags
Progressive jaundice, rapid unexplained weight loss, a new mass, gastrointestinal bleeding, fever, persistent vomiting or substantially altered pain requires urgent re-imaging and specialist review.
Investigation priorities
Assess calcification, atrophy, duct enlargement, stones, inflammatory mass, pseudocyst, obstruction and possible malignancy.
Management branches
Symptoms, nutritional decline or testing supports pancreatic exocrine insufficiency.
- Refer to a pancreatic-experienced dietitian and document stool, intake, weight, muscle, alcohol, smoking, vitamins and alternative malabsorption diagnoses.
- Start an available enteric-coated pancreatin product with all meals and snacks, teaching the person to spread the prescribed amount through eating.
- Review weight and stool response, then optimise timing and enzyme strength before adding acid suppression or investigating another cause.
- Use the current Specialist Pharmacy Service equivalence resource during supply disruption and explain any product or capsule-count change clearly.
Key medicines
Enteric-coated pancreatin replacementPrescribe an individual lipase-based amount with every meal and snack, spread through eating and titrated using current BNF and specialist guidance.Swallow microspheres without crushing, avoid inhalation or oral mucosal contact, check porcine acceptability, and review very high doses because fibrosing colonopathy is reported.
Proton-pump inhibitor adjunctUse a standard current BNF adult regimen as a specialist-informed trial when adequate correctly timed pancreatin remains clinically ineffective.First correct timing, dose and adherence; review infection, magnesium, bone and long-term indication risks and do not mask another malabsorption cause.