About This Page
This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Most common cause: chronic alcohol use (~70–80%). Also smoking, hereditary (PRSS1, SPINK1, CFTR mutations), autoimmune, idiopathic
- Chronic epigastric pain + exocrine insufficiency (steatorrhoea, weight loss) + endocrine insufficiency (diabetes mellitus)
- Diagnosis: CT showing pancreatic calcification is virtually pathognomonic. MRCP/EUS for early changes
- Exocrine insufficiency: pancreatic enzyme replacement therapy (PERT, e.g. Creon) with meals — titrate to stool output
- Increased risk of pancreatic cancer (~5% lifetime risk) — maintain vigilance
Overview
Chronic pancreatitis is a progressive fibroinflammatory condition of the pancreas leading to irreversible structural damage, with loss of exocrine function (maldigestion, steatorrhoea) and endocrine function (secondary diabetes mellitus). The most common cause is chronic alcohol consumption (70–80%), with smoking as a strong independent and synergistic risk factor. Other causes include hereditary pancreatitis (PRSS1 mutations), autoimmune pancreatitis (type 1 IgG4-related, type 2), tropical/nutritional, and idiopathic. Pathological hallmarks include atrophy, fibrosis, calcification, ductal strictures, and pseudocyst formation.
Epidemiology
Prevalence in the UK is approximately 30–50 per 100,000. More common in males (3:1) owing to higher alcohol consumption. Typical presentation is in 40–50-year-olds with a history of heavy alcohol use. Hereditary forms present earlier (childhood/teens). Smoking independently doubles the risk and accelerates progression. The risk of pancreatic cancer is increased approximately 5-fold.
Clinical Features
Symptoms
Chronic epigastric pain radiating to back (often relapsing-remitting, can be constant)
Pain worsened by eating and alcohol
Steatorrhoea (pale, greasy, foul-smelling, difficult-to-flush stools) — exocrine insufficiency
Weight loss and malnutrition
Symptoms of diabetes: polyuria, polydipsia, fatigue (endocrine insufficiency — "type 3c" diabetes)
Bloating and flatulence
New-onset or worsening back pain, jaundice, weight loss (raises concern for pancreatic cancer)
Signs
Epigastric tenderness
Signs of malnutrition: cachexia, low BMI, muscle wasting
Signs of fat-soluble vitamin deficiency (A, D, E, K): bruising, osteomalacia, night blindness
Epigastric mass (pseudocyst)
Stigmata of chronic liver disease (if alcohol-related)
Investigations
First-line
CT abdomenPancreatic calcification (pathognomonic), ductal dilatation, atrophy, pseudocysts. Sensitivity ~80% for established disease
HbA1c and fasting glucoseScreen for secondary diabetes (type 3c) — check every 6 months per NICE NG104
Faecal elastase-1 (FE-1)FE-1 <200 µg/g = exocrine insufficiency; <100 µg/g = severe insufficiency. Simple stool test, not affected by PERT
Second-line
MRCP or secretin-MRCPDuctal anatomy: strictures, dilatation, calculi. Better than CT for early/mild changes
Endoscopic ultrasound (EUS)Most sensitive test for early chronic pancreatitis — Rosemont criteria. Also useful for tissue sampling if mass lesion
Nutritional bloodsVitamin A, D, E, K levels, prealbumin, iron, B12, folate, calcium, magnesium
Specialist
DEXA scanBone mineral density assessment — osteoporosis common (vitamin D and calcium malabsorption). Every 2 years per NICE NG104
Genetic testingIf early onset (<30 years), family history, or no identifiable cause — PRSS1, SPINK1, CFTR, CTRC mutations
IgG4 level + pancreatic biopsyIf autoimmune pancreatitis suspected (diffuse "sausage-shaped" pancreas, raised IgG4, responds to steroids)
Management
NICE NG104 (Pancreatitis), 20181
Lifestyle
- Alcohol abstinence — essential (reduces pain episodes and slows progression)
- Smoking cessation — smoking independently accelerates disease progression
- Small frequent meals, low-fat diet (dietitian input essential)
- Refer to alcohol services if alcohol-dependent
2
Exocrine insufficiency
- Pancreatic enzyme replacement therapy (PERT): Creon 25,000–50,000 units with meals, 10,000–25,000 units with snacks
- Titrate dose to stool output — aim for formed, non-greasy stools
- Add PPI if poor PERT response (acid can inactivate enzymes)
- Supplement fat-soluble vitamins (A, D, E, K) and calcium as needed
3
Pain management
- WHO analgesic ladder: paracetamol → weak opioid (codeine/tramadol) → strong opioid (morphine/oxycodone)
- Neuropathic pain adjuncts: pregabalin or amitriptyline
- Endoscopic therapy: pancreatic duct stenting, extracorporeal shockwave lithotripsy (ESWL) for ductal stones
- Surgery for refractory pain: lateral pancreaticojejunostomy (Frey/Puestow procedure) if dilated duct; resection if focal disease
4
Monitoring
- HbA1c every 6 months (screen for diabetes)
- DEXA scan every 2 years (osteoporosis risk)
- Nutritional review including fat-soluble vitamins annually
- Vigilance for pancreatic cancer — any new or changing symptoms should prompt investigation
Complications
- Pancreatic exocrine insufficiency: Steatorrhoea, fat-soluble vitamin deficiency, malnutrition
- Type 3c diabetes mellitus: Both insulin and glucagon deficiency — brittle, high hypoglycaemia risk
- Pseudocyst: Encapsulated fluid collection — can cause pain, gastric outlet obstruction, or become infected
- Bile duct/duodenal obstruction: From inflammatory mass or fibrosis in pancreatic head
- Pancreatic cancer: ~5% lifetime risk — heightened vigilance required
- Splenic vein thrombosis: Left-sided portal hypertension → gastric varices
UKMLA Exam Tips
- 1Pancreatic calcification on CT = chronic pancreatitis until proven otherwise
- 2Faecal elastase <200 µg/g = exocrine insufficiency — a simple, non-invasive stool test
- 3Type 3c diabetes: both insulin AND glucagon deficiency → higher hypoglycaemia risk than T1DM or T2DM
- 4Creon must be taken WITH meals (not before or after) — enzymes need to mix with food in duodenum
- 5Autoimmune pancreatitis type 1: raised IgG4, sausage-shaped pancreas on CT, responds dramatically to steroids
- 6Smoking is an independent risk factor for chronic pancreatitis (not just alcohol) — must advise cessation
practicetest your knowledge on chronic pancreatitisApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — gastroenterology and beyond.
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