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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
Key points
- Most common adult cause in the US is chronic alcohol exposure; smoking independently accelerates disease
- Classic: chronic epigastric pain radiating to back, steatorrhea, weight loss, diabetes, pancreatic calcifications
- CT can show calcifications and duct dilation; fecal elastase supports exocrine insufficiency
- Treat with alcohol/smoking cessation, pancreatic enzyme replacement, fat-soluble vitamins, and pain strategy
- New painless jaundice or weight loss raises concern for pancreatic cancer
Overview
Chronic pancreatitis is irreversible inflammation and fibrosis causing loss of exocrine and endocrine function. Recurrent acute pancreatitis, toxic-metabolic injury, obstructive duct disease, genetic disorders, and autoimmune pancreatitis can contribute.
Epidemiology
Alcohol and smoking are dominant modifiable risks. Other causes include hereditary pancreatitis, cystic fibrosis variants, hypertriglyceridemia, hypercalcemia, obstructing tumors/strictures, pancreas divisum, and autoimmune pancreatitis.
Clinical Features
Symptoms
Epigastric pain radiating to the back
Nausea, vomiting, anorexia
Pain may improve leaning forward
Steatorrhea and weight loss in chronic disease
Fever, hypotension, oliguria, hypoxemia, jaundice, or severe persistent pain
Signs
Epigastric tenderness
Tachycardia, dehydration, ileus
Cullen or Grey Turner sign in hemorrhagic pancreatitis
Shock, hypoxemia, peritonitis, or jaundice
Investigations
First-line
Serum lipase>=3x upper limit supports acute pancreatitis; may be normal in chronic burnt-out disease
CMP, CBC, BUN, hematocrit, calcium, triglyceridesSeverity and etiology assessment
RUQ ultrasoundEvaluate gallstones in acute pancreatitis
Second-line
Contrast CT abdomenDiagnostic uncertainty or failure to improve after 48-72 h
MRCP/EUSDuctal disease, stones, malignancy, chronic pancreatitis evaluation
Fecal elastaseLow value supports exocrine insufficiency in chronic pancreatitis
Specialist
ERCPTherapeutic for cholangitis or persistent biliary obstruction, not routine pancreatitis
IgG4If autoimmune pancreatitis suspected
1
Acute management
- Moderately aggressive lactated Ringer fluids with reassessment
- Opioid analgesia and antiemetics
- Early oral feeding as tolerated in mild disease
- No prophylactic antibiotics for sterile necrosis
2
Cause-specific
- Same-admission cholecystectomy for mild gallstone pancreatitis
- ERCP within 24 h if cholangitis
- Treat alcohol use disorder or severe hypertriglyceridemia
3
Chronic management
- Alcohol and smoking cessation
- Pancreatic enzyme replacement with meals for steatorrhea
- Fat-soluble vitamin replacement and diabetes monitoring
- Endoscopic/surgical therapy for obstructing stones or strictures
Complications
- Acute: Pseudocyst, necrosis, infected necrosis, ARDS, AKI, hypocalcemia.
- Chronic: Exocrine insufficiency, diabetes, pseudocyst, biliary obstruction, pancreatic cancer risk.
USMLE Step 2 CK Exam Tips
- 1Acute pancreatitis diagnosis is 2 of 3 criteria
- 2Lipase level does not track severity
- 3Gallstone pancreatitis + cholangitis = ERCP
- 4No prophylactic antibiotics for sterile necrosis
- 5Early feeding is preferred in mild acute pancreatitis
- 6Pancreatic calcifications + steatorrhea = chronic pancreatitis
- 7Fecal elastase supports pancreatic exocrine insufficiency
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