Chronic pancreatitis: Risk Factors and Clinico-Radiological Profile

Abstract

Chronic pancreatitis is a disease condition characterized by progressive inflammation and fibrosis of pancreas. It manifests with pain abdomen, endocrine and exocrine dysfunction. Diagnosis is often difficult and is relied mostly on radiological examination. The aim of this study was to identify associated risk factors and correlate the clinical presentation with various radiological changes of the pancreas.We conducted a prospective hospital based observational study in patients presenting with abdominal pain and evaluated the etiology, clinical presentation and radiological changes of pancreas among 68 chronic pancreatitis patients visiting Gastroenterology Unit, Department of Medicine, National Academy of Medical Sciences, Bir Hospital during 1 year period (November 2019 to October 2020 AD). The results showed mean age of 35.75 ± 11.43 years with predominant male patients (76.4%). Pain abdomen was present in all patients with mean duration of 16.5 months, followed by diabetes in 27.9%. Alcohol was the major risk (n=42, 61.8%) and no cause was identified in 22 (32.3%) patients. Pancreatic parenchymal calcification in 65 (95.6%), duct dilation in 61 (89.7%) and gland atrophy in 39 (57.3%) were major structural changes detected in computed tomography scan, more reliably than ultrasonography. One third of patients had diabetes mellitus, which was significantly higher in female (63.2%) and had major radiological changes of chronic pancreatitis at diagnosis. Alcohol was the common risk of chronic pancreatitis. Structural changes suggestive of disease was demonstrated better by computed tomography.

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Chronic pancreatitis: Risk Factors and Clinico-Radiological Profile
Jiwan Thapa,1 Ramila Shrestha,1 Ram Krishna Tamang,2 Shankar Baral,1 and
Bhuwneshwer Yadav1
ABSTRACT
Chronic pancreatitis is a disease condition characterized by progressive inammation and brosis
of pancreas. It manifests with pain abdomen, endocrine and exocrine dysfunction. Diagnosis is
often dicult and is relied mostly on radiological examination. The aim of this study was to
identify associated risk factors and correlate the clinical presentation with various radiological
changes of the pancreas.We conducted a prospective hospital based observational study in
patients presenting with abdominal pain and evaluated the etiology, clinical presentation and
radiological changes of pancreas among 68 chronic pancreatitis patients visiting Gastroenterology
Unit, Department of Medicine, National Academy of Medical Sciences, Bir Hospital during 1 year
period (November 2019 to October 2020 AD). The results showed mean age of 35.75 ± 11.43
years with predominant male patients (76.4%). Pain abdomen was present in all patients with
mean duration of 16.5 months, followed by diabetes in 27.9%. Alcohol was the major risk (n=42,
61.8%) and no cause was identied in 22 (32.3%) patients. Pancreatic parenchymal calcication
in 65 (95.6%), duct dilation in 61 (89.7%) and gland atrophy in 39 (57.3%) were major structural
changes detected in computed tomography scan, more reliably than ultrasonography. One third
of patients had diabetes mellitus, which was signicantly higher in female (63.2%) and had
major radiological changes of chronic pancreatitis at diagnosis. Alcohol was the common risk
of chronic pancreatitis. Structural changes suggestive of disease was demonstrated better by
computed tomography.
1Department of Gastroenterology, Bir hospital 2Department of Community Medicine, Nepal Medical College
Teaching Hospital, Attarkhel, Gokarneshwor-8, Kathmandu, Nepal
Corresponding author
Dr. Jiwan Thapa,
Department of Gastroenterology, Bir hospital,
Kathmandu, Nepal
Email: jitha15@yahoo.com
Orcid No: https://orcid.org/0000-0001-6616-9595
DOI: https://doi.org/10.3126/nmcj.v23i2.38526
Keywords
Alcohol, chronic pancreatitis, computed
tomography, pain abdomen
Original Article Nepal Med Coll J 2020; 23 (2): 153-8
Received on: March 02, 2021
Accepted for publication: May 19, 2021

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Introduction
Chronic pancreatitis (CP) is a syndrome
of progressive inammatory disorder
characterized clinically by abdominal pain and
endocrine-exocrine pancreatic insuciency
with severe impact on quality of life and
long-term sequela.1,2 Prevalence varies from
6-7/100000 in Europe3 to 126/100,000 population
in South India for idiopathic pancreatitis.4 The
median age of disease affection is 48 years.
CP affects male and female in 6.5:1 ratio and
mortality rate is approximately 17% at 59
months from the disease onset.5
Though 20% patients of chronic pancreatitis
are incidentally diagnosed, most patients
present with abdominal pain (epigastric, dull
aching pain of constant or intermittent nature
lasting several hours to even days, radiating to
the back or laterally to the anks) or sequela
of pancreatic insuciency like diabetes, weight
loss and diarrhea.6,7 Idiopathic (41%-67%),
alcohol (34%-50%) and smoking (25%) remains
the major associated risks of CP.8-11 Cessation of
alcohol intake and smoking in these patients
is essential to slow disease progression and
improve overall health.3 Diagnosis is based
on a combination of clinical ndings, tests
for endocrine and exocrine pancreatic
insuciency and radiological ndings. Classical
diagnostic ndings on radiology are gland
atrophy, calcication, ductal abnormalities.7
Data regarding characteristics of CP in Nepal
are very few. In this study, we aim to identify
the associated risks, clinical presentation and
radiological changes [ultrasonography (USG)
and computed tomography scan (CT scan)] of
chronic pancreatitis.
Materials and Methods
This is a prospective, cross sectional, hospital
based observational study among 68 CP
patients conducted at Gastroenterology unit,
Bir Hospital, National Academy of Medical
Sciences after approval from the Institutional
Review Board (IRB) from November 2019 to
October 2020 AD. Patients of age eighteen years
and above, with pain abdomen undergone
ultrasonography examination with any
evidence of chronic pancreatitis were further
assessed with computed tomography scan
for gland atrophy, calcication and ductal
abnormalities were included. Patients not
providing consent, pregnant and other causes
of pain abdomen were excluded. The most
characteristic imaging features dened are
pancreatic atrophy (size less than 21 mm, 14 mm
and 7 mm in head, body and tail respectively),
calcication and ductal abnormalities (dilation
if > 3 mm in the head and 2 mm upstream if
stricture or irregular contour) currently in
practice as standard reporting system in use in
radiology.12 Burnout disease causes endocrine
insuciency of which diabetes mellitus is
common and is diagnosed by clinical and
laboratory examination. Fasting blood glucose
>126mg/dl, random plasma glucose >200mg/
dl with symptoms of hyperglycemia or HbA1c
>6.5% was considered diabetes mellitus in
our study as dened by American Diabetes
Association.13 Chronic diarrhea was dened
clinically as passage of more than three stools/
day for 4 weeks.14 Ascites was dened by
presence of peritoneal uid by imaging and
raised ascitic amylase greater than ve times
the upper limit of normal value. Presence of
jaundice was dened as serum bilirubin level
greater than 1.5 mg/dl, hypercalcemia and
hypertryglyceridemia associated pancreatitis if
the serum calcium was >11mg/dl and triglyceride
level was >1000mg/dl respectively.14 Alcohol
use problem was dened as consumption of >14
standard drinks/week in male and >7 standard
drink/week in female15 and smoking consumed
if on daily basis for more than 5 years. USG
changes were then compared with CT changes
for diagnostic characteristics and correlation
was done with various clinical features.
Statistical Analysis: Data was processed in
Microsoft Excel 2010 and analysis done in
SPSS version 16.0. The data analysis tools are
descriptive (frequency table with percentage)
as well as inferential (t-test, chi-square test,
kappa value). The P-value< 0.05 was taken as
signicant statistical differences.
Results
The mean age was 35.75 ± 11.43 years. Fifty
two patients (76.4%) were male among them 8
(11.7%) were under 20 years of age. The most
common associated risks were alcohol (61.7%),
followed by smoking (45.5%) and idiopathic
(32.3%) as shown in table 1. Two male patients
had positive family history of pancreatitis.
Alcohol intake and smoking were signicantly
higher in male than female. None of the patients
had hypertriglyceridemia or hypercalcemia as
cause of CP.
All patients presented with pain abdomen of
average duration of 16.5 months, followed by
diabetes (27.9%) which was signicantly higher
in female patients (table 2).

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Pancreatic calcication (95.5%), duct dilatation
(89.7%) with average duct size of 6.33mm and
atropy (57.3%) were the commonest features
identied by CT scan with higher diagnostic
reliablity than USG (44.1%, 45.5%, 29.4%
respectively). Pseudocyst was present in 21
(30.88 %) patients with mean size of 7.86cm.
Intraductal calculi was also detected in greater
proportion by CT scan i.e, 33 patients (48.5%)
with mean size of 4.85 mm. All the radiological
features of CP studied were detected
signicantly in higher frequency by CT scan
than USG with moderate agreement as shown
in table 3.
Diabetic patients had a mean pain duration of
18.6 months, longer than others (15.6 months),
their mean fasting blood glucose level was
128.89 mg/dl and HbA1C of 8.07%. Diarrhea
was an uncommon presentation (5.8%) and
none reported steatorrhea. Clinical correlation
with radiological changes demonstrated a
signicant pancreatic structural and ductal
changes if patient had pain abdomen, diabetes,
Table 1: Risk Factors
Parameters Gender Total p-value
Male Female
Smoking 29 (93.5%) 2 (6.5%) 31(45.59%) 0.006
Alcohol 20 (95.2%) 2 (4.8%) 42 (61.76%) 0.000
Smoking and alcohol 27 (93.10%) 2 (6.90%) 29 (42.65%) 0.000
Family history 2 (100%) 0 (0%) 2 (2.94%) 0.296
Idiopathic 8 (36.36%) 14 (63.63%) 22 (32.35%) 0.000
Table 2: Clinical Presentation
Presentation
Sex Total p-value
Male Female
Pain abdomen 52 (76.4%) 16 (23.9) 67 (98.53%) 0.765
Diarrhea 4 (100%) 0 (0%) 4 (5.89%) 0.566
Diabetes 7 (36.8%) 12 63.2% 19 (27.94%) 0.000
Ascites 10 (100%) 0 (0%) 10 (14.71%) 0.135
Jaundice 6 (75%) 2 (25%) 8 (11.76%) 0.917
Abdominal lump 9 (100%) 0 (0%) 9 (13.24%) 0.172
Table 3: Radiological prole
Features Method Kappa value p-value
USG CT scan
Calcication 30 (44.12%) 65 (95.59%) 0.07 0.115
Calculi 14 (20.59%) 35 (51.47%) 0.277 0.004
Stricture 2 (2.94%) 10 (14.71%) -0.052 0.551
Duct
abnormality
Dilation 41 (45.59%) 61 (89.71%) 0.175 0.011
Irregularity 11 (16.18%) 24 (35.29%) 0.449 0.000
Atropy 20 (29.41%) 39 (57.35%) 0.473 0.000
Pseudocyst 17 (25%) 29 (42.65%) 0.619 0.000
Thapa et al

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ascites and lump abdomen as shown in table 4.
Majority of patients presenting with pain had
ductal changes and calci cation with almost
52.2% having intraductal calculi of varying
sizes.
Nine patients (13.2%) had common bile duct
dilatation with stricture causing jaundice in
8. 11.7% (8) had pleural effusion (6 left and
2 right). Other infrequent clinical  ndings
includes portal vein thrombosis=3, weight
loss=2, splenomegaly=2, long term use of
nonsteroidal in ammatory drugs for pain
abdomen=2. Pancreatic cystic neoplasm was
detected in three patients and one patient had
carcinoma of pancreas at diagnosis. Palpable
abdominal lump was found in nine patients,
predominantly the pseudocyst and pancreatic
ascites in 10 male patients.
Table 4: Clinico- radiological correlation
Presentation NFeatures USG CT Scan p-value
Pain abdomen 67
Duct dilation 31(46.27%) 61(91.04%) 0.034
Calci cation 29 (43.28%) 64 (95.52%) 0.000
Calculi 14 (20.89%) 35 (52.24%) 0.000
Irregularity 11 (16.42%) 24 (35.82%) 0.011
Atropy 19 (28.36%) 38 (56.72%) 0.001
Pseudocyst 16 (23.88%) 26 (38.81%) 0.063
Diabetes
mellitus 19
Calci cation 5 (26.32%) 19 (100%) 0.000
Duct dilation 9 (47.37%) 19 (100%) 0.001
irregularity 3 (15.79%) 8 (42.11%) 0.018
Jaundice 8
Calci cation 4 (50%) 8 (100%) 0.002
Duct dilation 5 (62.5%) 8 (100%) 0.20
Pseudocyst 2 (25%) 4 (50%) 0.061
Ascites 10
Calci cation 4 (40%) 9 (90%) 0.057
Duct dilation 2 (20%) 9 (90%) 0.005
Atropy 4 (90%) 9 (40%) 0.057
Abdominal
lump 9
Calci cation 4 (44.44%) 9 (100%) 0.029
Stricture 2 (22.22%) 9 (100%) 0.002
Duct dilation 3 (33.33%) 9 (100%) 0.009
Atropy 3 (33.33%) 9 (100%) 0.009
Fig. 1: CT scan image demonstrating
atrophied pancreas with dilated duct and few
parenchymal calci cation

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Discussion
In this study conducted at a referral hospital,
chronic pancreatitis could be assessed in
68 patients during one year amid the Covid
pandemic during study period. Mean age of
affected patients was 35.75 ± 11.43 years, range
18-65 years. More than 2/3rd (76.4%) cases
were male and 15.3% were of age below 20
years. Forty two (61.8%) patients were alcohol
consumers, 31 (45.6%) were smokers and 22
(32.3%) had no identiable risk factors. Alcohol
and smoking were signicantly higher in male
patients. We observed relatively younger
patients affected in whom assessment of genetic
risks is important cause which is limited in
our settings due unavailability of resources.
Twenty nine (42.65%) patients had history of
both alcohol use and smoking as shown in table
1.
Pain abdomen was present in all patients
since it was considered as major inclusion
criteria and is a frequent reason for hospital
visits. Assessment of asymptomatic chronic
pancreatitis is important because the diagnostic
features used currently appear only with
chronic inammation and subsequent brosis.
Development of pancreatic insuciency results
only when greater than 90% of the organ
is damaged denoting a long asymptomatic
course.7,16 Diabetes was observed in 27.9%,
predominantly in female, lower than reported
from study from Eastern Nepal (n=37, 67.3%)
and India (n= 1086, 40.5%).9,17 Nine (13.24%)
of our patients presented with palpable
abdominal lump and 10 (14.71%) presented
with ascites implicating the complications
associated with disease at diagnosis itself. Only
4 patients complained diarrhea.
As the disease presents clinically only after
greater proportion of irreversible of loss of
function, detection at an early course and
avoidance of risk factors and management of
impending complications is the main stay of
therapy for better quality of life.3 No single
method is dened as gold standard for diagnosis
of CP, the combination of characteristic clinical,
laboratory and radiological features denes
irreversible inammation and subsequent
brosis suggestive of CP.7 Most important
radiological changes in disease include
pancreatic parenchymal changes include
gland atrophy, calcication, duct changes,
pseudocysts and stricture.7,18 Calcication,
duct dilation, atrophy of gland were present
in our study in higher frequency with better
diagnostic reliability of CT scan than USG
similar to others.7,19 Atrophy (n=39, 57.35%)
was more common than a study from Eastern
Nepal (n=20, 36.4%).9 Intraductal calculi
of mean size 4.85 mm was identied in 35
(51.47%), demanding endotherapy to prevent
further damage of gland. CT scan signicantly
detected pseudocyst in 29 (42.65%) versus USG
in 17 (25%) (p value: 0.03) patients similar to
study by Rosso et al.20
Pain and diabetes remains the major features
at diagnosis. Both clinical manifestations were
better correlated with the structural changes
like atrophy, duct dilation, calcication,
intraductal calculi as demonstrated in imaging
studies implicating these features only develop
after long standing pancreatic inammation,
as in our patients with mean pain duration
of 16.5 months. This study also demonstrated
common bile duct stricture in 9 (13.2%) patients
as sequela of chronic pancreatitis. Diabetics
had higher HbA1C level 8.04 + 1.34 implying
dicult to control. Few patients (4) also had
pancreatic neoplasm which highlights the role
of imaging in early diagnosis.
This study has several limitations. We couldn’t
diagnose asymptomatic CP patients which is a
major step in management of disease in early
stage to prevent complications. Outcome of
therapies and study of genetic risk factors was
limited by availability of resources. Moreover
this is a hospital based study with small sample
size. Larger population based studies are
needed to estimate the disease burden and
diagnose at an early stage for appropriate
management.
In Conclusion, Chronic pancreatitis is a disease
with signicant morbidity. Alcohol was the
main avoidable risk factor identied in our
study. CT scan was key to diagnose structural
changes of pancreas in chronic pancreatitis.
Source for this Research Fund: None
Conict of Interest: None
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