Review Article The Korean Journal of Pancreas and Biliary Tract 2017;22: pissn eissn

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1 Review Article The Korean Journal of Pancreas and Biliary Tract 2017;22: pissn eissn 만성췌장염의임상상, 자연경과및합병증 한림대학교의과대학한림대학교성심병원내과 추진우 문성훈 Clinical Features, Natural History, and Complications of Chronic Pancreatitis Jin Woo Choo, Sung-Hoon Moon Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea Chronic pancreatitis is a debilitating disease characterized by abdominal pain, exocrine insufficiency, and diabetes mellitus and has had great social, economic, and psychological impacts. Traditional definition of chronic pancreatitis has been based on irreversible histological findings such as self-sustaining chronic inflammation, fibrosis, and eventual destruction of ductal, exocrine, and endocrine tissues. In contrast, the traditional characteristics of acute pancreatitis have been thought as a complete recovery of pancreatic function and morphology during the convalescence period. Acute and chronic pancreatitis have been considered separated disease entities. However, the current idea regarding the natural course of pancreatitis is that acute pancreatitis can progress to the intermediate step of recurrent acute pancreatitis, and finally to chronic pancreatitis. This evolution can be characterized by a sequence of necrotic and fibrotic events, or described by sentinel acute pancreatitis event (SAPE) hypothesis. Therefore, chronic pancreatitis is better defined as a progressive inflammatory and fibrotic disease of the pancreas with clinical features of abdominal pain, malnutrition, diabetes mellitus and imaging features of pancreatic parenchymal/ ductal calcifications. The complications of chronic pancreatitis include pseudocyst, pseudoaneurysm, fistula, biliary stricture, and duodenal stricture. This review describes the progression from acute to chronic pancreatitis, the mechanisms and nature of abdominal pain, steatorrhea, pancreatogenic diabetes mellitus, pseudocyst, pseudoaneurysm, and biliary stricture associated with chronic pancreatitis. Keywords: Pancreatitis, Chronic, Abdominal pain, Natural history, Diabetes mellitus Received Sep. 26, 2016 Revised Nov. 8, 2016 Accepted Nov. 23, 2016 Corresponding author : Sung-Hoon Moon Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22 Gwanpyeong-ro 170beon-gil, Dongan-gu, Anyang 14068, Korea Tel Fax ; endomoon@naver.com This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright 2017 by The Korean Journal of Pancreas and Biliary Tract Copyright 2017 by Korean Pancreatobiliary Association 63

2 Clinical Features of Chronic Pancreatitis 서론,, (malnutrition), (calcification)..,, (acinar cell). Whitcomb (mechanistic). 1, (exocrine insufficiency) (endocrine insufficiency) %,. 2,,. 췌장염의진행과정. 3, (continuum). 6,7 " - (necrosis-fibrosis sequence hypothesis)" (latent stage), (compensatory stage), (transitional stage) (advanced stage). 9. Whitcomb "sentinel acute pancreatitis event (SAPE) ". 10 SAPE (resident macrophage). - (transforming growth factor-beta) (pancreatic stellate cell),,. (ischemia) (cytokine) ( 8,492 ). 7 22%, 10%. 36%.,. 7 임상상과자연경과, (steatorrhea).,.,, (,, ). 64

3 Jin Woo Choo, et al. 1. 복통.,.. 1) 복통의발생기전 ,12 (noceceptive nerves) (alteration).,, (peripheral and central sensitization) (hyperalgesia), (allodynia)..,,. Dimcevski ,, (electroencephalogram) (projection).,, (referred pain). 13 pregabalin ) 복통의양상및자연경과 ,., burn out. 19 Lankisch burn out. Ammann Muellhaupt A (short episodes/relapsing) 10.. B (constant/prolonged episodes). B 65

4 Clinical Features of Chronic Pancreatitis A. 11 burn-out. 18 Mullady 21, (pattern; intermittent vs. chronic) (severity; mild to moderate vs. severe) 5 (Table 1) % A (episodes of mild to moderate pain, usually controlled by medication), B (constant mild to moderate pain, usually controlled by medication), C (usually pain free with episodes of severe pain), D (constant mild pain plus episodes of severe pain), E (constant severe pain that does not change) 14.0%, 9.2%, 30.9%, 38.2%, 7.7%. 21 B, D E (Ammann B ) 55%, 45% A C, (Ammann A ) Ammann.,,.,,. (p = 0.725) (p = 0.142) Zurich burn out 18,19. Mullady 21 Wilcox Mullady 21 45% D 15.6%. 22 burn-out. Zurich (Dutch Pancreatitis Study Group) , , (probable chronic pancreatitis), (definite chronic pancreatitis). 2 80%. 24,25 2. 지방변증 (exocrine) 10%.. Table 1. Pain patterns of chronic pancreatitis 21,22 Pattern No pain No pain Definition Temporal nature (Ammann type*) Pain severity A Usually pain free, but episodes of mild to moderate pain Intermittent (A) Mild-moderate B Constant mild to moderate pain Constant (B) Mild-moderate C Usually free of abdominal pain, but episodes of severe pain Intermittent (A) Severe D Constant mild to moderate pain plus episodes of severe pain Constant (B) Severe E Constant severe pain Constant (B) Severe *Ammann et al. 19 classified the pattern of abdominal pain in chronic pancreatitis as either intermittent/short-lived pain episodes (Type A) or prolonged period of persistent (daily) and/or clusters of recurrent severe pain exacerbations (Type B). 66

Jin Woo Choo, et al. (gastric lipase).. 50-80% 10-20. 19,20,26 13.1, 26.3 16.9. 26 3. 당뇨병 (islet cell) (tropical pancreatitis). 40-80%. 26,27 19.8, 26.3, 11.9. 26 6-10. 19,28. 29 III.

5 Jin Woo Choo, et al. (gastric lipase) % ,20, , 당뇨병 (islet cell) (tropical pancreatitis) %. 26, , 26.3, , III. Other specific types C. Diseases of exocrine pancreas 3c. 30, %. 27,. 3c (pancreatic polypeptide response) 1, 2, (HbA 1c ). 31 National Institute of Diabetes and Digestive and Kidney Disease National Cancer Institute 3c (incretin) 췌장석회화,,, (Fig. 1). 33,34 0-4%, %, %. 23,26,. 23,35-38 Lee 39 A B Fig. 1. Abdominal computed tomography findings of a 49 year-old male with alcoholic chronic pancreatitis. Pancreatic ductal calcification (A, circle) and parenchymal calcifications (B) are seen. 67

Clinical Features of Chronic Pancreatitis 59 59.3% 51.6 88.1%.,,. Campisi 40 790 13.0% 68% 13.6%, 4.8%, 5.8%, 3.9% 3.9%. 67%, 88%, 91% 100%. 40 5. 가성낭종및가성동맥류 25% (Fig. 2).

6 Clinical Features of Chronic Pancreatitis % %.,,. Campisi % 68% 13.6%, 4.8%, 5.8%, 3.9% 3.9%. 67%, 88%, 91% 100% 가성낭종및가성동맥류 25% (Fig. 2). 19,20,26,41, %,,, (fistula).,, (32%) 37%, 26% (p < 0.05). 43 1, (29.7%) 39.9% (228/572), 19.8% (116/587) % 5-10%. 45,46. (Fig. 3). 34 (13 ) (21 ) (11.8%) A B Fig. 2. Abdominal computed tomography findings of a 57 year-old male with alcoholic chronic pancreatitis. Pancreatic duct stone (arrow) with upstream dilatation (A) and pseudocyst (B) are noted. 68

Jin Woo Choo, et al. 5. 46 6. 담도협착..,, (Fig. 4). 10%. 48 1,159 16% (186 ) 12.5% (145 ), 44 521 17.9% (93 ) 11.7% (61 ) 11.5% (60 ). 43 결론 A C Fig. 3.

Emergency angiography demonstrated pseudoaneurysm of the splenic artery (B). After embolization with coils and glue (C), no contrast leakage is seen (D). B D.,.,,.. A B Fig. 4.

7 Jin Woo Choo, et al 담도협착..,, (Fig. 4). 10%. 48 1,159 16% (186 ) 12.5% (145 ), % (93 ) 11.7% (61 ) 11.5% (60 ). 43 결론 A C Fig. 3. Serial imaging findings of 53 year-old male with alcoholic recurrent pancreatitis. Abdominal computed tomography showed ruptured pseudoaneurysm (A). Emergency angiography demonstrated pseudoaneurysm of the splenic artery (B). After embolization with coils and glue (C), no contrast leakage is seen (D). B D.,.,,.. A B Fig. 4. Imaging findings of a 59 year-old male with alcoholic chronic pancreatitis. Abdominal computed tomography showed pancreatic calcifications with bile duct dilatation (A). Endoscopic retrograde cholangiography showed intrapancreatic bile duct stricture with proximal duct dilatation (B). 69

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