Inflammatory pancreatic diseases in older patients: recognition and management.

The aging process influences and modifies the clinical picture and treatment modalities of inflammatory pancreatic diseases in elderly patients. The two major categories of inflammatory exocrine pancreatic diseases seen in the elderly are acute pancreatitis (AP) and chronic pancreatitis (CP). In elderly patients with AP, the presence of concomitant diseases affecting renal, hepatic and cardiopulmonary function make the early clinical assessment of the severity of AP inaccurate at the time of admission to hospital. In addition, the classical multifactorial scoring system routinely utilised in clinical practice to determine the severity of AP may overscore elderly patients because increasing age is associated with more points. Contrast-enhanced computed tomography is particularly useful in assessing the severity of AP and is required in all patients suspected with severe AP. It should be repeated after a certain time period to monitor the disease. The most important aspect of the management of elderly patients with severe AP is the prevention and treatment of systemic and local complications. Treatment of AP should address the removal of aetiological factor(s) and support of organ systems and hydroelectrolytic/caloric balance; specific treatments (antiproteases, antibacterials) should also be administered to patients with severe AP. Surgery is indicated mainly when infection occurs following pancreatic necrosis and/or fluid collection. However, in selected patients with a high anaesthetic risk, alternative, less invasive drainage options (percutaneous, endoscopic) should be considered. CP rarely occurs in older age, and it should be suspected based on clinical findings. The greatest challenge is the differentiation between CP and pancreatic cancer. Treatment of CP in the elderly should be directed at controlling the symptoms, by management of diabetes and exocrine insufficiency because pain and complications are rare in elderly patients with CP. Compliance with treatment should be periodically assessed if insulin and/or oral enzyme supplementation is required. Careful evaluation of nutritional status and its prompt correction is also important.