Chronic pancreatitis refers to longstanding inflammation of the pancreas that leads to irreversible glandular destruction, and affects the pancreas's ability to function normally. This may follow episodes of acute pancreatitis, or occur without an identifiable attack. It is more common in men, and usually connected to alcohol. People with chronic pancreatitis require ongoing medical care to minimise their symptoms, to slow the progression of the condition whenever possible, and to address any complications that arise. In most cases, treatment controls but does not cure the underlying problem.
Alcohol is the most common risk factor (80 percent). Very rarely, gallstones lead to chronic pancreatitis. Genetic and congenital abnormalities of the pancreas are also implicated, and in some instances the cause of chronic pancreatitis is unknown (idiopathic).
Early disease is asymptomatic.
Frequent abdominal pain is the most common symptom of chronic pancreatitis. This is situated in the middle of the abdomen and often radiates to the back, or may be primarily situated at the back. The pain is often exacerbated by food or alcohol, and may be relieved by sitting up or leaning forward. It may be associated with nausea and vomiting. Acute attacks may still occur in chronic disease.
Weight loss is common and is due to malabsorption of nutrients. The pancreas plays a vital role in the digestion of food and a lack of lipase (an enzyme involved in fat digestion) leads to fat malabsorption and steatorrhoea (diarrhea with pale, offensive stools with visible fat globules).
Low blood calcium levels result from defective calcium absorption and protein malabsorption due to deficient pancreatic enzymes (proteases) that digest proteins, contributes to weight loss.
In severe cases, the pancreas loses its ability to produce enough insulin, leading to diabetes.
If pancreatic function is severely affected, a person may also experience symptoms of vitamin and nutrient deficiencies.
Chronic pancreatitis can lead to a variety of complications. Jaundice may be caused by distortion of the common bile duct or associated liver cirrhosis affecting the drainage of bile from the liver and gallbladder. There is a risk of pancreatic cancer that can be very difficult to distinguish from chronic pancreatitis, especially in the earlier stages. Other complications include the formation of cyst-like structures around the pancreas, blockage of the duct that drains the pancreas due to strictures, and stones. Bleeding from varicose veins in the swallowing tube (esophageal varices) can also occur.
Plain abdominal X-rays may reveal pancreatic calcifications in 30 percent in the later stages of the disease. These are most common in people who have alcoholic pancreatitis.
Abdominal ultrasound is used to assess the pancreatic duct for abnormalities, tumours and cysts. ERCP can reveal pancreatic duct and side branch abnormalities, while magnetic resonance gives excellent images of the pancreas and the ducts without instrumentation.
It can be difficult to determine if chronic pancreatitis or another problem is the cause of a person's illness. Tests may be normal, especially during the first two to three years of the condition. It can also be difficult to distinguish chronic pancreatitis from acute pancreatitis. Serum amylase and lipase may be elevated in acute on chronic episodes of pain, but is often normal in between. Liver function tests (albumin and clotting studies) may be abnormal due to the associated malabsorption, cirrhosis or if ductal abnormalities due to the pancreatitis are interfering with drainage from the gallbladder and indirectly affecting the liver.
Functional tests of the pancreas are not routinely performed. However, stool tests can detect steatorrhoea, or abnormal levels of fat in a stool sample. The presence of high levels of fat indicates fat malabsorption.
TREATMENT and PROGNOSIS
Treatment is aimed at pain relief, correction of poor pancreatic function, and measures to manage complications.
Avoiding alcohol is the single most important treatment for persons with pancreatitis due to alcohol. This can ease pain and reduce the risk of acute pancreatitis.
Similarly, eating smaller, low-fat meals or fasting for several days may contribute to pain relief by eliminating meal-associated stimulation of the pancreas. However, fasting usually requires hospitalisation for intravenous feeding.
Early in the course of chronic pancreatitis, non-steroidal anti-inflammatory drugs (NSAIDs), usually control pain.
Pancreatic enzyme supplements may alleviate pain in some patients by decreasing meal-associated stimulation of the pancreas. Narcotic analgesics (for example, oxycodone and fentanyl) are powerful pain-relieving drugs that require a prescription. These drugs are often recommended if pancreatic enzymes fail to relieve pain.
Surgery can open parts of the pancreas that are blocked or remove part or the entire pancreas, and is indicated in patients with intractable pain, or pancreatic cysts.
In patients with fat malabsorption and steatorrhoea, a low-fat diet is indicated. This usually relieves the steatorrhoea, but does not restore fat absorption to normal levels. Oral supplements that contain the enzyme lipase (like Creon) can reduce fat malabsorption and steatorrhoea. These supplements may become more effective if acid-suppressing drugs are added. Alternatively, encapsulated preparations containing larger amounts of the enzyme may be effective. Dietary advice is necessary.
Diabetes mellitus due to chronic pancreatitis is often difficult to control despite modest insulin requirement
The information provided in this article was correct at the time of publishing. At Mediclinic we endeavour to provide our patients and readers with accurate and reliable information, which is why we continually review and update our content. However, due to the dynamic nature of clinical information and medicine, some information may from time to time become outdated prior to revision.