What's to know about chronic pancreatitis?
The pancreas is a gland organ that is located in the abdomen, behind the stomach and below the ribcage. It specializes in producing important enzymes and hormones that help break down and digest foods. It also makes insulin to moderate the levels of sugar in the blood.
The most common cause is long-term alcohol abuse - it is thought to account for between 70 and 80 percent of all cases.
Chronic pancreatitis results in over 122,000 visits to a doctor and 56,000 hospitalizations annually in the United States.
Significantly more men than women are affected.
The pancreas produces important enzymes and hormones that help break down foods.
The following treatments are commonly recommended for chronic pancreatitis.
People with chronic pancreatitis will need to undergo some lifestyle changes. These will include:
- Stopping alcohol consumption: Giving up drinking will help prevent further damage to the pancreas. It will also contribute significantly towards relieving the pain. Some people may need professional help to quit alcohol.
- Stopping tobacco use: Smoking is not a cause of pancreatitis, but it can accelerate the progression of the disease.
Treatment should not only focus on helping ease the pain symptoms, but also depression which is a common consequence of long-term pain.
Doctors will usually use a step-by-step approach, in which mild painkillers are prescribed, gradually becoming stronger until pain becomes manageable.
The pancreas may stop producing insulin if the damage is extensive. The individual is likely to have developed diabetes type 1.
Regular insulin treatment will become part of the treatment for the rest of the person's life. Diabetes type 1 caused by chronic pancreatitis involves injections, not tablets, because most likely the digestive system will not be able to break them down.
Severe chronic pain sometimes does not respond to painkilling medications. The ducts in the pancreas may have become blocked, causing an accumulation of digestive juices which puts pressure on them, causing intense pain. Another cause of chronic and intense pain could be inflammation of the head of the pancreas.
Several forms of surgery may be recommended to treat more severe cases.
A narrow, hollow, flexible tube called an endoscope is inserted into the digestive system, guided by ultrasound. A device with a tiny, deflated balloon at the end is threaded through the endoscope. When it reaches the duct, the balloon is inflated, thus widening the duct. A stent is placed to stop the duct from narrowing back.
The head of the pancreas is surgically removed. This not only relieves the pain caused by inflammation irritating the nerve endings, but it also reduces pressure on the ducts. Three main techniques are used for pancreas resection:
- The Beger procedure: This involves resection of the inflamed pancreatic head with careful sparing of the duodenum, the rest of the pancreas is reconnected to the intestines.
- The Frey procedure: This is used when the doctor believes pain is being caused by both inflammation of the head of the pancreas as well as the blocked ducts. The Frey procedure adds a longitudinal duct decompression to the pancreatic head resection - the head of the pancreas is surgically removed, and the ducts are decompressed by connecting them directly to the intestines.
- Pylorus-sparing pancreaticoduodenectomy (PPPD): The gallbladder, ducts, and the head of the pancreas are all surgically removed. This is only done in very severe cases of intense chronic pain where the head of the pancreas is inflamed, and the ducts are also blocked. This is the most effective procedure for reducing pain and conserving pancreas function. However, it has the highest risk of infection and internal bleeding.
This involves the surgical removal of the whole pancreas. It is very effective in dealing with the pain. However, a person who has had a total pancreatectomy will be dependent on treatment for some of the vital functions of the pancreas, such as the release of insulin.
Autologous pancreatic islet cell transplantation (APICT)
During the total pancreatectomy procedure, a suspension of isolated islet cells is created from the surgically removed pancreas and injected into the portal vein of the liver. The islets cells will function as a free graft in the liver and will produce insulin.
Taking dietary measures to reduce the effects of pancreatitis are vital.
The pancreas is involved in digestion, but pancreatitis can impair this function. This means that people with the disease will have difficulty digesting many foods.
Rather than three large meals a day, people with pancreatitis will be advised instead to consume six small meals. It is also better to follow a low-fat diet.
Managing the diet during pancreatitis aims to achieve four outcomes:
- reducing the risk of malnutrition and shortages of certain nutrients
- avoiding high or low blood sugar
- managing or preventing diabetes, kidney disease, and other complications
- decreasing the likelihood of an acute flare-up of pancreatitis
A diet plan will either be drawn up by the doctor, or the patient may be referred to a qualified dietitian. The plan is based on the current levels of nutrients in the blood shown in diagnostic testing.
Meal plans will generally involve food sources that are high in protein and have dense nutritional content. These are likely to include whole grains, vegetables, fruits, low-fat dairy products, and lean protein sources, such as boneless chicken and fish.
Fatty, oily, or greasy foods should be avoided, as these can trigger the pancreas to release more enzymes than usual. As a primary cause of chronic pancreatitis, alcohol is also best avoided while on a pancreatitis-friendly diet.
Depending on the extent of the damage, patients may also have to take artificial versions of some enzymes to aid digestion. These will ease bloating, make their feces less greasy and foul-smelling, and help any abdominal cramps.
A person with chronic pancreatitis may experience abdominal pain that travels along the back.
Common signs and symptoms of chronic pancreatitis include:
- severe upper abdominal pain that can sometimes travel along the back and is more intense following a meal
- nausea and vomiting, more commonly experienced during episodes of pain
As the disease progresses the episodes of pain become more frequent and severe. Some patients eventually suffer constant abdominal pain.
As chronic pancreatitis progresses, and the ability of the pancreas to produce digestive juices deteriorates, the following symptoms may appear:
- smelly and greasy stools
- abdominal cramps
Eventually, the pancreas may not be able to produce insulin at all, leading to type 1 diabetes, which can produce the following symptoms:
- frequent urination
- intense hunger
- weight loss
- blurred vision
Chronic pancreatitis is usually a complication of recurrent episodes of acute pancreatitis. These can lead to permanent damage in the pancreas.
Acute pancreatitis is caused when trypsin becomes activated within the pancreas. Trypsin is an enzyme that is produced in the pancreas and released into the intestines, where it breaks down proteins as part of the digestive system.
Trypsin is inactive until it has reached the intestines. If trypsin becomes activated inside the pancreas, it will start to digest the pancreas itself, leading to irritation and inflammation of the pancreas. This becomes acute pancreatitis.
Alcohol can cause a process which triggers the activation of trypsin inside the pancreas, as can gallstones.
People who misuse alcohol and develop acute pancreatitis tend to have repeated episodes, and eventually develop chronic pancreatitis.
The repeated bouts of acute pancreatitis eventually take their toll on the pancreas, causing permanent damage, which then becomes chronic pancreatitis.
This is also known as alcoholic chronic pancreatitis.
Idiopathic chronic pancreatitis
When a disease is idiopathic, it has no known cause or reason. Idiopathic chronic pancreatitis accounts for most of the remaining cases.
Most cases of idiopathic chronic pancreatitis develop in people aged 10 to 20 years and those aged over 50 years.
Nobody is certain why other age groups are rarely affected. The SPINK-1 and The CFTR genes, types of mutated genes, exist in about 50 percent of patients with idiopathic chronic pancreatitis. These genetic mutations may undermine the functions of the pancreas.
Other much rarer causes include:
- autoimmune chronic pancreatitis, in which the person's own immune system attacks the pancreas
- heredity pancreatitis, where patients have a genetic condition and are born with a faulty pancreas
- cystic fibrosis, another genetic condition that damages organs including the pancreas
There are no reliable tests to diagnose chronic pancreatitis. A doctor will suspect the disease because of the patient's symptoms, history of repeated acute pancreatitis flare-ups, or alcohol abuse.
Blood tests may be useful in checking the blood glucose levels, which may be elevated.
Blood tests for elevated levels of amylase and lipase are not reliable at this stage. Amylase and lipase blood levels rise during the first couple of days of pancreatitis, and then settle back to normal after five to seven days. A patient with chronic pancreatitis would have had the disease for much longer.
Doctors need to have a good look at the pancreas in order to diagnose the disease properly. This will most likely involve:
- An ultrasound scan: High frequency sound waves create an image on a monitor of the pancreas and its surroundings.
- A CT scan: X-rays are used to take many pictures of the same area from several angles, which are then placed together to produce a 3-D image. The scan will reveal changes of chronic pancreatitis.
- Magnetic resonance cholangiopancreatography (MRCP) scan: This scan shows the bile and pancreatic ducts more clearly than a CT scan.
- An endoscopic retrograde cholangio-pancreatography (ERCP) scan: An endoscope is inserted into the digestive system. The doctor uses ultrasound to guide the endoscope through.
Patients with chronic pancreatitis have an elevated risk of developing pancreatic cancer. If symptoms worsen, especially the narrowing of the pancreatic duct, doctors may suspect cancer. If so, they will order a CT scan, MRI scan, or endoscopic study.
Constant or recurring pain may cause anxiety, irritability, stress, and depression.
There are several ways in which chronic pancreatitis can develop and become more harmful to a person's wellbeing.
Stress, anxiety, and depression
The disease may have an effect on the patient's psychological and emotional well being. Constant or recurring pain, which is often severe, may cause distress, anxiety, irritability, stress, and depression.
It is important for patients to tell their doctors if they are emotionally or psychologically affected. If there is a support group in your area, being able to talk to people who share the same condition may help you feel less isolated and more able to cope.
This is a collection of tissue, fluid, debris, pancreatic enzymes, and blood in the abdomen, caused by leakage of digestive fluids escaping from a faulty pancreatic duct.
Pseudocysts do not usually cause any health problems. However, sometimes they can become infected, cause blockage to part of the intestine, or rupture and cause internal bleeding. If this happens, the cyst will have to be surgically drained.
Even though pancreatic cancer is more common among patients with chronic pancreatitis, the risk is only 1 in 500.
Patients with acute pancreatitis significantly reduce their risk of developing chronic pancreatitis if they give up drinking alcohol. This is especially the case for patients who drink heavily and regularly.