Chronic pancreatitis is long-term progressive inflammatory disease of the pancreas that leads to permanent deterioration of the structure and function of the pancreas. It is estimated that in Western Europe and North American chronic pancreatitis is diagnosed in 3 to 9 people in every 100,000 each year.
The most common cause is long-term alcohol abuse - it is thought to account for approximately 70% of all cases. The gradual rise in the incidence of chronic pancreatitis in several countries around the globe has been attributed to increasing alcohol consumption and earlier diagnosis.
Chronic pancreatitis results in over 122,000 outpatient visits and 56,000 hospitalizations annually in the USA. Significantly more men than women are affected.
Chronic pancreatitis usually begins in adults aged 40 to 50.
What is the pancreas?
The pancreas produces important enzymes and hormones that help break down foods.
The pancreas is a gland organ that is located in the abdomen, behind the stomach and below the ribcage.
The pancreas is part of the digestive system and produces important enzymes and hormones that help break down foods. It has an endocrine function because it releases juices directly into the bloodstream, and it has an exocrine function because it releases juices into ducts.
Enzymes, or digestive juices, produced by the pancreas are secreted into the small intestine to further break down food after it has left the stomach. The gland also produces the hormone insulin and secretes it into the bloodstream in order to regulate the body's glucose or sugar level.
Symptoms of chronic pancreatitis
Common signs and symptoms of chronic pancreatitis include:
- Pain - the patient may feel pain in the upper abdomen. The pain may sometimes be severe and can travel along the back. It is usually more intense after eating. Some pain relief may be gained by leaning forward or curling into a ball.
- Nausea and vomiting - more commonly experienced during episodes of pain.
- Constant 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 pancreas' ability to produce digestive juices deteriorates, the following symptoms may appear:
- Smelly and greasy feces (stools)
- Abdominal cramps
- Flatulence (breaking wind, farting)
Eventually the pancreas may not be able to produce insulin, leading to diabetes type 1, with the following symptoms:
- Frequent urination
- Intense hunger
- Weight loss
- Tiredness (fatigue)
- Blurred vision
Causes of chronic pancreatitis
Chronic pancreatitis is usually the follow-on of repeated episodes of acute pancreatitis which lead to permanent damage of the pancreas.
Acute pancreatitis is caused when trypsin becomes activated within the pancreas. Trypsin is an enzyme 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 - acute pancreatitis. Alcohol can cause a process which triggers the activation of trypsin inside the pancreas, as can gallstones.
Alcohol misuse causes 70% of chronic pancreatitis cases
People who misuse alcohol and develop acute pancreatitis tend to have repeated episodes, and eventually develop chronic pancreatitis (long-term) - that is why 70% of all chronic pancreatitis cases are caused by alcohol misuse. The repeated bouts of acute pancreatitis eventually take their toll on the pancreas, causing permanent damage, which then becomes chronic pancreatitis - also known as alcoholic chronic pancreatitis.
According to the National Health Service, UK, long-term alcoholic misuse that typically causes chronic pancreatitis consists of about 10 to 15 years of 10 units of alcohol per day or more. A typical 750ml bottle of 12% wine contains 9 units of alcohol. Approximately 5% to 10% of people with long-term alcohol misuse develop chronic pancreatitis.
Experts believe that patients with alcoholic chronic pancreatitis have specific genetic mutations which make them more susceptible to the effects of alcohol.
Idiopathic chronic pancreatitis makes up the bulk of the remaining 30% of cases
When a disease is idiopathic it means there is no known cause or reason to explain why or how it developed. Idiopathic chronic pancreatitis accounts for most of the remaining cases. Most cases of idiopathic chronic pancreatitis start to develop in people aged 10 to 20 years, and those over 50.
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% of patients with idiopathic chronic pancreatitis. Experts believe 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, and cystic fibrosis, another genetic condition which damages certain organs.
Diagnosis of chronic pancreatitis
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 (computed tomography) 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.
- MRCP (magnetic resonance cholangiopancreatography) scan - this scan will show the bile and pancreatic ducts more clearly than a CT scan.
- An ERCP (endoscopic retrograde cholangio-pancreatography) scan - an endoscope (thin, flexible tube with a camera at the end) 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.
Treatments for chronic pancreatitis
The following treatments are commonly recommended for chronic pancreatitis.
1) Lifestyle changes
Patients with chronic pancreatitis will need to undergo some lifestyle changes. These will include:
Stop drinking - 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.
Stop smoking - smoking is not a cause of pancreatitis, but it can accelerate the progression of the disease.
Diet - the pancreas is involved in digestion; pancreatitis damages the functions of the pancreas. This means that patients with the disease will have difficulty digesting many foods. Rather than three large meals a day, patients will be advised to change to six small meals. It is also better to avoid fatty meals, i.e. to follow a low-fat diet.
A diet plan will either be drawn up by the doctor, or the patient may be referred to a qualified dietitian.
Depending on the extent of pancreatic damage, patients may also have to take artificial versions of some enzymes to aid digestion. These will ease bloating, make the feces less greasy and foul-smelling, and help the abdominal cramps.
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 the patient responds.
The pancreas may stop producing insulin if the damage is extensive. The patient will have developed diabetes type 1. Regular insulin treatment will become part of the treatment for the rest of the patient'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 (top section) of the pancreas. The inflammation aggravates the nerve endings.
5) Endoscopic surgery
A narrow, hollow, flexible tube (endoscope) goes into the digestive system guided by ultrasound. A devise 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.
6) Pancreas resection
The head of the pancreas is surgically removed. This not only relieves the pain caused by inflammation which was 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 gall bladder, 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 blocked as well. This is the most effective procedure for reducing pain and conserving pancreas function. However, it has the highest risk infection and internal bleeding.
7) Total pancreatectomy
This involves the surgical removal of the whole pancreas. It is very effective in dealing with the pain. However, the patient will be totally dependent on treatment for some of the vital functions of the pancreas, such as the release of insulin.
8) 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 - they will exist in the liver where they produce insulin.
Complications of chronic pancreatitis
Stress, anxiety, 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 don't usually cause any 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.
Prevention of chronic pancreatitis
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.