Chronic Pancreatitis

Chronic pancreatitis is inflammation of the pancreas that occurs over many years. The chronic inflammation results in permanent and irreversible damage to the pancreas.

What is the pancreas?

The pancreas is an organ in the upper abdomen lying behind the stomach and is attached to the back wall of the abdomen. It produces enzymes that pass into the pancreas duct which empties, together with the bile duct, into the duodenum (the first part of the small intestine just after the stomach). The pancreas enzymes are needed to digest food. The pancreas also has special group of cells that make important hormones such as the insulin. These hormones are passed into the blood stream to control the blood sugar level.

What is pancreatitis?

Pancreatitis is the inflammation of the pancreas. There are two types:

1. Acute pancreatitis: the inflammation occurs suddenly and last for days. It tends to disappear completely often without leaving a permanent damage. Click here to read more about acute pancreatitis.
2. Chronic pancreatitis: the inflammation is persistent but less intense. It causes scarring and damage to the pancreas that is irreversible.

How common is chronic pancreatitis?

In Australia, about 4 in 100,000 people develop chronic pancreatitis each year. The rate is increasing due to the increase in alcohol consumption. Chronic pancreatitis is more common in men than women.

What are the causes of chronic pancreatitis?

1. Alcohol is responsible for 7 out of 10 cases.
2. Genetic causes e.g. cystic fibrosis
3. Autoimmune. This is when the immune system attacks the pancreas e.g. Sjogren's syndrome
4. Malnutrition
5. Hereditary pancreatitis
6. Gallstones, if neglected. Click here to read more about gallstones.
7. Drugs e.g. azathioprine, and some diuretics.
8. Trauma to the pancreas
9. Metabolic disorders e.g. hypertriglyceridaemia and hypercalcaemia.
10. Unknown. No cause is found in 2 out of 10 patients.

What happens in chronic pancreatitis?

The persistent inflammation in the pancreas result in scarring and damage to parts of the pancreas. This leads to not enough digestive enzymes and insulin being made by the pancreas. The lack of enzymes results in poor digestion of food causing malabsorption. The lack of insulin results in diabetes.
As the damage progress, stones made of calcium form inside the pancreas and its duct causing blockage to the duct. The scarring process affects other nearby structures such as the bile duct and local nerves.
This process takes many years to develop and by the time it is diagnosed, significant damage had already occurred.

What are the symptoms of chronic pancreatitis?

1. Abdominal pain. The pain is typically in the upper abdomen and spread to the back. The pain is persistent and may be eased by sitting leaning forward. Earlier in the disease, attacks are closely related to drinking alcohol but as the inflammation progress, pain can occur despite abstinence from alcohol.
2. Malabsorption (poor digestion). The digestion of fat and certain vitamins is particularly affected. Undigested fat causes pale, smelly, loose stools that are difficult to flush in the toilet (steatorrhoea).
3. Weight loss as a result of malabsorption
4. Diabetes.
5. Nausea and vomiting

What are the tests for chronic pancreatitis?

Unfortunately, early diagnosis is difficult as no single test can reliable pick chronic pancreatitis.

• Blood tests to check blood count, kidney and liver function
• Blood tests for diabetes
• Stool tests to diagnose malabsorption
• CT scan may show damage and calcification in the pancreas and any complications.
• MRCP. This is MRI scan of the bile duct to diagnose blockage of the bile duct by stones or by scarring.

What are the complications of chronic pancreatitis?

• Pseudocysts. These are fluid collections near the pancreas rich in pancreas enzymes resulting from leak of pancreas fluid due to a blocked pancreas duct. They occur in about 1 in 4 patients with chronic pancreatitis. They can press on nearby organs causing symptoms.
• Pancreas ascites.
• Diabetes.
• Blockage of the bile duct.
• Cancer of the pancreas.
• Gastrointestinal bleeding
• Narcotic dependence – due to the severity of pain many patients become dependent on narcotic drugs such as morphine.
• Other less common complications such as thrombosis in blood vessels near the pancreas.

What is the treatment of chronic pancreatitis?

• Total and permanent abstinence from alcohol – this is the most essential part of treatment.
• Painkillers
• Enzyme replacement therapy- capsules containing aritificial enzymes may be needed to help digestion and treat steatorrhoea.
• Dietary fat restriction
• Insulin – if diabetes develop.
• Vitamins
• Surgery – if required

What is the role of surgery in the treatment of chronic pancreatitis?

Most patients with chronic pancreatitis do not need surgery. Surgery may be needed in:

1. Persistent severe pain not helped by painkillers
2. Management of complications of chronic pancreatitis.

Patients with obstruction in pancreas duct may benefit from operation to drain the pancreas duct and remove large calcium stones (e.g. Puestow procedure).
When scarring affect one part of the pancreas, then removing that part may help the pain.
Complications such as pseudocyst or bile duct blockage often require surgery.
New techniques are emerging that allow some of these interventions to be done endoscopically.

What is the outlook for chronic pancreatitis?

Alcohol related chronic pancreatitis is a serious disease. Life expectancy is reduced by 10-20 years in patients who continue to drink alcohol. In patients who stop drinking the outlook is much better.