Chronic pancreatitis

What causes chronic pancreatitis?

There are several possible reasons why a person may develop chronic pancreatitis. Repeated attacks of acute pancreatitis, from whatever cause, can lead to a state of chronic inflammation. The principal causes of chronic pancreatitis can be listed as follows:
  • Alcohol abuse is one of the commonest causes of chronic pancreatitis worldwide
  • Tropical pancreatitis is seen in parts of Southern Asia and Africa, and has a typical presentation and progression
  • Blockage of the pancreatic duct due to a stone, or a narrowing (stricture) of the duct or due to a congenital anomaly (pancreas divisum), can lead to chronic pancreatitis
  • Hypercalcaemia i.e. a persistently raised serum calcium level (often due to an overactive parathyroid gland) can cause chronic pancreatitis
  • Hereditary pancreatitis is a rare condition that runs in some families and affects people at a young age
  • Untreated biliary disease, in the form of gallstones or stones in the bile duct can cause repeated bouts of acute pancreatitis and then lead to a chronic state
  • Autoimmune pancreatitis is a condition where one’s own immune sysytem attacks one’s pancreas
  • Idiopathic pancreatitis refers to the group of patients in whom the cause is not clear
  • Rarely chronic pancreatitis can develop due to certain drugs or after radiotherapy for cancer
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What are the symptoms of chronic pancreatitis?

The symptoms are as follows:
  • Pain is the most common symptom. It can be quite severe and usually involves the upper abdomen and the back (the pancreas lied towards the back of the abdomen)
  • Passing greasy, light coloured, loose stools is called steatorrhea. This occurs because the pancreas is not making enough digestive enzyme and some of the fatty foods are going through undigested
  • Weight loss can occur
  • Compression of the duodenum (a part of the bowel) by a swollen pancreas can cause a hold up in the passage of food and lead to vomiting
  • Compression of the bile duct by a swollen pancreas can cause jaundice
  • Diabetes can sometimes develop when the pancreas is extensively scarred
  • Autoimmune pancreatitis is a condition where one’s own immune sysytem attacks one’s pancreas
  • Bleeding into the gut can sometimes be the first symptom

What tests are done to make the diagnosis of chronic pancreatitis?

The appearance of the pancreas is usually assessed on the basis of a CT scan. The appearance of the pancreatic ducts is assessed by doing an ERCP (an endoscopic procedure) or an MR scan called MRCP.
MRCP picture of the pancreatic duct
This MRCP picture shows chronic pancreatitis causing a narrowing of the pancreatic duct, with a swollen tortuous duct visible upstream
The functions of the pancreas, as you already know, are to make insulin, and make digestive enzymes. The former can be assessed by measurement of the fasting blood sugar (glucose) level. If the blood sugar level is raised, we know that the pancreas is not making enough insulin and the person has developed diabetes. The other function, of making digestive enzyme, is more difficult to assess, and various tests are described in the books. Two of the tests commonly used are the faecal elastase test (this measures the level of an enzyme called elastase in the stools) or the Pancreolauryl test.

What is the treatment of chronic pancreatitis?

Let us break this up into several separate steps:
  • The first and foremost priority is pain relief. One gradually works through a hierarchy of pain-killers starting with the less potent ones such as non-steroidals like ibuprofen and diclofenac, to stronger pain-killers like the opiates (morphine and drugs similar to it). Even among the opiates, there are milder ones that can be taken by mouth, such codeine or Tramadol, but some patients with chronic pancreatitis do get habituated to injections of opiates like morphine or pethidine. There are oral preparations of morphine as well (tablets, syrups and long-acting tablets). Certain opiate preparations can be worn as skin patches (like nicotine patches) that last 2-3 days. All medications have side-effects and these have to be balanced against the need to obtain relief from pain. If you are a patient, you should discuss your need for pain relief with your doctor. Coeliac block and Thoracoscopic splanchnicectomy are two procedures that divide some of the nerves responsible for transmitting pain signals, and may confer some relief of pain. Again, these need to be discussed with a doctor
  • If the patient has diarrhea and fat-intolerance from a lack of pancreatic enzyme, enzyme preparations can be taken with each meal
  • If diabetes has developed, that needs a medical consultation and treatment, with diet, oral medications or insulin
  • Genetic screening of the patient and his/her family may be called for in patients with hereditary pancreatitis or a strong family history of pancreatitis and in young patients with chronic pancreatitis without a clear cause
  • Surgical procedures may become necessary to deal with the following situations, should they develop
    • Intractable pain
    • Pancreatic duct stenosis (narrowing)
    • Cysts and pseudocysts
    • Biliary obstruction
    • Duodenal obstruction
    • Suspicion of cancer
    • Portal or splenic vein thrombosis
Surgery in patients with chronic pancreatitis can be technically challenging, and is not always associated with lasting relief of symptoms. If you are a patient and you need more information, you need to discuss this further with a doctor, preferably a specialist in pancreatic disease.