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Chronic Pancreatitis

Pancreatitis is inflammation of the pancreas. The pancreas is a large gland behind the stomach and close to the duodenum-the first part of the small intestine. The pancreas secretes digestive juices, or enzymes, into the duodenum through a tube called the pancreatic duct. Pancreatic enzymes join with bile-a liquid produced in the liver and stored in the gallbladder-to digest food. The pancreas also releases the hormones insulin and glucagon into the bloodstream. These hormones help the body regulate the glucose it takes from food for energy.

Normally, digestive enzymes secreted by the pancreas do not become active until they reach the small intestine. But when the pancreas is inflamed, the enzymes inside it attack and damage the tissues that produce them. Pancreatitis can be acute or chronic. Either form is serious and can lead to complications. In severe cases, bleeding, infection, and permanent tissue damage may occur.Both forms of pancreatitis occur more often in men than women.

 

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What is chronic pancreatitis?

Chronic pancreatitis is inflammation of the pancreas that does not heal or improve-it gets worse over time and leads to permanent damage. Chronic pancreatitis, like acute pancreatitis, occurs when digestive enzymes attack the pancreas and nearby tissues, causing episodes of pain. Chronic pancreatitis often develops in people who are between the ages of 30 and 40.

The most common cause of chronic pancreatitis is many years of heavy alcohol use. The chronic form of pancreatitis can be triggered by one acute attack that damages the pancreatic duct. The damaged duct causes the pancreas to become inflamed. Scar tissue develops and the pancreas is slowly destroyed.

Other causes of chronic pancreatitis are

  • hereditary disorders of the pancreas
  • cystic fibrosis-the most common inherited disorder leading to chronic pancreatitis
  • hypercalcemia-high levels of calcium in the blood
  • hyperlipidemia or hypertriglyceridemia-high levels of blood fats
  • some medicines
  • certain autoimmune conditions
  • unknown causes

Hereditary pancreatitis can present in a person younger than age 30, but it might not be diagnosed for several years. Episodes of abdominal pain and diarrhea lasting several days come and go over time and can progress to chronic pancreatitis. A diagnosis of hereditary pancreatitis is likely if the person has two or more family members with pancreatitis in more than one generation.

Symptoms

Most people with chronic pancreatitis experience upper abdominal pain, although some people have no pain at all. The pain may spread to the back, feel worse when eating or drinking, and become constant and disabling. In some cases, abdominal pain goes away as the condition worsens, most likely because the pancreas is no longer making digestive enzymes. Other symptoms include

  • nausea
  • vomiting
  • weight loss
  • diarrhea
  • oily stools

People with chronic pancreatitis often lose weight, even when their appetite and eating habits are normal. The weight loss occurs because the body does not secrete enough pancreatic enzymes to digest food, so nutrients are not absorbed normally. Poor digestion leads to malnutrition due to excretion of fat in the stool.

Diagnosis

Chronic pancreatitis is often confused with acute pancreatitis because the symptoms are similar. As with acute pancreatitis, the doctor will conduct a thorough medical history and physical examination. Blood tests may help the doctor know if the pancreas is still making enough digestive enzymes, but sometimes these enzymes appear normal even though the person has chronic pancreatitis.

In more advanced stages of pancreatitis, when malabsorption and diabetes can occur, the doctor may order blood, urine, and stool tests to help diagnose chronic pancreatitis and monitor its progression.

After ordering x rays of the abdomen, the doctor will conduct one or more of the tests used to diagnose acute pancreatitis-abdominal ultrasound, CT scan, EUS, and MRCP.

Treatment

Treatment for chronic pancreatitis may require hospitalization for pain management, IV hydration, and nutritional support. Nasogastric feedings may be necessary for several weeks if the person continues to lose weight.

When a normal diet is resumed, the doctor may prescribe synthetic pancreatic enzymes if the pancreas does not secrete enough of its own. The enzymes should be taken with every meal to help the person digest food and regain some weight. The next step is to plan a nutritious diet that is low in fat and includes small, frequent meals. A dietitian can assist in developing a meal plan. Drinking plenty of fluids and limiting caffeinated beverages is also important.

People with chronic pancreatitis are strongly advised not to smoke or consume alcoholic beverages, even if the pancreatitis is mild or in the early stages.

Surgical Apporaches

Partial or Complete Pancreatectomy

Surgery may be recommended if a blockage is found. In severe cases, part or all of the pancreas may be removed.

Islet Cell Autotransplantion for Chronic Pancreatitis

 Building on its expertise in organ transplantation, UCSF is the only medical center west of the Mississippi offering islet transplantation as an option for managing the diabetes that results from a treatment of last resort-removal of the diseased pancreas. The procedure, in which functioning islet cells are harvested after the pancreas is removed and then are infused into the patient's liver, is performed by Hobart Harris, M.D., M.P.H., Chief of General Surgery at UCSF, and Andrew Posselt, M.D., Ph.D., a transplant surgeon and codirector of the UCSF Pancreatic Islet Transplant Program. 

Inflammation associated with recurrent bouts of pancreatitis causes scarring and blockage of the pancreatic ducts. This produces chronic pain that is often difficult to relieve with medications. In addition to pain, patients may also develop malabsorption because the function of digestive enzymes is compromised.

Removing the entire pancreas provides significant pain relief, but leaves patients severely diabetic because they no longer have pancreatic islets, which produce insulin. After removal of the pancreas, patients are completely dependent on external sources of insulin and their blood sugar can be extremely difficult to control.

Complications

People with chronic pancreatitis who continue to consume large amounts of alcohol may develop sudden bouts of severe abdominal pain.

As with acute pancreatitis, ERCP is used to identify and treat complications associated with chronic pancreatitis such as gallstones, pseudocysts, and narrowing or obstruction of the ducts. Chronic pancreatitis also can lead to calcification of the pancreas, which means the pancreatic tissue hardens from deposits of insoluble calcium salts. Surgery may be necessary to remove part of the pancreas.

In cases involving persistent pain, surgery or other procedures are sometimes recommended to block the nerves in the abdominal area that cause pain.

When pancreatic tissue is destroyed in chronic pancreatitis and the insulin-producing cells of the pancreas, called beta cells, have been damaged, diabetes may develop. People with a family history of diabetes are more likely to develop the disease. If diabetes occurs, insulin or other medicines are needed to keep blood glucose at normal levels. A health care provider works with the patient to develop a regimen of medication, diet, and frequent blood glucose monitoring.

Pediatric Chronic Pancreatitis

Chronic pancreatitis in children is rare. Trauma to the pancreas and hereditary pancreatitis are two known causes of childhood pancreatitis. Children with cystic fibrosis-a progressive and incurable lung disease-may be at risk of developing pancreatitis. But more often the cause of pancreatitis in children is unknown.

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