Chronic Pancreatitis

What is chronic pancreatitis?

Chronic pancreatitis is a disease in which the structure and the function of the pancreas are permanently damaged over a long period.

The pancreas is an organ lying behind the stomach with very important tasks in the digestive system. It has two chief tasks:

• To produce the enzymes that digest food, particularly fats, proteins and carbohydrates,
• To produce insulin and the other hormones that regulate the blood sugar.

In chronic pancreatitis, damage and scarring (fibrosis) may develop in the tissue of the pancreas over time. As the disease advances the capacity of the pancreas to produce digestive enzymes may fall, and in some patients the production of insulin may also be disturbed.

For this reason chronic pancreatitis is not a disease that only causes pain; in its later stages it can also cause impaired digestion and absorption, weight loss, vitamin deficiencies and diabetes.

What are the causes of chronic pancreatitis?

There is no single cause of chronic pancreatitis. Sometimes more than one factor plays a part together.

Alcohol

Drinking alcohol in large amounts over a long period is one of the important causes of chronic pancreatitis.

But not everyone who drinks alcohol develops chronic pancreatitis, and not everyone with chronic pancreatitis drinks alcohol.

The person’s genetic characteristics, smoking and other factors can also affect whether the disease develops.

Smoking

Smoking is an independent risk factor for chronic pancreatitis.

It can also speed up the progression of the disease. Stopping smoking is therefore an important part of treatment for people with chronic pancreatitis.

Repeated attacks of acute pancreatitis

In some people, repeated attacks of acute pancreatitis can over time lead to permanent damage to the pancreas and to chronic pancreatitis.

Genetic causes

Genetic factors may play a part particularly in people whose disease began at a young age, who have a family history of pancreatitis, or who have recurrent pancreatitis of unexplained cause.

Obstruction of the pancreatic duct

Strictures, stones or certain structural problems causing long-standing obstruction of the pancreatic duct can contribute to the development of chronic pancreatitis.

Autoimmune pancreatitis

Autoimmune pancreatitis, in which the immune system affects the pancreas, has different characteristics from the other kinds of chronic pancreatitis, and its treatment is different too.

Accurate diagnosis is therefore important.

Chronic pancreatitis of unknown cause

Despite all investigations, no clear cause is found in some patients. This is called idiopathic chronic pancreatitis.

What are the symptoms of chronic pancreatitis?

The symptoms of the disease can vary considerably from person to person and with the stage of the disease.

The commonest symptoms are:

• Pain in the upper abdomen,
• Pain going through to the back,
• Abdominal pain that may increase after meals,
• Nausea,
• Loss of appetite,
• Weight loss,
• Fatty stools,
• Diarrhoea or changes in bowel habit,
• Bloating and wind.

But pain is not necessarily present in every patient with chronic pancreatitis.

In some patients the disease is first noticed through weight loss, fatty stools or the development of diabetes.

What is the pain like in chronic pancreatitis?

The pain is generally felt in the upper middle part of the abdomen and may spread through to the back.

In some patients it may increase after meals. At the beginning it comes and goes; in later stages it may become more frequent or constant.

But the pattern of the pain in chronic pancreatitis is quite variable. There is not always a direct relationship between the progression of the disease and the severity of the pain.

Why does chronic pancreatitis impair digestion?

The pancreas normally secretes powerful digestive enzymes into the small bowel after meals.

These enzymes help to break down in particular:

• fats → into fatty acids,
• proteins → into smaller structures,
• carbohydrates → into absorbable sugars.

As chronic pancreatitis advances, the pancreas may not be able to produce enough digestive enzymes.

This state is called exocrine pancreatic insufficiency.

When food cannot be broken down enough, its absorption from the bowel may also be disturbed. Maldigestion and malabsorption may then develop.

What are fatty stools (steatorrhoea)?

The digestion of fats depends to a great extent on the pancreatic enzymes.

When the pancreas’s production of enzymes falls seriously, fats cannot be digested sufficiently and begin to be passed in the stool.

This is called steatorrhoea.

The stool may be:

• Bulky,
• Greasy or shiny,
• Pale in colour,
• Foul-smelling,
• Liable to stick to the lavatory and hard to flush away.

Long-standing fat malabsorption can contribute to weight loss and, in particular, to deficiency of vitamins A, D, E and K.

Does chronic pancreatitis cause weight loss?

Yes.

Weight loss may have more than one cause.

Food not being sufficiently digested because of the fall in pancreatic enzymes is one of the important causes. Eating less because of pain, cutting down meals for fear that pain will follow, and the development of diabetes can also contribute to weight loss.

Where there is marked weight loss, the cause must be assessed.

Can chronic pancreatitis cause diabetes?

Yes.

The pancreas produces not only digestive enzymes but also the hormones that regulate the blood sugar.

As the disease advances the insulin-producing cells may also be damaged, and diabetes due to the pancreas may develop.

This type of diabetes differs in some ways from classical type 1 and type 2 diabetes, and is also called type 3c diabetes.

The blood sugar should therefore be assessed at intervals in patients with chronic pancreatitis.

How is chronic pancreatitis diagnosed?

The diagnosis does not rest on a single blood test.

The patient’s history, their symptoms and imaging methods are assessed together.

The methods that may be used include:

• Computed tomography (CT),
• Magnetic resonance imaging and MRCP,
• Endoscopic ultrasound (EUS),
• Other tests of pancreatic function in selected situations.

In advanced chronic pancreatitis, imaging may show changes such as calcifications in the pancreas, widening or irregularity of the pancreatic duct, stones in the duct, and shrinkage of the pancreatic tissue.

In the early stage the diagnosis can be more difficult.

Can amylase and lipase be normal?

Yes.

This is an important matter that patients ask about often.

While amylase and lipase are often raised in acute pancreatitis, these enzymes can be normal in chronic pancreatitis.

So a normal amylase or lipase result does not on its own exclude chronic pancreatitis.

Why is an EUS done?

Endoscopic ultrasound (EUS) helps to assess the pancreas at high resolution.

It can be useful particularly in patients where CT or MRI has not given a definite answer and early chronic pancreatitis is suspected.

But the EUS findings must also be assessed together with the patient’s other clinical and imaging findings.

What is the faecal elastase test?

Measuring pancreatic elastase in the stool is a non-invasive test used often to assess the exocrine function of the pancreas.

Low values may suggest that the pancreas is not producing enough digestive enzymes.

But the result is not assessed on its own. It should be remembered in particular that the result can come out lower than it truly is in very watery stool.

How is chronic pancreatitis treated?

Treatment in chronic pancreatitis is planned for the individual.

The aims can be summarised as:

• Controlling the pain,
• Reducing further damage to the pancreas,
• Correcting problems of digestion and nutrition,
• Preventing deficiencies of vitamins and minerals,
• Treating diabetes,
• Detecting and treating any complications that may develop.

What is pancreatic enzyme treatment?

In patients who develop exocrine pancreatic insufficiency, pancreatic enzyme replacement therapy (PERT) may be used.

These medicines help to take the place of the digestive enzymes the pancreas cannot produce in sufficient quantity.

The enzymes are generally taken with main meals and with snacks.

When used at a suitable dose:

• Fatty stools may lessen,
• Digestion may improve,
• Weight loss may be prevented, or gaining weight may become easier,
• It may help the nutritional state to improve.

The dose of enzyme treatment is adjusted according to the person’s meals, their symptoms and their response to treatment.

How should one eat with chronic pancreatitis?

In the past, very low-fat diets were recommended to patients with chronic pancreatitis. Today the approach is more individual.

The chief aim is to ensure enough energy and protein are taken and that malnutrition is prevented.

It is not right for patients to restrict fat excessively without need. In people with exocrine pancreatic insufficiency, the aim is adequate and balanced eating with suitable pancreatic enzyme treatment.

In patients with weight loss or nutritional deficiency, nutritional support may be planned separately.

Stopping alcohol and smoking is particularly important in managing the disease.

Which vitamins may become deficient?

In marked fat malabsorption in particular, the absorption of the fat-soluble

vitamins A, D, E and K

may be reduced.

Disturbance of vitamin D and calcium metabolism can also affect bone health.

For this reason, in long-standing chronic pancreatitis the patient’s nutritional state and, where needed, their vitamin and mineral levels are assessed.

What are the complications of chronic pancreatitis?

During the course of the disease some people may develop:

• Exocrine pancreatic insufficiency,
• Malabsorption and malnutrition,
• Diabetes,
• A pancreatic pseudocyst,
• Stones or a stricture in the pancreatic duct,
• Problems due to pressure on the bile duct or the duodenum,
• Complications involving the blood vessels.

These complications are not expected to develop in every patient.

Is endoscopic treatment or an operation needed?

Not every patient with chronic pancreatitis needs an endoscopic procedure or an operation.

But endoscopic or surgical treatments may come into consideration in situations such as stones or a stricture in the pancreatic duct, a rise in the pressure within the duct, certain pseudocysts, or pain resistant to treatment.

Which method is suitable is decided according to the structure of the pancreas and the patient’s clinical state.

Does chronic pancreatitis turn into pancreatic cancer?

The risk of pancreatic cancer is increased in people with chronic pancreatitis compared with the general population. But this does not mean that everyone with chronic pancreatitis will develop pancreatic cancer.

Reassessment is needed particularly where there is new pain or pain that changes in character, unexplained marked weight loss, jaundice, or an unexpected deterioration in the existing state.

In certain hereditary forms of pancreatitis the risk may be more marked and the approach to follow-up may differ.

When should a doctor be consulted?

Assessment for pancreatic disease may be needed particularly where there is:

• Constant or recurrent upper abdominal pain,
• Abdominal pain going through to the back,
• Unexplained weight loss,
• Fatty, foul-smelling stools,
• Newly developed diabetes,
• Jaundice,
• Repeated attacks of pancreatitis.

Where there are new and marked complaints such as sudden, very severe abdominal pain, persistent vomiting, fever or jaundice, medical assessment should be made without delay.

Remember

Chronic pancreatitis is not a disease of the pancreas that only causes pain.

As the disease advances, the production of digestive enzymes by the pancreas may fall, and exocrine pancreatic insufficiency, malabsorption, weight loss and vitamin deficiencies may develop. Where the hormone production of the pancreas is affected, diabetes may follow.

In treatment, what matters is not only reducing the pain but avoiding smoking and alcohol, ensuring adequate nutrition, treating pancreatic enzyme insufficiency and diabetes, and watching for the complications that may develop.