What is Chronic Pancreatitis (Pancreatitis)?
The pancreas is a digestion organ that has two main roles. It helps break down large food molecules like proteins, carbs, and fats. It does this with the help of bile from another duct in our bodies. The pancreas has a main duct, a secondary duct, and several different kinds of cells inside it. These ducts can either get blocked or have genetic abnormalities. Continuous inflammation can cause scarring and hardened tissue in the ducts, causing permanent damage and affecting its ability to work correctly.
Chronic pancreatitis is a persistent inflammation of the pancreas, affecting both of its functions. When it affects the pancreas’ ability to help in digestion, patients may face issues like pancreatic insufficiency, fatty stools, and weight loss. Pancreatic insufficiency occurs when more than 90% of the pancreas is damaged. Depending on how severe the disease is, it can affect up to 85% of those with serious chronic pancreatitis. When the ability of the pancreas to produce certain hormones is affected, it can eventually lead to a certain type of diabetes known as pancreatogenic diabetes.
Chronic pancreatitis doesn’t act like acute pancreatitis. The latter condition causes sudden severe abdominal pain that may be felt in the back. People with chronic pancreatitis might not show any symptoms for a long time. However, they might also experience continuous abdominal pain, and the pain can get severe enough to require hospitalization. Chronic pancreatitis and acute pancreatitis also differ in the types of inflammation cells present. For example, acute pancreatitis mainly involves a type of white blood cell called neutrophils, while chronic pancreatitis involves more mononuclear cells.
What Causes Chronic Pancreatitis (Pancreatitis)?
Chronic pancreatitis, a long-lasting inflammation of the pancreas, can be caused by a range of factors. Over-consumption of alcohol, blockages in the pancreatic duct due to cancer, stones, or injury, certain genetic conditions like cystic fibrosis or hereditary pancreatitis, chemotherapy, and autoimmune diseases like lupus or autoimmune pancreatitis all contribute to this condition. Recent research also suggests that lacking certain vitamins and antioxidants could influence the development of this disease.
Alcohol is the leading cause of chronic pancreatitis. Drinking excess alcohol causes the pancreas to release more proteins, thickening its fluids and potentially leading to blockages, fibrosis (scarring), and atrophy (wasting away). However, not everyone who abuses alcohol ends up with this condition – less than 10% in fact – suggesting that other factors are at play as well.
Other common causes include high calcium levels in the blood (hypercalcemia), high levels of blood fats (hyperlipidemia), particularly types 1 and V, nutritional factors, blockages of the pancreatic duct (which can be present from birth or develop later), and certain medications.
Risk Factors and Frequency for Chronic Pancreatitis (Pancreatitis)
Chronic pancreatitis is a condition that’s often difficult to diagnose compared to other illnesses, especially if it’s caused by alcohol, as it tends to progress slowly without being noticed. An epidemiological report from 2014 estimated that the incidence, or number of new cases over time, has been fairly steady. However, the actual prevalence of the disease might be higher than estimated, indicating further research is needed.
- This condition is more prevalent among African Americans in the US than Caucasians.
- When chronic pancreatitis is due to alcohol, it tends to occur more frequently in males.
- In contrast, cases related to high lipids in the blood, or hyperlipidemia, are common among females.
- The average age at diagnosis is usually 45.
Signs and Symptoms of Chronic Pancreatitis (Pancreatitis)
Chronic pancreatitis is a condition that affects the pancreas, an organ crucial for digestion. People with this condition might experience prolonged abdominal pain that comes and goes, weight loss, and a sense of relief from pain when they lean forward. It’s important to note that some people might not experience any symptoms at all. When symptoms do occur, they may include feelings of nausea, vomiting, and the production of greasy, foul-smelling stools that are difficult to flush (also known as steatorrhea).
As the disease progresses, another common symptom is glucose intolerance or pancreatic diabetes, especially in those with a history of excessive alcohol consumption, smoking, cancer that causes blockage in pancreatic ducts, high blood cholesterol, systemic diseases, autoimmune diseases, and cystic fibrosis. Another symptom to look out for includes unexplainable weight loss, diarrhea, and steatorrhea (where the body can’t absorb fat, leading to oily stools).
Drawing the knees towards the chest can sometimes relieve pain during a severe episode of abdominal pain. There can also be physical signs like a detectable mass in the abdomen, indicating the formation of a pseudocyst, or fluid-filled sac. Signs of malnutrition like weight loss can be seen in those suffering from chronic pancreatitis for a long time.
- Prolonged and intermittent abdominal pain
- Weight loss
- Relief of pain when leaning forward
- Nausea and vomiting
- Steatorrhea – greasy, foul-smelling, hard-to-flush stools
- Glucose intolerance or pancreatic diabetes in advanced stages
- History of risk factors like alcohol abuse, tobacco use, certain diseases
- Relief from a severe pain attack when drawing knees to chest
- Possibility to palpate a mass indicate presence of a pseudocyst.
- Signs of long-term malnutrition
Testing for Chronic Pancreatitis (Pancreatitis)
For someone suspected of having chronic pancreatitis, a range of lab studies are typically necessary. This might include exams like a Complete Blood Count (CBC), a basic metabolic panel (BMP), liver function tests (LFTs), and tests checking the levels of lipase, amylase, a lipid panel, and an indicator called fecal-elastase-1. Sometimes, the results of lipase and amylase tests can display higher values but and are usually normal due to significant scarring and fibrosis of the pancreas.
In children, genetic testing for a condition known as Cystic Fibrosis (CFTR) should be performed.
In scenarios where doctors believe chronic pancreatitis might be because of an autoimmune response, they may order tests for inflammatory markers, such as ESR, CRP, ANA, RF, antibodies, and immunoglobulins. To determine the presence and extent of steatorrhea (excess fat in feces), a 72-hour quantitative fecal fat test is seen as the best method. This test confirms the condition if values are greater than 7 gm per day. Alternatively, a single stool sample can be tested for fecal elastase-1 to evaluate for pancreatic insufficiency. This method is the most sensitive and specific alternative to the fecal fat test.
When it comes to imaging studies, Magnetic Resonance Cholangiopancreatography (MRCP) is considered top-tier because it can show clear signs like calcifications, pancreatic enlargement, and blocked or dilated ducts. As compared to transabdominal ultrasound or x-rays, MRCP offers higher sensitivity and specificity for diagnosing chronic pancreatitis.
Historically, Endoscopic Retrograde Cholangiopancreatography (ERCP) has been the preferred test for diagnosing chronic pancreatitis, usually when no steatorrhea is present, or when x-rays don’t show calcifications. However, many hospitals now favor using MRCPs and only use ERCPs if a therapeutic intervention is warranted. Endoscopic ultrasound is another imaging method that can help diagnose the disease.
Tests that measure pancreatic function are sensitive, but they should be done early in the onset of the disease. Sampling fluids from the small intestine (duodenal aspirates) can help determine the output of amylase, pancreatic bicarbonate, and lipase. During an ERCP, a tube can be inserted into the pancreatic duct and pancreatic juice can then be assessed for these parameters.
There are also certain guidelines for the current methods:
* A CT scan is very useful for imaging the abdomen and assessing the shape and structure of the pancreas.
* It can also be used to rule out other diseases.
* If a CT scan comes out normal, an MRCP is recommended.
* A secretin-stimulated MRCP can help spot subtle changes in the ducts, as well as assess ductal compliance and exocrine function.
* Endoscopic ultrasound can detect ductal and parenchyma changes early in the disease.
Treatment Options for Chronic Pancreatitis (Pancreatitis)
The aim of treatment is to reduce stomach pain and enhance the body’s ability to digest and absorb nutrients. The pain could be due to inflammation, nerve-related mechanisms, or blockages in the ducts responsible for discharging bodily waste. Generally, patients are advised to consume low-fat meals in small quantities frequently. They should also replace fat-absorbable vitamins and pancreatic enzymes. If pain persists even after changing diet and adding enzyme replacements, patients are usually given non-narcotic medicines first before exploring opioids. Although there is ongoing research about the usefulness of antioxidants, no definitive conclusions have been made yet. Recent studies have suggested positive results from using medium-chain fats. Surgery might be needed for patients who don’t respond to medicinal treatments and continue experiencing pain.
Patient behavior adjustments can help avoid worsening the condition. It’s crucial that patients stop drinking alcohol and quit smoking. Individuals suffering from chronic pain and loss of appetite may need to be admitted to the hospital. In many cases, these patients require strong pain relief medicines and supplemental nutrition. Pancreatic enzymes, typically taken during a meal, can help reduce pain. However, the effectiveness of these enzymes is still debatable.
Surgery may be necessary in cases involving:
- Abscess, fistula, or pseudocyst in the pancreas
- Pancreatic ascites (accumulation of fluid in the pancreas)
- Blockage of the bile duct
- Narrowing of the duodenum causing gastric outlet blockage
- Bleeding varices due to a clot in the spleen vein
Removing the pancreas through surgery can yield good outcomes when performed by skilled surgeons. However, this procedure might have a mortality rate exceeding 10%. Furthermore, life may be difficult without a functioning pancreas. Today, many complications can be managed by interventional radiology, such as the drainage of fluid and the placement of a stent. A procedure known as celiac ganglion blockade can help reduce pain, but it can carry the risk of paralysis due to transverse myelopathy, which is a neurological disorder affecting the spine. Endoscopic approaches for celiac nerve blocks haven’t proven to be beneficial. Endoscopy is often used to clear blockages in the pancreatic duct, but this method is successful in only 60% of patients.
What else can Chronic Pancreatitis (Pancreatitis) be?
When trying to diagnose chronic pancreatitis, doctors will also consider and try to exclude other conditions that could cause similar symptoms. These conditions might include:
- Peptic ulcer disease (stomach ulcers)
- Cholelithiasis (gallstones)
- Biliary obstruction or biliary colic (issues with the bile ducts)
- Acute pancreatitis (a severe, sudden inflammation of the pancreas)
- Pancreatic malignancy (pancreatic cancer)
- Pseudocyst (fluid-filled sac in the pancreas)
- Chronic mesenteric ischemia (poor blood supply to your intestines)
These possibilities must be thoughtfully considered and screened out using relevant tests to ensure an accurate diagnosis.
What to expect with Chronic Pancreatitis (Pancreatitis)
The likelihood of recovery worsens with ongoing alcohol use, smoking, and advanced liver disease. After ten years, the survival rate is approximately 70%, decreasing to 45% at twenty years. Some of the serious complications include the formation of pseudocysts, blockages in the bile duct or duodenum (the first part of the small intestine).
Additional complications could include diabetes, which affects around 30% of patients, as well as the development of swollen veins in the stomach (gastric varices), and the formation of abnormal blood-filled bulges in the walls of a blood vessel (pseudoaneurysms).
Possible Complications When Diagnosed with Chronic Pancreatitis (Pancreatitis)
Chronic pancreatitis, a long-lasting inflammation of the pancreas, can lead to several health problems. These complications range from simple issues to more serious conditions, such as:
- Development of a pseudocyst that can block the bile duct
- Repeated instances of acute pancreatitis, particularly in alcoholics who don’t stop drinking
- Formation of clots in the splenic vein
- Accumulation of fluid in the abdomen or pleura around the lungs, although rare
- Pseudoaneurysms, which are false aneurysms, occasionally occurring in vessels close to the pancreas
- Pancreatic diabetes that tends to occur late in the disease progression
It’s also important to know that people with chronic pancreatitis have a higher risk for developing pancreatic cancer.
Preventing Chronic Pancreatitis (Pancreatitis)
People diagnosed with chronic pancreatitis, often caused by long-term alcohol use, should be advised to stop both drinking alcohol and smoking (if they smoke). They should have a check-up within one to two months. If the patient is experiencing steatorrhea – a condition characterized by the over production of fat in stools – a diet that’s high in protein and carbs but low in fats is recommended. Ideally, daily fat consumption should not exceed 20 grams. However, such a diet might result in the body not absorbing enough fat-soluble vitamins, so taking additional supplements through the mouth is advised.
