Chronic Pancreatitis
Chronic pancreatitis is a progressive inflammatory condition of the pancreas continuing over a long period, and resulting in permanent structural and functional damage to the pancreas.
- Continuous or intermittent pain in the upper part of the abdomen is the usual symptom.
- In addition to the typical symptoms, imaging tests and blood tests may help in diagnosis.
- Treatment of chronic pancreatitis include diet modifications, giving complete rest to the pancreas, administration of pain relieving drugs and supplements of pancreatic enzymes.
Alcoholism is the major cause of chronic pancreatitis in the United States, accounting for almost half the cases. People who carry the gene for a condition called cystic fibrosis, and those who have this disease, account for most of the other cases. Pancreatitis may be caused by autoimmune disease or heredity too. In a few cases, when the reason for the chronic pancreatitis cannot be identified, it is known as idiopathic. If an episode of severe acute pancreatitis had narrowed the pancreatic duct, it can lead to the development of chronic pancreatitis. In certain tropical countries like Nigeria, Indonesia and India, chronic pancreatitis is found to occur without any apparent reason. This is known as tropical pancreatitis. It usually affects youngsters and children.
Symptoms
Chronic pancreatitis has the same symptoms which occur in acute pancreatitis. Two distinct patterns are usually observed. One of them is an almost constant pain of varying intensity felt in the upper part of the abdomen. When people have this type of pattern, there is a high possibility of complications due to chronic pancreatitis being present. Formation of a cyst, an inflammatory lump, or cancer of the pancreas, may be the usual complication. In the other pattern, intermittent attacks, usually referred to as flare ups, occur. Each episode exhibits symptoms of acute pancreatitis of mild or moderate intensity. The duration of the flare ups may vary, with severe pain lasting several hours, to even several days, at a time. Irrespective of the pattern of symptoms, the pain may finally stop when the chronic disease steadily progresses to cause severe damage to the enzyme-secreting tissues of the pancreas, eventually destroying them. It may take a period of 6 to 10 years for the disease to reach this stage.
When the gradual destruction of the pancreatic tissue results in the decreased production of the digestive enzymes, pancreatic insufficiency develops. Without sufficient amount of digestive enzymes, the breakdown of food cannot be complete. Inadequately digested food cannot be absorbed by the small intestine and this condition leads to malabsorption. Bulky and extremely foul-smelling light colored stools usually indicate malabsorption. Fatty stools termed steatorrhea may have visible droplets of oil. The stool may contain many undigested and partially digested food particles, especially muscle fibers. Malabsorption may result in deficiency diseases and weight loss. People develop diabetes when the insulin-producing endocrine glands of the pancreas get destroyed with the progress of the chronic pancreatitis.
Diagnosis
When a patient who has acute pancreatitis complains of frequent flare ups or worsening of symptoms, chronic pancreatitis is suspected. When a person with a history of alcoholism comes with the typical symptoms, then also the possibility of chronic pancreatitis needs to be investigated. High blood levels of pancreatic enzymes lipase and amylase may be indicative of chronic pancreatitis. High blood glucose levels are another indication. But blood tests cannot be treated as confirmation of diagnosis.
Further investigations include Computed tomography, or CT scan, to detect the changes or abnormalities typically caused by chronic pancreatitis. If the result of this test is inconclusive, other tests such as endoscopic retrograde cholangiopancreatography or endoscopic ultrasonography may be done. In endoscopic ultrasonography, the probe is introduced into the duodenum with the help of an endoscope inserted through the mouth. Magnetic resonance cholangiopancreatography, or MRCP for short, is a specially designed MRI test which gives clearer pictures of the pancreatic and bile ducts than a CT scan. Because of this, MRCP is often preferred to CT scan.
The risk of developing pancreatic cancer is very high in people who have chronic pancreatitis. If the usual symptoms of pancreatitis are found to worsen, cancer is suspected and further investigations are done. The diagnostic tests for pancreatic cancer include CT scan and endoscopic evaluation in addition to blood tests. MRI scan also may be done.
Chronic Pancreatitis Treatment
The repeated episodes of chronic pancreatitis are treated by resting the digestive system completely. People with chronic pancreatitis should strictly avoid alcohol consumption even when their condition had not developed due to alcoholism. During flare ups, the patient is hospitalized and all nutritional support is given intravenously. Resting the pancreas may relieve the abdominal pain to some extent, but opioid analgesics may be necessary. People may need large amounts of opioid medication to get relief from pain, which can make them addicted to the drugs. In the case of chronic pancreatitis, drug therapy is not usually a satisfactory measure for pain relief.
After a period of fasting, oral feeding is restarted when the symptoms subside. Avoiding large meals, and taking several small meals low in fats, usually helps in avoiding frequent flare-ups. An effort is made to reduce malabsorption by taking supplements of pancreatic enzymes. It may reduce steatorrhea and improve digestion and absorption of nutrients. To reduce the acid production by the stomach, proton pump inhibitors or histamine-2 (H2) blockers may be given. The overall condition of the patient improves with this treatment and weight gain may be achieved. If the improvement is not satisfactory, further reducing the fat content in the food may help. To avoid the deficiency of fat-soluble vitamins such as vitamins A and D, they should be taken as supplements. Vitamin E and K are also fat-soluble.
If pain does not subside in spite of the drug therapy and diet modifications, further investigations are done check for complications. Possible complications include the formation of a pseudocyst, which is an accumulation of the debris of pancreatic cells, fluids and enzymes around the pancreas. If pain is caused by a rapidly enlarging pseudocyst, it is surgically drained. If an inflammatory mass in the pancreas is the reason of pain, it is removed surgically.
When such complications are not detected, pain management may involve the injection of alcohol and an anesthetic drug bupivacaine combined, directly into the nerves leaving the pancreas. It may bring relief from pain by blocking the impulses of pain so that they do not reach the brain. If anesthetic injection does not help, surgery may be considered. If there is enlargement of the pancreatic duct, a bypass surgery to connect the pancreas to the duodenum usually helps reduce the pain in 70 to 80% percent cases. If the duct is not enlarged, surgical removal of a portion of the pancreas is the option. When the surgery is performed, insulin-secreting cells of the pancreas are also lost, resulting in the development of diabetes. This option is considered in the case of patients who have quit alcohol consumption and are capable of managing the resultant diabetes.
Diabetes caused by chronic pancreatitis does not respond to taking oral antidiabetic drugs. Since the secretion of insulin as well as that of its counterpart glucagon is affected by chronic pancreatitis, taking insulin shots for blood sugar control poses some risks. The decreased levels of glucagon in the blood can cause excess insulin to remain in the blood, leading to coma due to hypoglycemia.
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Yasser Elnahas
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