Chronic Pancreatitis

Chronic pancreatitis is a continuing, chronic, and irreversible inflammatory process of the pancreas without the possibility of healing, which worsens over time, leading to permanent damage and tissue scarring. The pancreas is the organ behind the stomach, connected to the bowel. It produces enzymes necessary for digestion and helps regulate the body's glucose levels by producing the hormones insulin and glucagon.

Symptoms of chronic pancreatitis are pain in the upper abdomen, nausea, and vomiting. The most common causes are chronic consumption of large amounts of alcohol over many years, using tobacco products, autoimmune conditions, and repeated episodes of acute pancreatitis. Chronic pancreatitis can lead to diabetes, chronic pain, malnutrition, and, in a small number of cases, pancreatic cancer. 1

Treatment for chronic pancreatitis involves painkillers and fluids, usually given intravenously during hospitalization. Complications arising from this condition can be managed with enzyme and nutritional supplements as well as surgery. Chronic pancreatitis causes around 86,000 hospital stays in the United States each year. 2

Chronic pancreatitis is a serious condition and may be debilitating. It is not curable but can be managed with treatment. The prognosis can be significantly improved by not drinking alcohol.

Chronic pancreatitis is a long-lasting condition. Episodes of acute pancreatitis can be fully treated, usually through hospitalization, and will resolve in a few days. Acute pancreatitis is commonly caused by gallstones or by drinking large amounts of alcohol. Repeated episodes of acute pancreatitis can lead to chronic pancreatitis.

The most common symptom of chronic pancreatitis is very strong pain in the abdomen, often in the mid-abdomen or left upper abdomen area, and that can radiate to the mid-back area. This is comparable to an episode of acute pancreatitis. Pain is usually: 3 4 5

• Severe enough to need strong painkillers
• Initially sporadic but may become continuous
• Present after eating or drinking
• Partly relieved by sitting up or leaning forward

Around 10 to 15 percent of people with chronic pancreatitis do not experience pain. In these cases, the condition is often discovered by investigating the reasons for significant weight loss. Chronic pancreatitis causes weight loss because the digestive system stops properly absorbing some nutrients following the pancreas no longer producing enough necessary digestive enzymes (malabsorption).

A small number of people may report that their pain decreases as the condition progresses, a phenomenon referred to as burn-out. However, most people’s experience of pain is likely to be erratic. 6

Other symptoms of chronic pancreatitis can include: 3 4

• Nausea
• Vomiting
• Diarrhea
• Greasy-looking, bad-smelling stools
• Pale or clay-colored stools
• Weight loss
• Flatulence
• Distended abdomen
• Tiredness

For some people with chronic pancreatitis, the first noticeable symptoms may actually be caused by complications rather than the condition itself.

The pancreas produces enzymes which aid digestion. If a person has chronic pancreatitis, the pancreas may become so damaged that it cannot produce enough enzymes to absorb nutrients from food. This can lead to a condition called malabsorption, which causes symptoms of: 3 7

• Weight loss
• Diarrhea
• Greasy-looking stools, known as steatorrhea
• Flatulence

The pancreas also produces insulin, which is important for regulating blood sugar. If the pancreas is damaged to the extent that it can no longer produce enough insulin, a person with chronic pancreatitis may develop diabetes. 3 8

Around 6 percent of people with chronic pancreatitis develop a blockage in their bile duct, and 1 to 2 percent will develop a blockage in their small intestine. Both conditions can cause pain, nausea and vomiting, while a blocked bile duct can also cause jaundice. Both conditions may need a surgical bypass. 9 10

Pancreatic pseudocysts develop in 20 to 40 percent of people with chronic pancreatitis, rising to up to 64 percent in people with alcohol-caused chronic pancreatitis. A pseudocyst is a sac filled with pancreatic enzymes, tissue and blood. They form when ducts in the pancreas become blocked. Pseudocysts may become infected, rupture or press on nearby organs. Symptoms of pseudocysts include: 11 12 13

• Bloating
• Abdominal pain
• Nausea
• Vomiting
• Loss of appetite

A leaking pseudocyst makes it more likely to develop ascites. Pancreatic ascites is the name for a buildup of fluid in the abdominal cavity that surrounds the stomach, intestines and liver. It causes abdominal pain and tenderness, a distended abdomen and weight loss. Pancreatic enzymes leaking into the abdominal cavity can directly damage body tissue. 14

Up to 45 percent of people with chronic pancreatitis develop a blood clot in the vein of the spleen. This can lead to internal bleeding and the spleen may need to be surgically removed. Other complications may develop with the spleen because of leaking pancreatic enzymes, owing to the proximity of the spleen and pancreas. These complications include: 15 16 17

• Blood clot in the splenic vein
• Pseudocyst in the spleen
• Spleen rupture
• Disruption of blood supply to the spleen, causing damage to tissue
• Hematoma, a solid swelling of clotted blood, in the spleen
• Bleeding from damaged parts of the spleen
• Necrosis, or death of cells, in the spleen

People with chronic pancreatitis, particularly post-menopausal women, men over 50 years old and people who also have malabsorption are at risk of developing problems with their bones. Osteopenia and osteoporosis are conditions that are at increased likelihood of developing. 18 19

Chronic pancreatitis increases the risk of developing pancreatic cancer. However, most people with chronic pancreatitis will not develop pancreatic cancer. 20

Chronic pancreatitis occurs when there is damage to the pancreas that does not heal or improve. There are several causes of chronic pancreatitis.

Repeated heavy alcohol use accounts for around 50 percent of chronic pancreatitis cases in the United States. More men than women develop alcohol-related pancreatitis. Using tobacco products is also a risk factor for chronic pancreatitis. 3 21

Genetics may be a cause of some cases of chronic pancreatitis. Around 85 to 95 percent of people with cystic fibrosis will develop some form of pancreas condition, including scarring of the pancreas which can lead to chronic pancreatitis. 22

Autoimmune conditions, where the immune system attacks its own body, such as rheumatoid arthritis, hypothyroidism and sclerosing cholangitis - a rare chronic liver condition - can cause chronic pancreatitis, as can certain genetic mutations. The most common symptoms of autoimmune pancreatitis are jaundice, weight loss and mild pain. Severe pain is unusual in autoimmune pancreatitis. 23

Other causes of chronic pancreatitis include: 4

• Blockage in pancreatic duct
• High levels of fats, known as lipids, in the blood
• High levels of calcium in the blood
• Repeated episodes of acute pancreatitis

In some cases of chronic pancreatitis, the cause is unknown, or idiopathic.

Chronic pancreatitis can be difficult to definitively diagnose, particularly in the early stages. People with the condition often present with symptoms caused by complications, such as weight loss, pain or greasy stools. Imaging tests and tests for pancreatic function can diagnose chronic pancreatitis, but the results may not point to a conclusive diagnosis in the early stages. 24

Diagnosis will start with taking a medical history and a physical examination. Blood tests may be performed which can also be used to identify or exclude other potential causes for the symptoms, such as problems with the gallbladder or bile duct. 25

There are various imaging tests for chronic pancreatitis that can provide information about inflammation, scarring and other damage:

CT Scan detects changes to the pancreas such as calcification, changes to pancreatic ducts or pseudocysts. CT scans are generally inconclusive in the early stages of chronic pancreatitis but are helpful to rule out other possible causes, such as [pancreatic cancer[(/conditions/pancreatic-cancer/). 3 24

Magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP), which focus on the area around the pancreas, are more accurate than a CT scan and are good for detecting masses in the pancreas and changes to pancreatic ducts. 3 24 26

Endoscopic retrograde cholangiopancreatography (ERCP), which combines endoscopy and x-rays, to diagnose problems of the bile and pancreatic ducts. As this diagnostic test is invasive, requiring a flexible camera to be inserted into the upper gastrointestinal tract, it is usually performed when a doctor expects to be able to treat a condition at the same time. 27

Endoscopic ultrasound is more invasive than CT or MRI scans, but allows for close-up examination of the pancreas. 3 24

Pancreatic function tests check how well the pancreas is working. A person with chronic pancreatitis will produce fewer digestive enzymes and less insulin as the pancreas becomes damaged.

Direct pancreatic function tests use an endoscope, which is a thin, flexible tube with a camera attached, to measure levels and stimulate the pancreas to produce enzymes. Direct pancreatic function tests can diagnose most cases of late stage chronic pancreatitis but can miss up to 25 percent of early stage cases. 3 24

Indirect pancreatic function tests measure the effects of chronic pancreatitis. For example, a high level of fat in the stool may indicate malabsorption. Indirect pancreatic function tests include: 3 24 28 29 30 31

• Fecal fat test, which measures the amount of fat in the stool
• Serum trypsinogen test, a blood test that measures trypsinogen, which is produced by the pancreas and converts to the digestive enzyme trypsin
• Blood tests to measure levels of lipase and amylase, which are other digestive enzymes produced by the pancreas
• Blood glucose test, which can indicate diabetes
• Fecal chymotrypsin and elastase tests, which can measure reduced levels of digestive enzymes in the stool

These tests are generally better at detecting chronic pancreatitis in its later, rather than early, stages, as they rely on identifying complications of the condition rather than changes to the pancreas itself.

For anyone with chronic pancreatitis, it is very important that they do not use tobacco products or drink alcohol, as this makes the liver deteriorate, leading to further complications which cause chronic pancreatitis to become worse.

As well as not drinking or using tobacco products, it is important for people with chronic pancreatitis to eat a healthy diet that the body can digest. This includes: 1

• Limiting the amount of fat
• Limiting the amount of caffeine
• Drinking lots of non-alcoholic fluids
• Making sure to get enough vitamins and minerals
• Eating small, frequent meals to aid digestion

If the pancreas is no longer producing enough digestive enzymes, pancreatic enzyme supplements can help support the digestive system. Supplements for vitamins A, D, E and K can also be helpful for people with malabsorption. For more information, see these resources on vitamin D deficiency and vitamin K deficiency.

If a person with chronic pancreatitis has also developed diabetes, they should be referred to an endocrinologist. This type of diabetes is called pancreatogenic diabetes or type 3c diabetes mellitus. In type 3c diabetes, blood glucose control may be more difficult to achieve. Treatment may vary for people with chronic pancreatitis as opposed to people with type 2 diabetes. 3 32

Surgery can be used to clear blockages in the pancreatic duct. In serious cases, the pancreas may be partially or wholly removed. If a person still has hormone-producing islets in the liver, these may be removed and re-inserted into the body to continue producing insulin, without which the person will develop type 3c diabetes. 33 34

Where a person with chronic pancreatitis experiences pain, this can be managed with painkillers. Mild to moderate pain can be managed with painkillers such as ibuprofen or paracetamol. More serious pain may require stronger painkillers. 3 35

Episodes of acute pancreatitis will often require a stay in hospital, to be treated with: 1 33

• Fluids administered intravenously
• Painkillers
• Drugs to reduce nausea and vomiting
• Feeding by tube or intravenously if the person cannot eat
• Antibiotics if the person has an infection in the pancreas

Drinking alcohol and using tobacco products are risk factors for developing chronic pancreatitis. The risk of developing chronic pancreatitis is reduced by avoiding alcohol and tobacco products.

Repeated episodes of acute pancreatitis increase the risk of developing chronic pancreatitis. It may be possible to reduce or avoid episodes of acute pancreatitis by stopping drinking alcohol and eating a healthy diet; this can help prevent episodes of acute pancreatitis caused by formation and interruption of the normal flow of the pancreatic duct fluid by gallstones.

• Pancreatic insufficiency - chronic

Q: Can chronic pancreatitis go away?
A: No. Chronic pancreatitis means that problems with the pancreas will not improve and leads to permanent damage. Careful management of the condition can make it easier to live with. Acute pancreatitis, on the other hand, is a form of pancreatitis that lasts a few days and then goes away.

Q: Is chronic pancreatitis fatal?
A: Chronic pancreatitis is a serious illness and, in some cases, can be fatal. A small number of people with chronic pancreatitis will develop pancreatic cancer, which can be fatal. Small numbers of people with chronic pancreatitis may die from complications following surgery or from a digestive hemorrhage. Another complication of chronic pancreatitis is diabetes, which may reduce life expectancy. If a person with chronic pancreatitis drinks alcohol and smokes they will likely have a poorer life expectancy. However, up to 80 percent of people with chronic pancreatitis will have a life expectancy of at least 10 years after the initial diagnosis. 36

Q: Can you drink alcohol with chronic pancreatitis?
A: A person with chronic pancreatitis should not drink alcohol. Continuing to drink alcohol will cause pain and damage the pancreas even further. Drinking alcohol makes the person’s overall prognosis worse and increases the risk of developing complications such as diabetes and pseudocysts. Life expectancy is reduced for people with chronic pancreatitis who continue to drink alcohol. 36 37