Alcohol use and cigarette smoking are two major causes of chronic pancreatitis.
Abdominal pain may be persistent or come and go.
The diagnosis is based on the symptoms, a history of recurring acute pancreatitis and alcohol use, imaging tests, and pancreatic function tests.
Treatment involves avoiding alcohol and cigarettes, modifying the diet, taking pancreatic enzyme supplements, and measures to relieve the pain.
(See also Overview of Pancreatitis Overview of Pancreatitis Pancreatitis is inflammation of the pancreas. The pancreas is a leaf-shaped organ about 5 inches (about 13 centimeters) long. It is surrounded by the lower edge of the stomach and the first... read more .)
The pancreas Pancreas The pancreas is an organ that contains two types of glandular tissue: Pancreatic acini Islets of Langerhans (See also Overview of the Digestive System.) The acini produce digestive enzymes.... read more is an organ in the upper abdomen that produces the hormone insulin and secretes pancreatic fluid through the pancreatic duct into the first part of the small intestine (duodenum). This pancreatic fluid contains digestive enzymes that help digest food.
In acute pancreatitis Acute Pancreatitis Acute pancreatitis is sudden inflammation of the pancreas that may be mild or life threatening but usually subsides. Gallstones and alcohol abuse are the main causes of acute pancreatitis. Severe... read more , inflammation develops quickly and subsides within a few days to a few weeks.
In chronic pancreatitis, inflammation is progressive and long-standing, which causes permanent damage and scarring (fibrosis) to the pancreas. This fibrosis is the hallmark of chronic pancreatitis. As chronic pancreatitis progresses, cells that secrete the digestive enzymes in the pancreatic fluid are slowly destroyed over time.
Locating the Pancreas
Causes of Chronic Pancreatitis
In the United States, about half of the cases of chronic pancreatitis are due to heavy alcohol consumption. People who smoke cigarettes also are at increased risk of developing chronic pancreatitis.
Less common causes of chronic pancreatitis include genetic disorders, such as cystic fibrosis Cystic Fibrosis (CF) Cystic fibrosis is a hereditary disease that causes certain glands to produce abnormally thick secretions, resulting in tissue and organ damage, especially in the lungs and the digestive tract... read more , hereditary pancreatitis, or autoimmune pancreatitis. Rarely, an attack of severe acute pancreatitis Acute Pancreatitis Acute pancreatitis is sudden inflammation of the pancreas that may be mild or life threatening but usually subsides. Gallstones and alcohol abuse are the main causes of acute pancreatitis. Severe... read more causes permanent scarring (fibrosis) of the pancreas that leads to chronic pancreatitis. In some people, chronic pancreatitis develops when the pancreatic duct is blocked (obstructed) by stones or a tumor.
Some cases of chronic pancreatitis have no clear cause (are idiopathic). In tropical countries (for example, India, Indonesia, and Nigeria), chronic pancreatitis of unknown cause occurs among children and young adults (called tropical pancreatitis).
Symptoms of Chronic Pancreatitis
Abdominal pain is a main symptom of chronic pancreatitis. The upper abdominal pain may vary in intensity, and flare-ups (bouts or attacks) may last for many hours or several days. Later on in the illness, pain tends to become constant. The pain is usually worse after meals and may be lessened by sitting upright or leaning forward.
As chronic pancreatitis progresses and the cells that secrete the digestive enzymes are destroyed, the abdominal pain may stop.
Pancreatic insufficiency is the other main symptom of chronic pancreatitis. Pancreatic insufficiency is a decrease in the amount of digestive enzymes in pancreatic fluid. As the amount of digestive enzymes decreases, food is inadequately broken down. Food that is inadequately broken down is not absorbed properly (malabsorption Overview of Malabsorption Malabsorption syndrome refers to a number of disorders in which nutrients from food are not absorbed properly in the small intestine. Certain disorders, infections, and surgical procedures can... read more ), and the person may produce bulky, unusually foul-smelling, greasy stools (steatorrhea). The stool is light-colored and may even contain oil droplets. Undigested muscle fibers may also be found in the feces. The inadequate absorption of food also leads to undernutrition Undernutrition Undernutrition is a deficiency of calories or of one or more essential nutrients. Undernutrition may develop because people cannot obtain or prepare food, have a disorder that makes eating or... read more , vitamin deficiencies Overview of Vitamins Vitamins are a vital part of a healthy diet. The recommended dietary allowance (RDA)—the amount most healthy people need each day to remain healthy—has been determined for most vitamins. A safe... read more , and weight loss.
Complications of chronic pancreatitis
A fluid collection called a pancreatic pseudocyst can develop. Pseudocysts can bleed or rupture, and ones that expand may cause pain or block the duodenum or bile ducts.
Eventually, the cells of the pancreas that secrete insulin may be destroyed, gradually leading to diabetes Diabetes Mellitus (DM) Diabetes mellitus is a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high. Urination and thirst are... read more .
Patients with chronic pancreatitis are at increased risk of pancreatic cancer Pancreatic Cancer Smoking, chronic pancreatitis, male sex, being black, and possibly long-standing diabetes are risk factors for pancreatic cancer. Abdominal pain, weight loss, jaundice, and vomiting are some... read more .
Diagnosis of Chronic Pancreatitis
Pancreatic function tests
Sometimes blood tests
A doctor suspects chronic pancreatitis because of a person’s symptoms and history of acute pancreatitis flare-ups or heavy alcohol use. Doctors use the results of imaging tests and pancreatic function tests to make the diagnosis.
Did You Know...
X-rays of the abdomen may be done to look for calcium deposits in the pancreas, which are present in some people with chronic pancreatitis.
Computed tomography Computed Tomography (CT) In computed tomography (CT), which used to be called computed axial tomography (CAT), an x-ray source and x-ray detector rotate around a person. In modern scanners, the x-ray detector usually... read more (CT) of the abdomen may be done to show changes of chronic pancreatitis and to look for complications, such as a pseudocyst.
Many doctors now do a special magnetic resonance imaging Magnetic Resonance Imaging (MRI) In magnetic resonance imaging (MRI), a strong magnetic field and very high frequency radio waves are used to produce highly detailed images. MRI does not use x-rays and is usually very safe... read more (MRI) test called magnetic resonance cholangiopancreatography Magnetic Resonance Imaging Imaging tests of the liver, gallbladder, and biliary tract include ultrasonography, radionuclide scanning, computed tomography (CT), magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreatography... read more (MRCP). MRCP shows the bile and pancreatic ducts more clearly than does CT.
Endoscopic retrograde cholangiopancreatography Endoscopic Retrograde Cholangiopancreatography Imaging tests of the liver, gallbladder, and biliary tract include ultrasonography, radionuclide scanning, computed tomography (CT), magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreatography... read more (ERCP) allows doctors to view the bile duct and pancreatic duct. This test is rarely used for the diagnosis of chronic pancreatitis, but doctors may do it if a certain treatment for the pancreatic duct is needed, such as placing a tube (stent) through a blockage or removing a stone in the duct.
Understanding Endoscopic Retrograde Cholangiopancreatography
In endoscopic retrograde cholangiopancreatography (ERCP), a radiopaque dye is introduced through an endoscope (a flexible viewing tube), which is inserted into the mouth and through the stomach into the duodenum (the first segment of the small intestine). The radiopaque dye is injected into the biliary tract just past the sphincter of Oddi. The dye then flows back up the biliary tract and often shows the pancreatic ducts.
Surgical instruments can also be used with the endoscope, allowing a doctor to remove a stone in a bile duct or insert a tube (stent) to bypass a bile duct blocked by scarring or cancer.
Endoscopic ultrasonography (passage of a flexible viewing tube with an ultrasound probe attached to it through the mouth into the stomach and the first segment of the small intestine) is another test that helps detect abnormalities in the pancreas and pancreatic duct.
Because people with chronic pancreatitis are at increased risk of pancreatic cancer, any worsening of symptoms or narrowing of the pancreatic duct makes doctors suspect cancer. In such cases, a doctor is likely to do blood tests, an MRI scan, a CT scan, and/or endoscopic ultrasonography.
Pancreatic function tests
For chronic pancreatitis, doctors may also do tests of the pancreas to see how it is functioning. These tests help doctors determine whether there is pancreatic insufficiency that can cause malabsorption Overview of Malabsorption Malabsorption syndrome refers to a number of disorders in which nutrients from food are not absorbed properly in the small intestine. Certain disorders, infections, and surgical procedures can... read more . Stool may be checked for levels of fat or a digestive enzyme such as elastase. Low levels of elastase indicate pancreatic insufficiency.
Blood tests are less useful in diagnosing chronic pancreatitis than in diagnosing acute pancreatitis, but they may indicate elevated levels of amylase and lipase (two enzymes produced by the pancreas). Also, blood tests can be used to check the level of sugar (glucose) in the blood, which may be elevated.
Treatment of Chronic Pancreatitis
Pancreatic enzyme supplements
Management of diabetes
The prognosis for chronic pancreatitis varies.
Even if alcohol is not the cause, all people with chronic pancreatitis should avoid drinking alcohol and stop smoking.
Pain control is the most challenging part of managing chronic pancreatitis, and treatments are focused on reducing pain and slowing disease progression. Eating four or five meals a day consisting of food low in fat may reduce secretion of pancreatic enzymes and reduce pain.
Opioid analgesics Opioid Pain Relievers Pain relievers (analgesics) are the main drugs used to treat pain. Doctors choose a pain reliever based on the type and duration of pain and on the drug's likely benefits and risks. Most pain... read more are sometimes needed to relieve the pain. Too often, pain relief measures do not relieve the pain, requiring increased amounts of opioids, which may put the person at risk of addiction. Doctors may recommend additional pain drugs, such as tricyclic antidepressants, gabapentin, pregabalin, and selective serotonin reuptake inhibitors (SSRIs), and prescribe them either alone or in combination with opioids to manage chronic pain, but results vary. Drug treatment of pain in chronic pancreatitis is often unsatisfactory.
Doctors may give corticosteroids to treat autoimmune pancreatitis.
Sometimes doctors may use an endoscope (a flexible viewing tube) to carry out treatment. Endoscopic treatment with endoscopic retrograde cholangiopancreatography Endoscopic Retrograde Cholangiopancreatography Imaging tests of the liver, gallbladder, and biliary tract include ultrasonography, radionuclide scanning, computed tomography (CT), magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreatography... read more (ERCP) may be used to drain a duct that is blocked by scarring (stricture), stones, or both. This procedure may provide pain relief.
Lithotripsy Stone removal Stones (calculi) are hard masses that form in the urinary tract and may cause pain, bleeding, or an infection or block of the flow of urine. Tiny stones may cause no symptoms, but larger stones... read more (a procedure that involves the use of shock waves to break up stones) may be used to treat stones that are large or stuck in the pancreatic duct.
Surgical treatment may be an option if the pancreatic ducts are dilated or if there is an inflammatory mass in one region of the pancreas. For instance, when the pancreatic duct is dilated, creating a bypass from the pancreas to the small intestine relieves the pain in about 70 to 80% of people. When the duct is not dilated, part of the pancreas may have to be removed. Removing part of the pancreas means that cells that produce insulin are removed as well, and diabetes may develop. Doctors reserve surgical treatment for people who have stopped using alcohol and who can manage any diabetes that develops.
Sometimes a pancreatic pseudocyst can cause pain as it expands and may have to be drained (decompressed) endoscopically or through the overlying skin.
Pancreatic enzyme supplements
Pancreatic enzyme supplementation may reduce chronic pain by reducing the secretion of pancreatic enzymes. Although enzyme therapy is often tried because it is safe and has few side effects, it may not provide substantial pain relief.
For people who have pancreatic insufficiency, taking tablets or capsules of pancreatic enzyme extracts with meals can make the stool less greasy and improve food absorption, but these problems are rarely eliminated. The supplements should be taken with meals. Doctors sometimes recommend people take a histamine-2 (H2) blocker or a proton pump inhibitor (drugs that reduce or prevent the production of stomach acid) with the pancreatic enzyme supplements. With pancreatic enzyme treatment, the person usually gains some weight, has fewer daily bowel movements, has no more oil droplets in the stool, and generally feels better. If these measures are ineffective, the person can try further decreasing fat intake. Supplements of the fat-soluble vitamins Fat-soluble vitamins Vitamins are a vital part of a healthy diet. The recommended dietary allowance (RDA)—the amount most healthy people need each day to remain healthy—has been determined for most vitamins. A safe... read more (A, D, E, and K) also may be needed.
Management of diabetes
(See also treatment of diabetes Treatment Diabetes mellitus is a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high. Urination and thirst are... read more .)
Hypoglycemic drugs taken by mouth rarely help treat diabetes caused by chronic pancreatitis. Insulin is generally needed but can cause a problem, because affected people also have decreased levels of glucagon, which is a hormone that acts to balance the effects of insulin. An excess of insulin in the bloodstream causes low glucose (sugar) levels in the blood, which can result in a hypoglycemic coma (see symptoms of hypoglycemia Symptoms Hypoglycemia is abnormally low levels of sugar (glucose) in the blood. Hypoglycemia is most often caused by drugs taken to control diabetes. Much less common causes of hypoglycemia include other... read more ).