Chronic Pancreatitis

Chronic pancreatitis is a long-lasting condition where the pancreas becomes inflamed, scarred, and progressively damaged over time, leading to permanent changes that affect digestion and blood sugar control.

Table of contents

• What Is Chronic Pancreatitis?
• The Role of the Pancreas
• Causes and Risk Factors
• Symptoms
• Diagnosis
• Complications
• Treatment
• Lifestyle Changes
• Who Is Affected

What Is Chronic Pancreatitis?

Chronic pancreatitis is a progressive disease where ongoing inflammation (swelling and irritation) of the pancreas causes permanent damage to the organ^[1]. Unlike acute pancreatitis, which appears suddenly and usually improves, chronic pancreatitis does not go away and becomes worse over time^[3].

Over time, normal pancreatic tissue is replaced by scar tissue, a process called fibrosis^[1]. This scarring makes the pancreas irregular and hard^[7]. In later stages of the disease, calcium deposits may form in the scarred areas. Fluid-filled cavities called pseudocysts may also develop around the pancreas^[7].

There is currently no cure for chronic pancreatitis^[4]. However, treatments are available to manage symptoms and address complications such as difficulty absorbing nutrients from food and problems with blood sugar control.

• Pancreas
• Pancreatic ducts
• Upper abdomen
• Digestive system

The Role of the Pancreas

The pancreas is an organ located in the upper half of the belly behind the stomach and in front of the spine^[7]. It is roughly 25 centimeters (nine inches) long and salmon pink in color^[7]. If you lay your right hand across your stomach, that is roughly the size and shape of your pancreas behind it^[3].

The pancreas has two important functions. First, it makes digestive enzymes (special proteins that break down food) that help digest proteins, carbohydrates, and fats^[1][2]. These enzymes travel through tubes inside the pancreas and empty into the upper part of the small intestine, where they mix with food and bile to help digest what you eat^[7].

Second, the pancreas makes hormones, including insulin^[2]. Insulin is a chemical that helps control blood sugar levels by allowing sugars to enter body cells from the blood to be used for energy^[7].

When chronic pancreatitis damages the pancreas, both of these functions can be affected. When over 90% of the organ is damaged, the pancreas cannot make enough digestive enzymes, leading to problems absorbing nutrients^[1]. Damage to the parts of the pancreas that make insulin can lead to diabetes^[2].

Causes and Risk Factors

The most common cause of chronic pancreatitis is drinking a lot of alcohol over a long period of time^[2][4]. Alcohol accounts for about 70% of cases in adults^[6]. Drinking too much alcohol can cause the pancreas to become inflamed for a short time (acute pancreatitis). If you keep drinking and keep getting acute pancreatitis, it can develop into chronic pancreatitis^[4].

Smoking tobacco is also recognized as harmful to the pancreas and may trigger pancreatitis^[6][7]. Even if your chronic pancreatitis was not caused by alcohol or smoking, these habits can make the damage worse.

Other causes of chronic pancreatitis include^[2][5][6]:

• An attack of acute pancreatitis that damages the pancreatic ducts
• A blockage of the main pancreatic duct caused by cancer or stones
• Problems when the immune system attacks the pancreas (autoimmune pancreatitis)
• Cystic fibrosis
• Hereditary diseases of the pancreas (genetic mutations passed down in families)
• High levels of fats called triglycerides in the blood
• Excess calcium in the blood (from overactive parathyroid gland)
• Certain medicines

In some cases, the cause is unknown^[2]. Most people with chronic pancreatitis probably have a combination of family (genetic) and environmental factors^[7].

Symptoms

The main symptom of chronic pancreatitis is pain in your belly^[4]. The pain is usually felt in the upper part of your belly, just below your ribs, but it may also spread to your back^[2][4]. Some people describe it as if the pain is boring through from front to back^[4].

The pain may be constant or come and go. It can be severe or feel like a dull ache^[4]. The pain often gets worse after eating or drinking alcohol^[2][4]. It may feel better when you sit down and lean forward^[4]. However, some people with chronic pancreatitis report little to no pain^[15].

Other symptoms of chronic pancreatitis can include^[4][5]:

• Feeling sick (nausea) or being sick (vomiting)
• Diarrhea or oily stools that are unusually foul-smelling, light-colored, and float or are difficult to flush away
• Feeling bloated or passing gas frequently
• Feeling thirsty or needing to urinate frequently
• Losing weight without trying to
• Loss of appetite
• Indigestion and pain after eating

These digestive symptoms happen because the damaged pancreas cannot produce enough enzymes to properly break down food, especially fats. As a result, your body cannot absorb all the nutrients from your food^[2].

Chronic pancreatitis symptoms can be similar to other conditions, such as irritable bowel syndrome or gallstones^[4].

Diagnosis

There is no single test for chronic pancreatitis^[4]. A doctor may need to rule out other possible causes of your symptoms first. Diagnosis can be difficult, especially in the early stages of the disease^[6][7].

Your healthcare provider will ask about your medical history, including your drinking and smoking habits, and any family history of pancreatic disease or cystic fibrosis^[2]. They will examine your belly, check if your skin and eyes look yellow (a sign of a liver problem), and weigh you to check if you are underweight^[4].

Blood and imaging tests are an important part of diagnosis^[2]. These may include:

• Blood tests: These look for high levels of pancreatic enzymes called amylase and lipase, which may spill into the blood^[2][5]. Other tests may check for blockage or damage of the gallbladder, certain inherited conditions, or vitamin levels^[2].
• Stool tests: These measure the level of fat in your stool or measure pancreatic enzyme elastase^[5][15].
• CT scan (computed tomography): This imaging test uses X-rays and a computer to create a three-dimensional image of your pancreas^[2][6]. Contrast-enhanced CT is the recommended initial imaging study^[6].
• Ultrasound: This test uses sound waves to create images of your abdominal organs^[4][15].
• MRI (magnetic resonance imaging) or MRCP (magnetic resonance cholangiopancreatography): These tests may be used if CT results are unclear in early stages^[6][15].
• Endoscopic ultrasound (EUS): A tube with an ultrasound device is passed through the mouth and into the digestive system to show inflammation, gallstones, cancer, and blockages^[2][6]. This test is favored over other procedures because of its increased safety and ability to evaluate both the pancreatic tissue and duct system^[6].
• ERCP (endoscopic retrograde cholangiopancreatography): This procedure looks at the bile and pancreatic ducts through an endoscope passed down the throat^[5].
• Gastroscopy: A thin tube with a camera inside is passed down your throat and into your stomach^[4].

Complications

As chronic pancreatitis progresses, the damage and scarring to the pancreas can cause several other problems^[4]:

Difficulty absorbing nutrients from food: This can cause weight loss and problems such as weakened bones (osteoporosis)^[4]. When your pancreas cannot make enough digestive enzymes, your body cannot properly break down and absorb nutrients, leading to malnutrition^[2].

Diabetes: Chronic pancreatitis can cause a type of diabetes called type 3c diabetes or pancreatogenic diabetes^[1][4]. This happens because the pancreas cannot make enough insulin to control blood sugar^[2]. Symptoms of diabetes include increased hunger and thirst, frequent urination, weight loss, and fatigue^[15].

Growths (cysts) around the pancreas: These fluid-filled cavities can become infected, bleed, or push against nearby organs^[4].

Blockages: A blockage can occur in the pancreas or in the bile ducts (small tubes in the digestive system). This can cause problems like pain or inflammation of the gallbladder^[4].

Increased risk of pancreatic cancer: People with chronic pancreatitis have a higher risk of getting pancreatic cancer^[4][6]. This risk is especially high in people with hereditary pancreatitis^[6]. Healthcare providers should counsel patients on this increased risk and evaluate patients with weight loss or jaundice (yellowing of skin and eyes) for cancer^[6].

Treatment

There is currently no cure for chronic pancreatitis^[4]. Treatment focuses on managing symptoms and complications. You will be supported by different healthcare professionals, including your doctor, specialist doctors, nurses, and food and nutrition specialists called dietitians^[4].

Pain management: Pain medicines are an important part of treatment^[4]. Although narcotics and antidepressants provide the most pain relief, about half of patients eventually require surgery^[6]. Pain medicines may cause side effects like constipation and drowsiness^[15].

Pancreatic enzyme replacement: Your doctor may prescribe pancreatic enzyme pills to help your body digest fat and protein^[4][19]. You must take these medicines with every meal and even with snacks^[5]. These enzymes help you digest food better, gain weight, and reduce diarrhea^[5]. Pancreatic enzyme replacement is indicated for steatorrhea (fatty stools) and malabsorption and may help relieve pain^[6].

Medicines for diabetes: If you develop diabetes, you will need medicines such as insulin to control your blood sugar^[4].

Nutritional support: Eating a proper diet is important for people with chronic pancreatitis to maintain a healthy weight and get the correct nutrients^[5]. You may need vitamin and calcium supplements^[5].

Hospital care: People with severe pain or who are losing weight may need to stay in the hospital for pain medicines, fluids given through a vein, and careful monitoring of food intake^[5]. Sometimes a feeding tube may be placed to give your intestine nutrients if you cannot eat by mouth^[5].

Procedures and surgery: Several procedures may be needed^[4]:

• Therapeutic endoscopy is used to treat symptomatic strictures (narrowed areas), stones, and pseudocysts^[6]. Endoscopic drainage of pseudocysts results in similar pain relief as surgery, with equivalent or lower mortality^[6].
• Decompressive surgical procedures, such as lateral pancreaticojejunostomy, are used for large duct disease (when the pancreatic duct is widened to 7 millimeters or more)^[6].
• Resection procedures, such as the Whipple procedure (pancreatoduodenectomy), are used for small duct disease or when the head of the pancreas is enlarged^[6]. These procedures typically result in significant pain relief^[6].
• Surgery to remove growths (cysts) or unblock blockages in the pancreas or bile ducts^[4].

Sometimes you may also have treatment for the cause of your pancreatitis. For example, steroid medicine can help if it is caused by your immune system attacking your pancreas^[4].

Lifestyle Changes

If you have chronic pancreatitis, there are important things you can do to help stop the damage to your pancreas from getting worse and reduce the risk of other problems^[4].

Do not drink alcohol: It is very important to stop drinking alcohol completely^[4][19]. Drinking alcohol can cause more damage to your pancreas and may make your pain worse, even if alcohol was not the original cause of your condition^[4][19]. Tell your doctor if you need help to quit. Counseling, support groups, and sometimes medicines can help you stay sober^[19].

Do not smoke: If you smoke, giving up can help slow down the damage to the pancreas^[4].

Eat a healthy, low-fat diet: Recommended dietary changes include^[6][19]:

• Eat small, frequent meals (4 to 6 small meals and snacks each day instead of 3 large meals)
• Eat a low-fat diet
• Choose lean meats and cut off all visible fat
• Eat poultry without the skin
• Bake, broil, or grill foods instead of frying them
• Use non-fat or low-fat milk, yogurt, and cheese
• Avoid cream soups and cream sauces
• Eat a variety of vegetables and fruits
• Eat whole grain cereals, breads, crackers, rice, or pasta
• Limit fats and oils to no more than 1 tablespoon per meal
• Avoid high-fat foods like chocolate, whole milk, ice cream, fried foods, sausage, bacon, pastries, and processed snack foods
• Drink plenty of liquids
• Limit caffeine

Your doctor and dietitian can help you make an eating plan that does not irritate your digestive system^[19]. Always talk with your doctor or dietitian before you make changes in your diet^[19].

Who Is Affected

Chronic pancreatitis is rare. In the UK, between 6,000 and 12,000 people are given a new diagnosis every year^[7]. Data from studies estimate that the incidence is between about 4 and 12 per 100,000 persons per year, with prevalence ranging from 37 to 42 per 100,000 persons^[6].

Men are affected 1.5 to 3 times more than women^[6][7]. The average age at diagnosis is 35 to 55 years^[6]. Chronic pancreatitis mainly affects adults and is more common in people who drink or smoke a lot^[4].

For people with acute pancreatitis, about 8 out of 100 people may go on to develop chronic pancreatitis^[7].