Chronic Pancreatitis

What is Chronic Pancreatitis?

The pancreas is a glandular organ located in the posterior aspect of the abdomen just below and behind the stomach. The pancreas produces digestive enzymes (exocrine function), which are emptied into the small bowel, as well as the hormone insulin (endocrine function), which enters the blood stream. Pancreatitis occurs when the pancreas gets irritated or swollen and causes severe upper abdominal pain that may also be felt in the back.

Chronic pancreatitis occurs when the pancreas becomes damaged by long-standing inflammation, which impacts the pancreas' ability to function normally. Individuals with chronic pancreatitis experience pain in the upper abdomen and have episodes of acute pancreatitis when the pancreas suddenly becomes inflamed, which requires hospitalization to control the symptoms and slow the damage to the pancreas.

What are the Symptoms of Chronic Pancreatitis?

Abdominal pain occurs in the majority of individuals with chronic pancreatitis. The pain resulting from chronic pancreatitis usually occurs in the upper abdomen and may radiate to the back. Pain typically worsens or occurs 20 to 30 minutes after eating a meal and may be relieved by sitting up or leaning forward. Individuals often experience nausea and vomiting along with their pain.

Difficulty digesting fatty foods The pancreas produces enzymes that aid in digestion. Because chronic pancreatitis causes damage to the pancreas, individuals may not be able to produce enough of these enzymes and can have difficulty digesting food, resulting in weight loss and, occasionally, diarrhea.  The greatest difficulty occurs in digesting fatty foods, and this can cause loose, greasy, foul-smelling stools. The inability to digest fat can also cause vitamin and nutrient deficiencies, leading to weight loss.

Diabetes A normal function of the pancreas is to produce insulin to help control blood sugar levels. In severe cases of chronic pancreatitis, the pancreas is no longer able to produce enough insulin, leading to diabetes. 

How is Chronic Pancreatitis Treated?

The goals of treatment are to help relieve pain, improve pancreatic function, and prevent and manage complications.

Pain Relief

A variety of measures are available to help relieve the pain of chronic pancreatitis. Simple measures may be sufficient early in the course of the condition; however, as the disease worsens, more extensive measures may be needed. Doctors will typically recommend one or more of the options below to help control pain from chronic pancreatitis. Patients should discuss these options thoroughly with their physician in order to understand the risks and benefits of each. If these measures are not sufficient to manage pain and other complications of chronic pancreatitis, surgery can be considered.

  • Avoiding alcohol is the single most important treatment for individuals with pancreatitis related to alcohol abuse.
  • A low-fat diet can reduce the pain of chronic pancreatitis.
  • Pancreatic enzyme supplements are often recommended because these enzymes replace the enzymes normally produced by the pancreas, allowing the pancreas to "rest."
  • Nonsteroidal antiinflammatory drugs (NSAIDs) can often control the pain early in the course of chronic pancreatitis.
  • Narcotic pain medicines can also control the pain of chronic pancreatitis but are typically not used initially because of their  addictive potential.
  • Nerve block: Because nerves transmit the sensation of pain, blocking the nerves’ ability to send your body this signal can relieve pain from chronic pancreatitis. In order to perform a nerve block, an injection is given directly into the nerves that carry pain messages from the pancreas. Nerve blocks are effective in about 50 percent of individual who undergo the procedure.
  • A stent (thin plastic tube) can be placed to widen the pancreatic ducts and reduce the pain associated with chronic pancreatitis. (Narrowing of the pancreatic ducts that occurs with chronic pancreatitis can block secretions from the pancreas causing the back-up of fluid, swelling, and inflammation.)>

Treatment of Digestive Problems

There are several treatments available for individuals who are unable to absorb enough fat or have excessive fat in their stool.

  • Dietary restriction of fat intake to 20 grams per day or less may be recommended.
  • Lipase supplements can reduce greasy stools and help the body to digest fat. These supplements partially replace the lipase normally produced by the pancreas.
  • Medium chain triglycerides are a form of dietary fat that are more easily digested and absorbed than the long chain triglycerides found in most foods. Medium chain triglycerides are a good source of calories for people with chronic pancreatitis who have lost weight. 

Surgery

The timing and role of surgery as a treatment for chronic pancreatitis is the subject of much debate. Some studies suggest that using surgery early may slow the progression of chronic pancreatitis, while other research suggests that the condition worsens even in people who have surgery early. Currently surgery is usually reserved for individuals with chronic pancreatitis who have dilated pancreatic ducts that no longer respond to other treatments.

Three surgical procedures are currently available:

  • Pancreaticojejunostomy is a surgical procedure that relieves blockage and pressure in the pancreatic ducts in about 80 percent of individuals. Pain often returns within one year in people who undergo this procedure.
  • Partial pancreatectomy is the surgical removal of part of the pancreas. Removing part of the pancreas has been demonstrated to relieve pain in some individuals with chronic pancreatitis.
  • Islet cell transplants are an experimental treatment for pancreatitis that involve removing the entire pancreas and then replacing the insulin-producing s islet cells.

References

Warshaw AL, Banks PA, Fernández-Del Castillo C. AGA technical review: treatment of pain in chronic pancreatitis. Gastroenterology 1998; 115:765.

Singh VV, Toskes PP. Medical therapy for chronic pancreatitis pain. Curr Gastroenterol Rep 2003; 5:110.

CONDITIONS OF THE GI TRACT