Chronic Pancreatitis

Chronic pancreatitis can cause abdominal pain, poor digestion, diabetes and other complications. Alcohol is the common cause. Treatment includes painkillers, other medication and, most importantly, stopping alcohol drinking for good. Surgery is sometimes needed.

What is the pancreas?

The pancreas is in the upper abdomen and lies behind the stomach and intestines (guts). It makes a fluid that contains enzymes (chemicals) that are needed to digest food. The enzymes are made in the pancreatic cells and are passed into tiny ducts (tubes). These ducts join together like branches of a tree to form the main pancreatic duct. This drains the enzyme-rich fluid into the duodenum (the part of the gut just after the stomach). The enzymes are in an inactive form in the pancreas (otherwise they would digest the pancreas). They are 'activated' in the duodenum to digest food.

Groups of special cells called 'Islets of Langerhans' are scattered throughout the pancreas. These cells make the hormones insulin and glucagon. The hormones are passed (secreted) directly into the bloodstream to control the blood sugar level.

The bile duct carries bile from the liver and gallbladder. This joins the pancreatic duct just before it opens into the duodenum. Bile also passes into the duodenum and helps to digest food.

What is pancreatitis?

Pancreatitis means inflammation of the pancreas. There are two types.

• Acute pancreatitis - when the inflammation develops quickly, over a few days or so. It usually goes away completely and leaves no permanent damage. Sometimes it is serious. Acute pancreatitis is not dealt with further in this leaflet.
• Chronic pancreatitis - when the inflammation is persistent. The inflammation tends to be less intense than acute pancreatitis but as it is ongoing it can cause scarring and damage. About 1 person in 100,000 develops chronic pancreatitis each year in the UK.

What are the causes of chronic pancreatitis?

• Alcohol - is the usual cause (about 8 in 10 cases). Men aged 40-50 are the commonest group of people affected. Alcohol related chronic pancreatitis usually follows a typical pattern. In most cases the person has been drinking heavily for 10 years or more before symptoms first begin. There is often a first bout of acute pancreatitis with severe abdominal pain and vomiting. This may settle but if drinking continues the pancreas becomes more and more damaged. Recurring bouts of acute pancreatitis may develop. Unlike a 'one off' acute pancreatitis, the pain may then not go and chronic (ongoing) pain and other symptoms then develop.
• Other causes - are uncommon. They include abnormalities of the pancreas such as narrowing of the pancreatic duct (due to various reasons) and rare hereditary causes. It develops in some people with cystic fibrosis.
• Malnutrition - and eating large amounts of cassava may be a cause in some tropical countries.
• Unknown - in some cases no cause can be identified.

(Gallstones which are a common cause of acute pancreatitis do not cause chronic pancreatitis.)

What happens in chronic pancreatitis?

A persistent inflammation develops in the pancreas. The reason why alcohol or other factors trigger this inflammation is not clear. Over time the inflammation causes scarring and damage to parts of the pancreas. Not enough enzymes and insulin may be made if there is a lot of damage and scarring. A lack of enzymes causes poor digestion of food (malabsorption). A lack of insulin causes diabetes. Over time clumps of calcium are deposited and form stones in the pancreas. (Again, the reason why this occurs is not clear.) These can be seen on x-rays. Calcium stones and/or scarring of the pancreatic ducts may block the flow of enzymes along the pancreatic ducts.

Chronic pancreatitis is often a slowly progressive condition. The time from the initial triggering of inflammation to damage, scarring, calcium stones and then to developing digestion problems or diabetes is often several years. However, many months or years of this process can go on before symptoms, such as pain, are first noticed.

What are the symptoms of chronic pancreatitis?

• Abdominal pain - just below the ribs is usual. The pain is typically felt spreading through to the back. It tends to be persistent and may be partly eased by leaning forward. It may be mild at first but can become severe. Eating often makes the pain worse so affected people tend not to eat much. Weight loss is then typical.
• Poor digestion (malabsorption) - occurs if not enough enzymes are made by the damaged pancreas. In particular, the digestion of fats and certain vitamins is affected. Undigested fat from the diet may remain in the gut and be passed with faeces (stools). This causes pale, smelly, loose stools that are difficult to flush away (steatorrhoea). Weight loss occurs if food is not fully digested.
• Diabetes - occurs in about 1 in 3 cases. This occurs when the pancreas cannot make sufficient insulin. Symptoms include excess thirst, passing large amounts of urine and further weight loss unless the diabetes is treated.
• Feeling sick (nausea) - and generally feeling unwell may also occur.

How is chronic pancreatitis diagnosed?

Diagnosing chronic pancreatitis in its early stages is often difficult. There is no easy test to detect early damage to the pancreas. Many pancreatic cells can be damaged before abnormalities show up on tests, x-rays or scans. Also, the amount of enzymes made by the pancreas and the number of insulin producing cells can become quite low before symptoms of poor digestion or diabetes develop. There are a number of causes of abdominal pain which may be confused with chronic pancreatitis. However, if other causes of persistent abdominal pain are ruled out and there is a history of regular heavy alcohol drinking then chronic pancreatitis is a likely diagnosis.

Once the damage and scarring to the pancreas is more severe, or when calcium stones start to form, then the damaged pancreas can be detected by x-rays or scans. By this time the condition is quite advanced and malabsorption or diabetes symptoms may have already developed.

Are there any complications that can develop?

• Pseudocyst - develops at some stage in about 1 in 4 people with chronic pancreatitis. This is when pancreatic fluid, rich in enzymes, collects into a cyst due to a blocked pancreatic duct. These can swell to various sizes. They may cause symptoms such as worsening pain, feeling sick and vomiting. Sometimes they go away without treatment. Sometimes they need to be drained or surgically removed.
• Ascites - sometimes occurs. This is fluid that collects in the abdominal cavity between the organs and guts.
• Blockage of the bile duct - is an uncommon complication. This causes jaundice as bile cannot get into the gut and leaks into the bloodstream. This makes your skin look yellow.
• Cancer of the pancreas - is more common in people with chronic pancreatitis. The risk increases in smokers and with increasing age.
• Rare complications - include blockage of the gut, bleeding or thrombosis (blood clot) in blood vessels near to the pancreas.

What is the treatment for chronic pancreatitis?

• Stop drinking alcohol for good - this is the most essential part of treatment.
• Painkillers - are usually needed to ease the pain. Controlling the pain sometimes becomes quite difficult and referral to a pain clinic may be needed. Apart from painkillers, other techniques to block the pain may be considered such as nerve blocks to the pancreas.
• Enzyme replacement medication - may be needed if the low level of enzymes causes poor digestion of food and steatorrhoea. Capsules containing artificial enzymes are taken with meals.
• Restricting fat in the diet - may be advised if steatorrhoea is bad.
• If diabetes develops - then medication or insulin injections will be needed to control the blood sugar level.
• Do not smoke - to minimise the risk of pancreatic cancer developing.

Surgery
Most people with chronic pancreatitis do not need surgery but an operation is sometimes needed. The common reason for surgery is for persistent bad pain that is not helped by painkillers or other methods. Improvement in pain occurs in about 7 in 10 patients who have surgery. The operation usually involves removing part of the pancreas. There are different techniques that remove different amounts of the pancreas. The one chosen depends on the severity of the illness, whether the pancreatic duct is blocked and on other factors. The pain recurs sometime in the future in some people who have an initial improvement with surgery.

Various other surgical procedures may be advised if there is a specific problem that can be corrected. For example, removal of a large calcium stone that is blocking the main pancreatic duct. Another procedure that may help in some people is to 'stretch' wide a narrowed pancreatic duct to allow better drainage of pancreatic enzymes.

Surgery may also be needed if a complication develops. For example, if a blocked bile duct or pseudocyst develops.

What is the outlook (prognosis) for chronic pancreatitis?

If alcohol is the cause of chronic pancreatitis then other alcohol related illnesses commonly also develop. (Pancreatitis is but one problem associated with persistent heavy alcohol drinking.) If alcohol drinking continues and pancreatitis becomes severe than life expectancy is typically reduced by 10-20 years. This is due to complications of pancreatitis or to other alcohol related illnesses. If alcohol drinking is stopped completely in the early stages of the condition then the outlook is better.

The outlook for other less common causes of chronic pancreatitis depends on the cause and severity of the condition.

Further help and information

Pancreatitis Supporters Network
P O Box 8938, Birmingham, B13 9FU
Tel: 0121 449 0667   Web: www.pancreatitis.org.uk/
Provides information and support for people with pancreatitis.

© EMIS and PIP 2004   Updated: May 2001   CHIQ Accredited