Chronic Pancreatitis

Pancreatitis is the chronic inflammation of the pancreas. There are acute and chronic forms of pancreatitis. In the following, we introduce the characteristics of chronic pancreatitis.

Definition: what is chronic pancreatitis?

Chronic inflammation of the pancreas (pancreatitis) is defined as chronic disease of the pancreas that progresses until there is failure of exocrine function (production of digestive enzymes) and later endocrine glandular function (production of hormones). Men between the ages of 30 and 40 are most affected.

Causes of chronic pancreatitis

In Western countries, the most common cause of chronic pancreatitis is alcohol abuse. Consumption of more than 80 grams of alcohol per day in men, more than 40 grams in women, is thought to cause irreparable damage after four to eight years. The exact correlations are not yet known in detail. It is known that alcohol interferes with numerous mechanisms in the body and thus also leads to damage of the pancreas. According to the underlying disease, the inflammation often has a chronic character, although even a single alcoholic episode is sufficient to trigger (acute) pancreatitis. Rare causes are:

  • Arteriosclerosis
  • Malformations
  • Biliary tract diseases
  • Disorders in hormone and fat metabolism
  • Injuries
  • Obstruction of the pancreatic duct

However, the cause of chronic pancreatitis often remains unknown.

Chronic pancreatitis: typical symptoms.

Chronic pancreatitis manifests itself in dull, but sometimes also cutting pain in the upper abdomen, which initially occurs occasionally and can be triggered by food or alcohol. The pain may radiate to the back. Later, the pain lasts for days or even weeks. Sufferers huddle together because this improves the pain. There are also painless forms (five percent of cases). Bloating, nausea, nausea and flatulence may occur. In the course of chronic pancreatitis, digestive disorders develop. However, these only become apparent when the pancreas is already providing only ten to 20 percent of its normal exocrine output. Greasy stools occur, and stool weight increases. Weight loss and jaundice are also possible.

Here’s how chronic pancreatitis is diagnosed

Diagnosis includes clinical examination, in which a tenderness in the upper and middle abdomen is found. Body weight in relation to height may be decreased. Elevations of pancreatic enzymes are not probative of chronic pancreatitis. They merely indicate inflammation (see also acute pancreatitis) or that secretions are retained (for example, in cysts). In advanced disease, steatorrhea (also known as fatty stools or pancreatic stools) develops and stool weight increases to more than 300 grams per day.

Different diagnostic procedures

Different procedures are used to diagnose chronic pancreatitis:

  • Ultrasound can be used to examine the outline of the pancreas and detect calcifications.
  • An x-ray also shows any calcifications that may be present. Calcifications are found in 70 percent of those affected.
  • Further details (extent of tissue destruction, bleeding) are shown with computed tomography.
  • In an ERCP (an endoscopic examination), the ducts of the pancreas as well as the bile ducts can be visualized and any constrictions can be identified. Constrictions can possibly be dilated endoscopically during the examination and gallstones removed.
  • With a cholangiogram (with the help of a contrast agent) narrowings of the bile duct or congestion of the same are visible.
  • To rule out pancreatic cancer, a biopsy under ultrasound or surgical opening of the abdomen is performed if necessary.
  • In addition to imaging techniques, tests to measure the functional capacity of the pancreas play an important role: this involves measuring the excretion of certain enzymes in the stool. The excretion of chymotrypsin falls below 5 units per gram of stool.
  • In the so-called pancreolauryl test, a fluorescent substance is administered.This substance is normally broken down by pancreatic enzymes known as esterases. Since fewer enzymes are present in the presence of chronic pancreatitis, this cleavage takes place to a lesser extent. By measuring how much fluorescein is excreted in the urine over 24 hours, the extent of functional impairment can be determined.
  • The most sensitive test, however, is the secretin-pancreozymin test: after the pancreas has been stimulated, a probe is used to remove secretion from the duodenum. Bicarbonate and pancreatic enzymes are then measured in this secretion. With this test, a functional impairment can be detected early.

Course in chronic inflammation of the pancreas.

In the course of the disease, initially the exocrine function of the pancreas fails, causing digestive problems. Later, diabetes develops due to the disruption of endocrine function. Chronic pancreatitis is a progressive disease. Usually, a symptom-free stage (approximately five years) is followed by a stage of acute inflammation, which leads to disturbances in exocrine and endocrine function after another five years. Patients’ life expectancy is reduced and prognosis is poor if alcohol use continues.

Potential complications

Cysts form in approximately 50 percent of cases. If the cysts reach a size of more than 5 cm, they must be surgically removed. This is because there is then a possibility that they will burst, their contents will be released and the enzymes they contain will attack blood vessels. This can lead to severe bleeding. A further complication can be narrowing of the nearby duodenum (stenosis). Such a narrowing of the bile duct may be accompanied by icterus (jaundice). Thrombosis of the splenic vein with enlargement of the spleen is also possible. Pancreatic cancer appears to be somewhat more common in people with chronic pancreatitis. Relapses of acute pancreatitis occur primarily in the first phase of the disease.

Treatment of chronic pancreatitis

Conservative treatment consists of the following measures:

Surgery may be necessary if complications have occurred or there is persistent pain. During surgery, parts of the pancreas may be removed or additional drains for pancreatic secretions into the intestine may be created. Cysts are removed or may also be punctured under ultrasound guidance.