Chronic pancreatitis

Synonyms :  

Clinical features, Diagnosis, Management, Prognosis, Nutrition, Herbs,

Chronic pancreatitis is defined as a continuing inflammatory disease of the pancreas, characterised by irreversible morphological/histological change and typically causing pain and/or permanent impairment of function. The majority of cases of chronic pancreatitis in the Western world occur as a result of persistent high alcohol consumption (70-80%). On the other hand only 5-10% of alcoholics develop chronic pancreatitis suggesting that other factors may be important in the pathogenesis of the disease. Biliary tract disease plays a less important role in chronic pancreatitis than in the acute form of the disease, but hypercalcaemia and hyperlipoproteinaemia (increased VLDL ? triglycerides) predispose to chronic pancreatitis. However 20% of patients have no apparent predisposing influences (idiopathic). The disease is most common in males between the ages of 35 and 45 years. Most experts believe that acute pancreatitis does not lead to chronic pancreatitis unless complications, such as persistent pseudocysts or ductal strictures are present. 

Pathogenesis is obscure but chronic pancreatitis may result from hypersecretion of protein which is not compensated for by an increase in ductal bicarbonate secretions. As a result of this protein plugs form within pancreatic ducts. Such plugs are observed in all forms of chronic pancreatitis, but in alcoholics these plugs may enlarge to form stones containing calcium carbonate precipitates. These stones then cause small duct obstruction and atrophy of the draining pancreatic lobules. Pancreas shows fibrosis and atrophy of glandular tissue, dilated duct system and calcification, but usually with preservation of the islets of Langerhans (insulin producing cells).  

Mechanisms of pain in chronic pancreatitis are unknown but may relate to pancreatic secretion rather than to intraductal obstructions because not all patients have ductal lesions. It has been suggested that alcohol can increase pancreatic secretion and consequently cause pain in this condition; total abstinence often provides pain relief.  

Clinical features:  < BACK TO TOP >

       Clinical presentation is very variable; the condition may present as repeated attacks of mild or moderately severe abdominal pain, or as persistent abdominal and back pain (many patients with unexplained abdominal pain may have undiagnosed chronic pancreatitis).

       On the other hand, the patient may be asymptomatic until pancreatic insufficiency and impaired digestion develop.

       However, most patients present with abdominal pain that occurs often within a few hours of an alcoholic bout/large fatty meal.

       The pain is usually steady, lasting more than 24 hours, sometimes few days or even weeks.

       It is located in the epigastrium or around the umbilicus, radiating to the back, usually accompanied by nausea and sometimes vomiting.

       Relief may be obtained by crouching forward or leaning forward over a chair.

       Weight loss is common due to malnutrition and malabsorption.

       Diarrhoea and steatorrhoea are frequent due to impaired digestion of lipids, deficiency of lipid soluble vitamins is often found.

       Diabetes mellitus eventually develops in about one fifth of patients due to destruction of insulin secreting cells.

Diagnosis:  < BACK TO TOP >

       Diffuse tenderness in the upper abdomen may be noted, with or without rigidity (guarding).

       Plain X-ray of the abdomen may show characteristic calcifications in the pancreas (sometimes no calcifications are found).

       Ultrasonography and CT scan can also be used to detect structural changes in the pancreas (calcifications, duct dilation, pancreatic atrophy and fibrosis).

       Endoscopic retrograde pancreatography can visualise the pancreatic duct system and reveal sites of obstruction.

       Testing of pancreatic function is done to assess pancreatic insufficiency. In the secretin-cholecystokinin test these two hormones are given intravenously after naso-duodenal intubation has been done, pancreatic secretions are collected and tested for the amount of bicarbonates, amylase and lipase.

       Cleavage tests are non-invasive and they are based on the cleavage of an orally given marker (e.g., N-benzoyl-tyrosil-p-aminobenzoic acid) by pancreatic enzymes, after what split segments (in the abovementioned example p-aminobenzoic acid) are absorbed and excreted in the urine where they can be measured.

       Stool collection for 5 days for measurement of fat can demonstrate the extent of steatorrhoea; trypsin level in faeces is also low.

Management  < BACK TO TOP >

       There is no specific treatment; abstinence from alcohol is absolutely essential.

       The diet should be normal and nutritious but low in fat, supplements of fat-soluble vitamins are often required.

       Preparations of pancreatic enzymes as capsules [Cotazym-S Forte, Viokase, Pancrease, Panazyme, Creon] are given during meals to help digestion; various natural alternatives such as papaya extract can be also tried. Such treatment is claimed to be able to reduce pain as well.

       Treatment of pain (analgesics) especially before meals to counteract the postprandial increase in pain may be tried.

       In case of diabetes, the patient is managed with diet and insulin.

       Surgery is attempted only in selected cases where there is confirmed pancreatic pseudocyst or dilation of the main pancreatic duct; the procedures are stones removal during ERP (“basketing?, drainage and partial resection (major surgery).

       Patients with chronic pancreatitis are at increased risk for pancreatic cancer; cancer occurs is approximately 4% of patients within 20 years after diagnosis of chronic pancreatitis.

Prognosis  < BACK TO TOP >

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Nutrition < BACK TO TOP >

Nutrition that alleviate or prevent Chronic pancreatitis :-
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Herbs < BACK TO TOP >

Herbs that alleviate or prevent Chronic pancreatitis :-
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