Chronic Pancreatitis

Chronic pancreatitis is characterised by repeated pancreatic inflammation. This leads to the destruction of pancreatic tissue leading to irreversible loss of both endocrine and exocrine function and formation of calcifications, pseudocysts and fibrosis.

Risk factors

The most common causes of chronic pancreatitis are alcohol and smoking. It is estimated that alcohol causes up to 80% of cases. Smoking is a cause in its own right but also is believed to increase the rate of progression of damage in other causes.

Other causes include:

  • Strictures follwoing Endoscopic Retrograde Cholangiopancreatography (ERCP).
  • Acute pancreatitis and its causes.
  • Tumours of both the pancreas and small intestines.
  • Autoimmune pancreatitis – IBD, primary biliary cirrhosis.
  • Genetic causes – including cystic fibrosis.
  • Drugs – thiazides, DPP4 inhibitors, azathioprine, tetracyclines etc.

Presentation

As with all patient presentations the best approach is an ABCDE method of assessment.

Patients with chronic pancreatitis are most likely to present with abdominal pain. This is usually a severe, dull, epigastric pain that often radiates to the back. When present, it may be intermittent or constant. It can be relieved by sitting upright/bending forward and could be brought on by eating.

Other presenting complaints:

  • Symptoms relating to endocrine insufficiency
    • Diabetes mellitus/impaired glucose regulation – thirst, weight loss, polyuria and in severe cases DKA.
  • Symptoms relating to exocrine insufficiency 
    • Fat malabsorption – bloating, diarrhoea (steatorrhoea), weight loss, abdominal cramps.
    • Metabolic bone disease – low trauma fractures.
  • Malnutrition
    • Often worse in those with pain and chronic pancreatitis caused by alcohol but estimated that up to 50% of those with chronic pancreatitis have an increased basal energy expenditure.
    • Can present with weight loss, fatigue.
  • Pancreatic cancer
  • Pseudocysts
    • Gastric outlet obstruction, biliary obstruction.

Examination

1. Inspection

  • Signs of alcohol misuse/chronic liver disease (jaundice, erythematous palms, hepatic flap etc).
  • Erythema ab igne – skin reaction caused by chronic exposure to heat (hot water bottles).

2. Palpation

  • Epigastric tenderness, ascites, distension.

Investigations

1. Blood tests

  • Liver function tests (ALP rise if compression of ducts/obstruction, ALT rise if associated liver disease). 
  • Glucose & HbA1C to monitor the risk of developing pancreatic endocrine insufficiency (new onset diabetes or worsening of known diabetes).

2. Stool tests

  • Check faecal elastase to assess pancreatic exocrine insufficiency (Normal stool-concentration of elastase exceeds 200 µg/g (depending on the method), and a concentration less than 100 µg/g stool usually means severe insufficiency). 

3. Assessment of nutrition

  • Multiple scoring systems available (nutrition risk screening, MUST etc)

4. Ultrasound

  • This can identify pancreatic calcification and other signs of chronic pancreatitis including pseudocysts, splenic vein thrombosis, biliary duct dilatation.
  • Helps to exclude other causes of pain/symptoms

5. CT scan

  • This is the best form of imaging for identifying changes of chronic pancreatitis

6. Other Imaging

  • Endoscopic US (EUS), MRI

Management

1. Lifestyle advice

  • Avoid alcohol – even if not the cause of the pancreatitis it can continue to exacerbate symptoms and increase damage. Referral to alcohol liaison teams can be useful for patients with dependence on alcohol.
  • Stop smoking – as above smoking increases the rate of progression of disease.

2. Nutrition

  • A referral to a dietician for a thorough assessment of daily nutritional targets and dietary advice
  • Often advised to eat a low-fat, high-protein diet with fat-soluble vitamin supplements (A, D, E, K)
  • In patients with symptoms of exocrine insufficiency, pancreatic enzyme supplements such as creon may be required with meals and snacks.
  • In some cases where weight loss persists despite intervention (diet change/oral supplements), enteral or very occasionally parenteral feeding may be required to meet metabolic and nutritional requirements.
  • Bone health – calcium and vitamin D supplements where required.

3. Analgesia

  • Consider specialist pain team referrals in these patients where mild/moderate analgesia not effective or where there are concerns of more neuropathic pain.
  • WHO pain ladder
  • Be aware long term anti-inflammatories will require gastric protection in form of Proton pump inhibitor (PPI).
  • As always opioids can cause constipation and so consideration of starting laxatives with these medications should be made.

4. Other medication

  • If the cause is an immune condition, then treatment of that condition may help reduce the symptom burden e.g. steroids in IBD.
  • Normal risks of steroids apply and especially need to think about osteoporosis risk in these patients due to metabolic bone disease.

5. Surgery

  • In the management of pain and other complications
  • Necrosis with infection – either endoscopic or percutaneous approach to drain and debride where necessary. However this is more seen after acute pancreatitis.
  • Pseudocyst – either endoscopic or surgical (laparoscopic/open) drainage for those causing symptoms or creating pressure on other structures/risk of rupture/possible infection.
  • Surgical procedures in chronic pancreatitis involve pancreatic parenchymal resection, pancreatic duct drainage or a combination of both (Pancreatico-jejunostomy, Frey’s Procedure, Beger’s procedure, pancreaticoduodenectomy/Whipple’s procedure)

References

  1. Hart, P. A. & Conwell, D. L., 2020. Chronic Pancreatitis: Managing a Difficult Disease. The American Journal of Gastroenterology, pp. 49-55.
  2. Kemalasar, I., Abdullah, M. & Simadibrata, M., 2018. Chronic Pancreatitis. The Indonesian Journal of Gastroenterology, Hepatology and Digestive Endoscopy, pp.107-117.
  3. NICE, 2018. Pancreatitis. [Online]. Available at: https://www.nice.org.uk/guidance/ng104/chapter/Recommendations#chronic-pancreatitis
  4. Rasmussen, H. H. et al., 2014. Nutrition in chronic pancreatitis. World Journal of Gastroenterology, p. 7267–7275.

Edited by Mudassar Khan (Y4 Medical Student)

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