Pancreatitis

Chronic pancreatitis is a long-lasting inflammation of the pancreas that leads to irreversible damage, fibrosis, and dysfunction of the organ. The pancreas is responsible for producing digestive enzymes and hormones, including insulin, which regulate blood sugar levels. Chronic pancreatitis can result in loss of pancreatic function, including the ability to secrete digestive enzymes and regulate blood sugar, and can lead to pancreatic insufficiency, diabetes, and other complications.

The primary causes of chronic pancreatitis include:

• Alcohol consumption: Chronic heavy alcohol use is the most common cause of chronic pancreatitis, accounting for about 70-80% of cases. The exact mechanism is not fully understood, but alcohol damages pancreatic cells, leading to inflammation and scarring over time.
• Genetic factors:
  • Mutations: Certain mutations can increase susceptibility to chronic pancreatitis. Mutations in the CFTR gene (cystic fibrosis transmembrane conductance regulator), which causes cystic fibrosis, and in genes such as PRSS1, SPINK1, and CFTR are known to predispose individuals to chronic pancreatitis.
  • Hereditary pancreatitis: This is a rare condition that can occur in families and is often caused by mutations in the PRSS1 gene, leading to increased activation of pancreatic enzymes within the pancreas.
• Autoimmune pancreatitis: This form of pancreatitis is caused by an abnormal immune response where the body’s immune system attacks the pancreas. It is associated with other autoimmune diseases like IgG4-related disease.
• Obstruction of the pancreatic duct: Blockage or narrowing of the pancreatic duct can cause chronic inflammation. This may occur due to pancreatic duct stones, strictures (narrowing of the duct), or tumours that obstruct the normal flow of pancreatic enzymes.
• Idiopathic: In many cases, the exact cause of chronic pancreatitis remains unknown, even after thorough investigation. This is referred to as idiopathic pancreatitis.
• Other causes: Hypercalcaemia (elevated blood calcium levels), high cholesterol (hyperlipidemia), and certain infections (e.g., mumps or hepatitis) can also contribute to the development of chronic pancreatitis.

Common symptoms include:

• Abdominal pain: The most common symptom is recurrent or persistent upper abdominal pain, which may radiate to the back.
• Digestive problems: As the pancreas becomes less able to produce digestive enzymes, patients may experience symptoms of pancreatic insufficiency:
  • Steatorrhea (fatty stools): This occurs due to malabsorption of fat.
  • Bloating, nausea, and diarrhoea: These are also common as food is not properly digested.
• Weight loss: Unexplained weight loss occurs because the body cannot properly digest food, leading to malnutrition. This can be exacerbated by poor appetite and diarrhoea.
• Diabetes: As the pancreas becomes damaged, the insulin-producing cells may also be affected, leading to diabetes mellitus. This can occur over time in people with chronic pancreatitis, especially if the condition is severe.
• Jaundice: If chronic pancreatitis causes obstruction of the bile duct (by a pancreatic pseudocyst or fibrosis), jaundice (yellowing of the skin and eyes) may develop.
• Nausea and vomiting: Persistent nausea and vomiting may occur, particularly during episodes of pain or in cases where there is a significant impairment of digestion.
• Fatigue: Chronic inflammation and the body’s inability to properly absorb nutrients can result in chronic fatigue and weakness.

Diagnosing chronic pancreatitis involves the following tests:

• Blood tests:
  • Amylase and lipase: The levels of these enzymes are typically elevated in acute pancreatitis, but in chronic pancreatitis, they may be normal or only mildly elevated.
  • Pancreatic function tests: These may assess how well the pancreas is producing digestive enzymes.
  • Glucose levels: Elevated blood sugar may indicate diabetes due to pancreatic damage.
  • Liver function tests: Elevated liver enzymes can suggest complications like bile duct obstruction.
• Imaging studies:
  • Abdominal ultrasound: This is the first-line imaging modality and may reveal pancreatic calcifications, bile duct dilation, or pancreatic masses.
  • CT scan: CT is a more detailed imaging technique that can identify structural changes in the pancreas, such as pancreatic calcifications, pseudocysts, or ductal strictures.
  • MRI/MRCP (magnetic resonance cholangiopancreatography): MRCP provides high-resolution images of the pancreatic duct and bile ducts, helping to identify ductal dilation, strictures, or stones.
• Endoscopy:
  • Endoscopic ultrasound (EUS): EUS is highly sensitive for detecting pancreatic calcifications and can also be used to obtain tissue samples (biopsy) for evaluation of the pancreas.
  • Endoscopic retrograde cholangiopancreatography (ERCP): This procedure is not commonly used for diagnosis but can be useful to visualise the pancreatic duct and remove stones or relieve ductal obstructions.
• Pancreatic function tests: These tests assess how well the pancreas is functioning in terms of enzyme production. The secretin stimulation test and faecal elastase levels are commonly used to evaluate pancreatic exocrine function.

The treatment of chronic pancreatitis is primarily aimed at managing pain, improving pancreatic function, and addressing complications. There is no cure for chronic pancreatitis, but treatment can help improve quality of life and reduce symptoms.

• Pain management: Pain is one of the most common and debilitating symptoms of chronic pancreatitis. Treatment options include:
  • Medications:
    1. Nonsteroidal anti-inflammatory drugs (NSAIDs): Used for mild-to-moderate pain relief.
    2. Opioids: In cases of severe pain, opioids may be used, but their long-term use should be closely monitored due to the risk of dependence.
    3. Gabapentin or pregabalin: These medications, which are used for nerve pain, can sometimes be helpful for chronic pancreatitis pain.
• Endoscopic therapy: If there is ductal obstruction, endoscopic drainage or stenting can help relieve pain.
• Surgical intervention:
  • Pancreatic surgery: In some cases, surgical intervention may be required to relieve pain, remove stones, or treat complications such as pseudocysts or strictures.
  • Pancreatic resection: For patients with localised disease, removing part of the pancreas may help alleviate symptoms.
  • Pancreatic duct drainage: This might be required for severe cases.
• Nutritional support:
  • Enzyme replacement therapy: Pancreatic enzyme supplements can help improve digestion and nutrient absorption in patients with pancreatic insufficiency. These are typically taken with meals.
  • Dietary changes: A low-fat, high-protein diet may be recommended to improve digestion and reduce discomfort. Patients should avoid alcohol and smoking to prevent further damage to the pancreas.
  • Vitamin supplementation: Deficiencies in fat-soluble vitamins (A, D, E, K) can occur due to poor absorption of fat. These may need to be replaced through supplements.
• Lifestyle changes:
  • Avoid alcohol: Alcohol consumption should be completely avoided in patients with chronic pancreatitis, as it can worsen the condition and cause flare-ups.
  • Smoking cessation: Smoking is a significant risk factor for the development and progression of chronic pancreatitis and should be avoided.
  • Weight management: Maintaining a healthy weight is important to reduce the strain on the pancreas and improve overall health.