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Pancreatitis (Chronic)

Introduction

Chronic pancreatitis is a condition where the pancreas becomes inflamed and the inflammation lasts for many years. The long-term inflammation causes the pancreas to become scarred and damaged.

The pancreas

The pancreas is a small, tadpole-shaped organ that is located behind the stomach and below the ribcage. The pancreas has two important functions:

  • it produces digestive juices that are used by the intestines to help digest food
  • it produces powerful ‘messenger chemicals’ called hormones

Insulin, which regulates the levels of sugar (glucose) in the blood is the most important hormone that is produced by the pancreas.

The most common symptom of chronic pancreatitis is repeated episodes of abdominal pain which can often be severe.

As the damage to the pancreas progresses, it begins to lose some of its functions, which can cause other symptoms, such as:

  • producing greasy, foul-smelling stools (faeces)
  • diarrhoea

See Chronic pancreatitis - symptoms for more information.

Acute pancreatitis is where the pancreas becomes inflamed quickly and the inflammation usually only lasts for a few days. See the A-Z topic about Acute pancreatitis for more information.

Causes of chronic pancreatitis

Alcohol

Persistent and long-term alcohol misuse is the most common cause of chronic pancreatitis. It is estimated that around two-thirds of cases of chronic pancreatitis occur in people who have a history of heavy drinking. This is because in certain individuals alcohol has a toxic (poisonous) effect on the tissue of the pancreas.

Autoimmune pancreatitis

Autoimmune pancreatitis is a recently recognised type of chronic pancreatitis. It occurs when the immune system (the body’s natural defence against illness and infection) mistakenly attacks the tissue of the pancreas. It is thought that 1 in 20 cases of chronic pancreatitis are autoimmune pancreatitis.

Chronic idiopathic pancreatitis

No obvious cause can be found in most of the remaining 25% of cases of chronic pancreatitis. This type of pancreatitis is called chronic idiopathic pancreatitis. Therefore, there is a large minority of people who are affected by chronic pancreatitis who do not have a history of alcohol abuse.

Hereditary pancreatitis

There is a very rare form of chronic pancreatitis known as hereditary pancreatitis, which is caused by genetic mutations that a person inherits from their parents.

A genetic mutation is when the instructions found in all living cells become ‘scrambled’ in some way, meaning that one or more of the processes of the body does not work in the way it should.

Hereditary pancreatitis tends to share the same symptoms as other forms of chronic pancreatitis except the symptoms develop much earlier in life, usually during childhood.

See Chronic pancreatitis - causes for more information.

Treating chronic pancreatitis

In most cases of chronic pancreatitis, there is no specific treatment to reduce the inflammation and repair the damage to the pancreas.

Therefore, treatment mainly focuses on pain relief using painkillers and, in the latter stages of the condition, medications that are designed to replicate the functions of the pancreas. Surgery is sometimes needed to treat severe chronic pain that does not respond to painkillers.

In autoimmune pancreatitis, steroid tablets (oral corticosteroids) usually prove effective in reducing the level of inflammation.

See Chronic pancreatitis - treatment for more information.

How common is chronic pancreatitis?

Chronic pancreatitis is an uncommon condition. It is estimated that only one new case of chronic pancreatitis is diagnosed for every 11,000 people. However, recently, the rates of chronic pancreatitis have increased because of a rise in alcohol consumption.

Who is affected by chronic pancreatitis?

Chronic pancreatitis that is related to alcohol consumption is most common in middle-aged men who are between 45 and 54 years of age.

Chronic idiopathic pancreatitis can affect adults of all ages.

Women are more often affected by chronic idiopathic pancreatitis than men.

Autoimmune pancreatitis usually first develops between 50 and 60 years of age. It occurs in twice as many men as women. The reason for this is unclear.

Complications

Type 1 diabetes is a common complication of chronic pancreatitis and affects about half of people with the condition. Diabetes occurs when the pancreas is damaged and is unable to produce insulin.

People with chronic pancreatitis also have an increased risk of developing pancreatic cancer.

See Chronic pancreatitis - complications for more information.

Outlook

With the exception of autoimmune pancreatitis (which responds well to treatment), the outlook for most cases of chronic pancreatitis is not good.

The pain can be difficult to treat and can affect a person’s quality of life. However, in many cases, after many years the pain improves or sometimes disappears.

People who do not smoke cigarettes and avoid drinking alcohol usually have a much better outlook. They tend to experience less pain and live longer than those who continue to drink and smoke after receiving a diagnosis.

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Symptoms

Repeated episodes of abdominal pain are the most common symptom of chronic pancreatitis. The pain usually develops in the middle or on the left side of your abdomen and can sometimes travel along your back.

Most people have described the pain as feeling like a dull but severe ache. The episodes of pain can last for several hours or sometimes days. The pain can sometimes occur after eating a meal, but often episodes of pain seem to have no trigger.

Leaning forwards or curling into a ball may help to relieve the pain to a certain extent. You may also experience symptoms of nausea and vomiting during the painful episodes. As chronic pancreatitis progresses, the painful episodes may become more frequent and severe.

Some people may eventually experience a constant mild to moderate pain in their abdomen in between episodes of severe pain. This pattern of symptoms is most common in people who continue to drink alcohol after diagnosis.

Some people who stop drinking alcohol may experience a reduction in the severity of their pain.

Advanced chronic pancreatitis

Additional symptoms can occur when the pancreas loses its ability to produce digestive juices, which help break down food in the digestive system. The pancreas usually only loses these functions many years after the original onset of symptoms.

The absence of digestive juices makes it difficult for your digestive system to break down fats and certain proteins. This can cause your faeces (stools) to become particularly smelly and greasy, and make them difficult to flush down the toilet. You may also experience:

  • bloating
  • abdominal cramps
  • excessive flatulence (breaking wind or farting)
  • back pain
  • weight loss
  • loss of appetite
  • jaundice (yellowing of the skin and eyes)

When to seek medical advice

Always visit your GP if you are experiencing severe pain. This is because pain is a warning sign and the worse the pain is the more likely it is that there is something seriously wrong inside your body.

You should also visit your GP if you develop symptoms of jaundice. Jaundice can have a range of causes other than pancreatitis, but it is usually a sign that there is something wrong with your digestive system.

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Causes

Chronic pancreatitis usually develops when repeated episodes of acute pancreatitis lead to permanent damage of your pancreas.

However, in a minority of cases chronic pancreatitis develops in people who have no previous history of pancreatitis. To understand the possible causes of chronic pancreatitis it is useful to learn more about acute pancreatitis.

Acute pancreatitis

The exact cause of acute pancreatitis is unclear, but most experts think that it has something to do with a chemical called trypsin. Trypsin is an enzyme that is produced by the pancreas. It is used to help break down the proteins in food to aid digestion.

When trypsin is produced by the pancreas it remains in an ‘inactive’ state and has no digestive properties. It is not until it is moved out of the pancreas and into the intestines that it becomes active and is able to start breaking down proteins.

It is thought that something causes trypsin to become active while it is still in the pancreas, and that it may begin to break down the cells of the pancreas. In effect, the pancreas starts to try to digest itself, causing it to become irritated and inflamed.

The two most common causes of acute pancreatitis are:

  • gallstones - it is thought that gallstones block an opening to the pancreas, which disrupts the normal workings of the cells in a similar way to alcohol, leading to the activation of trypsin
  • alcohol misuse - it is thought that the ethanol molecules in alcohol interfere with the normal workings of the cells of the pancreas, causing them to activate trypsin prematurely

Alcoholic chronic pancreatitis

Alcohol consumption is a significant risk factor that is associated with chronic pancreatitis, accounting for around 70% of all cases. People who consume large amounts of alcohol are at increased risk of having repeated episodes of acute pancreatitis.

Over time, repeated episodes of acute pancreatitis will eventually cause the pancreas to become permanently damaged, resulting in chronic pancreatitis. Chronic pancreatitis that has been caused by alcohol misuse is called alcoholic chronic pancreatitis.

Anyone who regularly consumes alcohol has an increased risk of developing chronic pancreatitis.

Smoking cigarettes appears to increase the harmful effects of alcohol on the pancreas.

Research has found that people who are heavy drinkers and who smoke 35 or more cigarettes a day are 13 times more likely to develop chronic pancreatitis than people who do not smoke or drink alcohol. However, only 1 in 10 people who are heavy drinkers will go on to develop chronic pancreatitis.

People who only smoke cigarettes but do not drink alcohol still have an increased risk of developing chronic pancreatitis (as well as other serious diseases such as heart disease and lung cancer). One study found that smokers were eight times more likely to develop chronic pancreatitis than non-smokers.

There is evidence that suggests that there are certain genetic mutations that make some people’s pancreas much more vulnerable to the harmful effects of alcohol. This could explain why only a minority of heavy drinkers are affected by chronic pancreatitis.

Genetic mutations are where the instructions that are found in all living cells become scrambled. This can cause some of the processes of the body to become disrupted.

Idiopathic chronic pancreatitis

In around one in four cases there is no obvious reason why a person develops chronic pancreatitis. This type of pancreatitis is known as idiopathic chronic pancreatitis.

Autoimmune pancreatitis

It is thought that autoimmune pancreatitis is caused by a genetic mutation that leads the immune system to malfunction and attack the tissue of the pancreas.

Researchers have found a number of specific genetic mutations that are particularly widespread in people with autoimmune pancreatitis.

Exactly how these mutations affect the immune system is unclear. However, many people with autoimmune pancreatitis also have other conditions that are caused by the immune system attacking healthy tissue. These conditions include ulcerative colitis or Crohn’s disease, both of which cause inflammation inside the digestive system.

This suggests that there is some underlying problem with the immune system in these cases.

Hereditary pancreatitis

Hereditary pancreatitis is a rare form of chronic pancreatitis that is thought to be caused by mutations in a number of genes, including the PRSS1 and the SPINK-1 gene. These mutations disrupt the normal working of the pancreas.

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Diagnosis

Unlike acute pancreatitis, there are no reliable blood tests that can be used to diagnose chronic pancreatitis. The condition can usually only be diagnosed by carrying out tests that are designed to look at the pancreas.

If your GP suspects that you have chronic pancreatitis, you will be referred for further testing. The tests will usually be carried out at your local hospital and may include:

  • an ultrasound scan, where sound waves are used to build up a picture of the inside of your pancreas
  • a computerised tomography (CT) scan, where a series of X-rays is taken to build up a more detailed, three-dimensional image of the pancreas
  • endoscopic ultrasonography (see below)
  • magnetic resonance cholangiopancreatography or MRCP (see below)

During an endoscopic ultrasonography a thin, flexible telescope, known as an endoscope, is passed through your mouth and towards your stomach. An ultrasound probe attached to the tip of the telescope is able to get close to the pancreas and take very accurate pictures of it.

You will usually be given a sedative to help you relax during the procedure.

An MRCP involves injecting you with a substance known as a contrast agent that will make your pancreas and surrounding organs, such as the gallbladder and liver, show up very clearly on an MRI scanner.

An MRI scanner is a type of imaging system that uses magnetic fields and radio waves to build up a detailed image of the inside of your body.

An MRCP is a useful way of checking whether gallstones may be contributing to your symptoms.

Biopsy

The symptoms of autoimmune pancreatitis can be very similar to pancreatic cancer. Therefore, if you have symptoms such as jaundice and weight loss, a biopsy may be recommended to rule out a diagnosis of pancreatic cancer.

biopsy involves taking a small sample of cells from the pancreas and sending it to a laboratory so it can be checked under a microscope for the presence of cancerous cells.

A biopsy can be taken using a long, thin needle that is passed through your abdomen. The needle can be guided towards the tumour using an ultrasound scan or computerised tomography (CT) scan.

Alternatively, a biopsy can be taken during an endoscopic ultrasonography (see above).

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Treatment

Lifestyle changes

If you are diagnosed with chronic pancreatitis, you will need to make some lifestyle changes. These are described below.

Alcohol

The most important thing is to stop drinking alcohol. This will help prevent your pancreas from being damaged further and it should also help to reduce the pain.

If you continue to drink alcohol it is likely that you will experience debilitating pain and you will be three times more likely to die from a complication of chronic pancreatitis.

Some people with alcoholic chronic pancreatitis will have a dependency on alcohol and will require additional help and support to stop drinking. If this applies to you, talk to your GP about getting help to stop drinking.

Treatment options for alcohol dependence include:

  • one-to-one counselling
  • self-help groups, such as Alcoholics Anonymous
  • a medication called acamprosate that can help reduce cravings for alcohol

See Alcohol misuse - treatment for more information.

Quitting smoking

If you smoke cigarettes, try to give up. Smoking can speed up the progress of chronic pancreatitis, making it more likely that your pancreas will lose its function.

It is recommended that you use an anti-smoking treatment, such as nicotine replacement therapy (NRT) or bupropion (a medication that is used to reduce cravings for cigarettes). People who use these types of treatments have a much greater success rate in permanently stopping smoking than those who try to quit using willpower alone.

If you want to give up smoking a good first step is to contact Smokers Helpline Wales on 0800 169 0 169 and Stop Smoking Wales on 0800 085 2219.  Stop Smoking Wales hold details of local support services.  These services offer the most effective support for people who want to give up smoking. Studies show you are four times more likely to give up smoking successfully if you do it with the help of the NHS.

You can also see the A-Z topic about Smoking - quitting and the Lifestyle & wellbeing Smoking section for further information and advice.

Dietary changes

The dietary advice for people with chronic pancreatitis is much the same as for people without the condition. Eat a healthy balanced diet that is low in fat, including plenty of fresh fruit and vegetables (five portions a day) and whole grains.

For more information see the Lifestyle & Wellbeing section on Healthy Eating.

Your GP will be able to provide you with appropriate dietary advice. Alternatively, they may refer you to a dietitian who will draw up a suitable dietary plan.

You may also be given medication that contains an artificial version of the enzymes that are produced by your pancreas to help improve the effectiveness of your digestive system. This type of medication is known as pancreatic enzyme supplements.

Side effects of pancreatic enzyme supplements include:

If you do experience side effects that are particularly troublesome then you should talk to your GP as your dosage may need to be adjusted.

Pain relief

Pain relief is an important part of the treatment of chronic pancreatitis. Not only is chronic pain physically distressing, it can also lead to depression.

A step-by-step approach to pain relief is usually recommended. This means that your GP will first try using painkillers that are not too strong. If these do not work, they will move to more powerful painkillers.

The first painkiller that is usually used is paracetamol or a non-steroidal anti-inflammatory drug (NSAID) type of painkiller, such as ibuprofen.

Taking NSAIDs on a long-term basis can increase your risk of developing stomach ulcers, so you may be prescribed an additional medication called a proton pump inhibitor (PPI). This can help protect against stomach ulcers.

See Stomach ulcers - treatment for more information.

If NSAIDs or paracetamol prove to be ineffective in controlling your pain, it is likely that you will require a stronger opiate-based painkiller, such as codeine or tramadol. Side effects of these types of medication include:

  • constipation
  • nausea
  • vomiting
  • drowsiness

The side effect of constipation can be particularly troublesome if you need to take an opiate-based painkiller on a long-term basis. In such circumstances, your GP may prescribe a laxative for you to help relieve your constipation. See Constipation - treatment for more information.

If you feel drowsy after taking an opiate-based painkiller you should avoid driving and using heavy tools or machines.

In some cases, an additional medication called amitriptyline may be recommended. Amitriptyline was originally designed to treat depression, which can help because many people with chronic pain conditions also experience episodes of depression. In some people, amitriptyline can also help to relieve pain.

If you experience an attack of very severe pain, you may require a stronger opiate-based painkiller, such as morphine or pethidine. Side effects of these types of painkillers include:

  • constipation
  • dizziness
  • drowsiness
  • nausea
  • vomiting

Long-term use of these stronger opiate-based painkillers is not usually recommended because there is a high risk of addiction. Therefore, if you have persistent, severe pain, surgery will usually be recommended.

Surgery

Surgery can be used to treat what are thought to be the two most common causes of severe pain in chronic pancreatitis. These are described below.

  • Openings in the pancreas can become blocked as a result of a build-up of calcium in the damaged tissue. The blockage can lead to a build-up of digestive juices which places the openings under increased pressure and causes pain.
  • The top section of the pancreas, known as the head of the pancreas, can become inflamed. The inflammation can irritate the main nerve ending that runs from the head of the pancreas, triggering pain.

Endoscopic surgery

In cases of chronic pancreatitis where the openings are blocked, it may be possible to relieve the pressure by widening the openings.

This can be achieved using an endoscope (a narrow, flexible tube) that is guided into your digestive system using an ultrasound scanner. A tiny balloon is passed down through the endoscope before being inflated to widen the duct. A tiny metal clasp, known as a stent, can then be used to keep the opening widened.

The results of this type of surgery are not usually permanent and further treatment may be required.

An alternative approach is to use endoscopic surgery to drain bile out of a blocked opening. This can provide effective pain relief in most cases and the results are usually permanent.

Pancreas resection

In cases where the head of the pancreas has become inflamed, and it is thought that the inflammation is irritating the nerve, the head of the pancreas can be surgically removed. This type of surgery is called a pancreas resection.

Removing the head of the pancreas can also reduce pressure on the ducts. Therefore, a pancreas resection can be used if an endoscopic treatment proves to be ineffective. The advantage of only removing the head of the pancreas is that the rest of the pancreas can often still produce insulin and digestive juices.

There are several techniques that can be used to carry out a pancreas resection. Two widely used techniques are:

  • the Beger procedure (a variant of this procedure is known as the Frey procedure)
  • a pylorus-preserving pancreaticoduodenectomy (PPPD)

These are briefly described below.

The Beger procedure

The Beger procedure is used to treat inflammation of the pancreas head. The inflamed tissue is removed and the rest of the pancreas is reconnected to the intestines.

The Frey procedure

The Frey procedure can be used to treat cases where there is evidence that the ducts of the pancreas have become blocked and the head of the pancreas has become inflamed. The inflamed part of the head is removed and the ducts are directly connected to the intestines, allowing the digestive juices to flow into the intestines.

Pylorus-preserving pancreaticoduodenectomy (PPPD)

A pylorus-preserving pancreaticoduodenectomy (PPPD) is usually recommended to treat the most severe cases of chronic pain, where there are both blocked ducts and inflammation of the head of the pancreas.

During a PPPD, the head of the pancreas is removed along with the gall bladder and bile ducts. The rest of the pancreas is reconnected to the stomach or bowel.

Results of pancreas resections

All three surgical techniques above seem to have the same levels of effectiveness in terms of reducing pain and preserving the function of the pancreas.

Possibly because it is the most complex of the three techniques, PPPD carries an increased risk of complications, such as infection and internal bleeding.

The Beger and Frey procedures carry a lower risk of complications and have faster recovery times and less post-operative pain than PPPDs.

Before deciding on a surgical procedure, you should discuss the pros and cons of each technique with your surgical team.

Total pancreatectomy

In the most serious cases of chronic pancreatitis, where the pancreas has been extensively damaged, it may be necessary to remove the entire pancreas. This type of surgery is known as a total pancreatectomy.

A total pancreatectomy can be very effective in treating pain. However, your pancreas will no longer be able to produce the insulin that is needed by your body.

Autologous pancreatic islet cell transplantation (APICT) is an experimental technique that attempts to overcome this disadvantage.

Autologous pancreatic islet cell transplantation (APICT)

During APICT special cells known as islet cells are removed from the pancreas. Islet cells are responsible for producing insulin.

The pancreas is then surgically removed from the body. At the same time, the islet cells are mixed with a special solution which is injected into the liver. If the APICT procedure is successful, the islet cells remain in the liver and begin to produce insulin.

In the short-term, APICT appears to be effective, but you may require additional insulin treatment in the long-term. See the NICE guidance about autologous pancreatic islet cell transplantation for more information.

Autoimmune pancreatitis

Unlike other types of chronic pancreatitis, the treatment of autoimmune pancreatitis is relatively straightforward. The inflammation affecting the pancreas can usually be relieved using steroid medication (corticosteroids).

However, taking corticosteroids for a long time can cause troublesome side effects, such as osteoporosis (weakening of the bones) and weight gain.

See the A-Z topic about Corticosteroids for more information.

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Complications

Pancreatic  diabetes

Around half of people with chronic pancreatitis will go on to develop diabetes, usually many years after receiving their diagnosis (it is not unusual for 20 years to pass before diabetes occurs).

Diabetes that occurs in cases of chronic pancreatitis is known as pancreatic or type 3 diabetes.

Diabetes occurs when your pancreas is no longer able to produce insulin. Insulin is a chemical that the body uses to break glucose down into energy. The main symptoms of diabetes are:

  • feeling very thirsty
  • going to the toilet a lot, particularly at night
  • extreme tiredness
  • weight loss and muscle wasting (loss of muscle bulk)

If you develop pancreatic diabetes, you will need to have regular insulin injections to compensate for the lack of natural insulin in your body.

See the A-Z topic about diabetes for more information.

Psychological effects of chronic pancreatitis

Any chronic health condition, particularly one that causes recurring or constant pain, such as chronic pancreatitis, can have an adverse effect on your emotional and psychological health.

One study that looked at people living with chronic pancreatitis found that one in seven people had some sort of psychological or emotional problem, such as stressanxiety or depression.

Contact your GP if you are experiencing psychological and emotional difficulties. Effective treatments are available that can help to improve the symptoms of stress, anxiety and depression.

Joining a support group for people with chronic pancreatitis, such as the Pancreatitis Supporters' Network, may also help. Talking to other people with the same condition can often help to reduce feelings of isolation and stress.

Pseudocysts

Another common complication of chronic pancreatitis is pseudocysts. These are sacs of fluid that can develop on the surface of the pancreas. They are thought to affect around one in four people with chronic pancreatitis.

In many cases, pseudocysts do not cause any symptoms and are only detected during a computerised tomography (CT) scan. However, in some people pseudocysts can cause the following symptoms:

  • bloating
  • indigestion
  • dull abdominal pain

If the pseudocysts are small and they are not causing any symptoms, there may be no need for further treatment because these types of cysts usually disappear on their own.

Treatment will usually be recommended if you are experiencing symptoms or the pseudocysts are larger than 6cm (2.3 inches) in diameter. Larger pseudocysts are at risk of bursting open which could cause internal bleeding or trigger an infection.

Pseudocysts can be treated by draining the fluid out of the cyst. This can be done by inserting a needle through your skin and into the cyst to drain away the fluid. Alternatively, an endoscopy may be used. This is where a thin, flexible tube called an endoscope is passed down your throat and tiny tools are used to drain away the fluid.

Pancreatic cancer

Chronic pancreatitis increases your risk of developing pancreatic cancer. However, the increased risk is relatively low. For example, it is estimated that for every 100 people with chronic pancreatitis, only one or two will develop pancreatic cancer.

The most common initial symptoms of pancreatic cancer are much the same as chronic pancreatitis. They include:

See the A-Z topic about Pancreatic cancer for more information.

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