Chronic Pancreatitis – An Overview

Chronic Pancreatitis Chronic Pancreatitis

Chronic Pancreatitis – An Overview

Summary

Chronic pancreatitis is a syndrome characterized by long-term inflammation of the pancreas, which leads to irreversible scarring, fibrosis, atrophy, and subsequent loss of the exocrine and endocrine functions of the organ. The etiology of this disease is varied, including excessive alcohol intake, smoking, metabolic abnormalities, autoimmune responses, genetic factors, mechanical obstruction, or idiopathic causes. Clinical manifestations of chronic pancreatitis may include chronic pain, which can be either constant or intermittent, digestive issues, diabetes mellitus, and weight loss; however, some patients can remain asymptomatic.

Due to the slow and progressive nature of chronic pancreatitis and because morphological changes are very subtle and nonspecific at early stages, the definitive diagnosis often occurs later in the course of the disease when unequivocal signs like calcifications or ductal abnormalities can be visualized. Diagnostic tools may include clinical evaluation, laboratory tests, imaging studies, and endoscopic techniques, while management options include lifestyle changes, medical intervention, and/or surgery.

Introduction to Chronic Pancreatitis

The pancreas is a large elongated organ that lies obliquely in the retroperitoneal space of the abdominal cavity and across the posterior abdominal wall. It can be divided into five sections, namely the uncinate process, head, neck, body, and tail, and it also has an internal system of ducts comprised of the main pancreatic duct (of Wirsung) and the accessory pancreatic duct. The pancreas has both endocrine and exocrine functions, synthesizing and releasing digestive enzymes, including peptidases, amylases, nucleases, and lipases; and also hormones such as insulin (released by the beta cells), glucagon (released by the alpha cells), and somatostatin (released by the delta cells), thus regulating the metabolism of glucose, lipids, and proteins in the body. (1)

Chronic pancreatitis is a progressive disease that is characterized by fibrosis, inflammation, and scarring of the pancreas, leading to permanent damage to the organ and eventual loss of both exocrine and endocrine functions.

Etiology of Chronic Pancreatitis

Causes of chronic pancreatitis are varied, and although for many years it was believed that alcoholism was the leading cause, it has been recently demonstrated that the etiology is multifactorial and can include genetic factors (hereditary pancreatitis or cystic fibrosis), ductal obstruction (stones, tumors, trauma), autoimmune diseases (autoimmune pancreatitis or systemic lupus erythematosus), chemotherapy, and cigarette smoking; being alcohol abuse the attributable etiology in less than 50% of cases. Furthermore, less than 10% of patients who have alcohol abuse go on to develop chronic pancreatitis. (2-6)

Epidemiology of Chronic Pancreatitis

Since chronic pancreatitis is insidious and the diagnosis usually occurs after several years, the prevalence of this disease is hard to ascertain. However, it has been estimated to be around 37 to 42 cases per 100,000 patients. (7-13) Although chronic pancreatitis can develop at an early age in patients with a genetic risk, in the United States, this disease is commonly diagnosed in patients around 35 to 55 years of age, with an average age of 45 years. Men are 1.5 to 3 times more affected than women, and patients of African American race are more likely to experience severe pain and show advanced morphological changes on imaging techniques when compared to patients of Caucasian race. (14, 15)

Physiopathology of Chronic Pancreatitis

The development of chronic pancreatitis seems to be multifactorial, involving genetic and environmental factors. Genetic factors imply the mutation of various genes, the most recognized one being the cationic trypsinogen (PRSS1) gene, which has an autosomal dominant inheritance pattern and has been shown to independently lead to the development of acute and chronic pancreatitis (hereditary pancreatitis); however, in some cases, the mutation of this gene can occur de novo. O

ne theory states that damage to the pancreas occurs as a result of calcification and stone development caused by the formation of plugs of protein within pancreatic structures as the result of impaired bicarbonate secretion. While another theory suggests that pancreatic parenchymal damage occurs as a result of the activation of digestive enzymes within the gland due to genetic or external factors, such as excessive alcohol consumption. (6, 15-18)

Clinical Findings in Chronic Pancreatitis

Patients with acute pancreatitis present with sudden onset abdominal pain that radiates to the back; however, patients with chronic pancreatitis can be asymptomatic. Nevertheless, the most common symptom that appears in up to 80% of cases is long-term abdominal pain (with or without radiation to the back) that can either be constant or present intermittently alternated with extended pain-free periods. In some cases, the pain appears or becomes worse after food intake (postprandial pain), and it is the most frequent cause of hospitalization, becoming a strong predictor of reduced quality of life, especially when it is constant. Other common signs and symptoms of chronic pancreatitis can also include: (12, 19-31)

  • Weight loss
  • Postural guarding, leaning forward.
  • Nausea and/or vomiting.
  • Diarrhea.
  • Steatorrhea.
  • Glucose intolerance or pancreatogenic diabetes (Type 3c diabetes) in advanced disease.
  • Signs of malnutrition in advanced disease.

A detailed medical history should include a review of systems, focusing on the onset of symptoms, frequency, location, intensity, duration, and stool appearance. It is equally important to interrogate the patient about their past medical history, social history (including cigarette smoking and alcohol intake), and family history to consider other possible differential diagnoses.

Diagnosis of Chronic Pancreatitis

Although there is not a single gold-standard test to diagnose chronic pancreatitis, a wide range of assessment tools can be used to accurately diagnose this disease at its early stages in order to provide timely care and improve the patient’s quality of life. Depending on the particular case, diagnosis can be achieved by using a combination of clinical evaluation, laboratory tests, imaging studies, and endoscopic techniques:

Laboratory Tests

Laboratory tests useful to aid in the diagnosis and assessment of chronic pancreatitis can include: (32-35)

  • Complete blood count (CBC).
  • Basic metabolic panel (BMP).
  • Liver function tests (LFTs).
  • Lipid panel.
  • Pancreatic function tests, including secretin-pancreozymin stimulation test, amino acid consumption test, serum trypsinogen test, and fecal elastase-1 test, among others.
  • Inflammatory markers, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).
  • 72-hour quantitative fecal fat in case of suspected steatorrhea.
  • In pediatric patients, genetic testing for CFTR (cystic fibrosis transmembrane conductance regulator) may be warranted.

It is important to note that both lipase and amylase levels can be either increased or at normal range (due to significant pancreatic scarring and fibrosis); therefore, it should not be considered diagnostic or prognostic.

Imaging Studies

Imaging studies are essential since they can serve to identify morphological changes in the pancreas, such as organ enlargement, calcifications (hallmark sign, often seen as a “chain of lakes”), ductal dilation or obstruction, and parenchymal atrophy, which are suggestive of chronic pancreatitis. (12, 36) Abdominal ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) are the most commonly used imaging modalities for the diagnosis of chronic pancreatitis. Magnetic resonance cholangiopancreatography (MRCP) can also be used due to its high sensitivity and specificity to diagnose this disease when the results of other imaging techniques are normal, but the suspicion of chronic pancreatitis remains. (13, 36)

Endoscopic Assessment

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) can be useful in visualizing ductal and parenchymal morphological changes and functional abnormalities early in the course of chronic pancreatitis. However, these tests are commonly used only after non-invasive imaging tests have failed to reveal pancreatic calcifications and/or there is no evidence of steatorrhea. Furthermore, since MRCP is available, ERCP is often used only in cases where therapeutic intervention is warranted to relieve obstruction in the pancreatic duct. (36-39)

Management of Chronic Pancreatitis

The management of chronic pancreatitis involves several interventions aimed at improving the patient’s quality of life, controlling abdominal pain, and preventing disease-related complications.

Lifestyle Changes

In order to prevent further damage to the pancreas and exacerbate symptoms, patients must be instructed to avoid alcohol consumption as well as refrain from smoking. An exercise routine adapted to the patient’s physical condition and a healthy low-fat, high-protein diet is also necessary, along with portion size control and supplementation with pancreatic enzymes and fat-soluble vitamins. In some cases of advanced disease, tube feeding may be required to ensure adequate nutrition.

Medical Management

The main goal of medical management is to prevent further damage to the organ and achieve pain control. Supplementation with pancreatic enzymes and fat-soluble vitamins may be used along with non-steroidal anti-inflammatory drugs (NSAIDs) to control disease-related symptoms. When pain management has not been achieved, a trial of opioids may be necessary. (12, 19, 38)

Surgery

Extracorporeal shock wave lithotripsy (ESWL) may be used for stone fragmentation before attempting surgery; however, a surgical approach may still be necessary in cases of severe chronic pancreatitis when other management options previously used have failed or when it is the only way to remove a significant obstruction in the pancreatic duct. In some cases, a partial or total pancreatectomy may need to be performed. (32, 40-42)

Prognosis of Chronic Pancreatitis

The prognosis for patients with chronic pancreatitis depends on many factors, like continued smoking and/or alcohol intake, age at diagnosis, concomitant liver disease, and the presence of other comorbidities and disease-related complications. Overall, the survival rate at 10 years is around 70%, decreasing to roughly 40% to 50% at 20 years. (43, 44)

Complications

Chronic pancreatitis can lead to a range of complications that can significantly impact a patient’s quality of life; therefore, it is crucial to regularly monitor patients with this disease to detect and manage complications early. The most common complications include:

Chronic pain

Chronic pain is the most common and debilitating complication of chronic pancreatitis. Continued inflammation and damage to the pancreas can lead to persistent and severe pain that is often difficult to manage. (31, 32)

Malnutrition and Other Digestive Issues

The pancreas plays an important role by producing enzymes that aid in digestion. In chronic pancreatitis, damage to the pancreas impairs the organ’s ability to produce enough enzymes to digest food properly, eventually leading to malnutrition and a myriad of digestive symptoms, such as bloating, nausea, constipation, and diarrhea.

Diabetes

Up to 70 to 90% of patients with chronic pancreatitis end up developing pancreatogenic diabetes mellitus (also known as Type 3c diabetes mellitus) due to impaired production of insulin. Therefore, screening for diabetes mellitus is recommended in all patients with chronic pancreatitis. (45-48)

Metabolic Bone Disease

Metabolic bone disease, also known as chronic pancreatitis-associated osteopathy, can develop in approximately 65% of patients in the form of either osteopenia or osteoporosis, therefore increasing the risk of low trauma fractures in this population. (49, 50)

Pancreatic Pseudocysts

Pancreatic pseudocysts are collections of fluid that can form in the pancreas secondary to the effects of chronic pancreatitis. These cysts can appear in up to 40% of cases and, depending on their size and location, can lead to biliary obstruction or gastroduodenal outlet obstruction. In severe cases, pancreatic pseudocysts may need to be drained or surgically removed. (51)

Pancreatic Cancer

The risk of developing pancreatic cancer, especially pancreatic ductal adenocarcinoma (PDAC), is around 4% to 5% in patients with chronic pancreatitis. Chronic inflammation of the pancreas can cause cellular changes that can eventually lead to cancer. Therefore, patients with chronic pancreatitis, especially those with complications like diabetes mellitus, should be regularly monitored for signs of pancreatic cancer. (52-54)

See Also

What is Dysphagia

Gastroesophageal Reflux Disease

Esophageal Cancer

Malabsorption Syndrome

Inflammatory Bowel Disease

Peptic Ulcer Disease

Acute Diarrhea in Adults

Acute Abdomen

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Current Version
June 1, 2023
Written By
Krystie Linares