Chronic Pancreatitis

Essentials

• Quitting alcohol consumption and smoking before the disease emerges
• Consider chronic pancreatitis as the cause of recurrent upper abdominal pain, weight loss and diarrhoea.
• Detect diabetes at an early stage in patients with chronic pancreatitis. Be careful not to induce hypoglycaemia in patients on insulin.
• Chronic pancreatitis is associated with an elevated risk of pancreatic cancer.

Aetiology

• Recurring acute pancreatites may lead to chronic pancreatitis.
• Alcohol is the underlying factor in 2/3 of cases, and smoking is a significant factor in more than half of cases.
  • If alcohol is the aetiology, the patient is often a heavy drinker who has consumed 150-175 g of pure alcohol daily over 10-15 years before the clinical onset of the disease.
• Gallstone disease
• Metabolic disorders (hypertriglyceridaemia, hyperparathyroidism)
• Hereditary chronic pancreatitis (hereditary pancreatic calcification)
• The autoimmune form of chronic pancreatitis is associated with primary sclerosing cholangitis Primary Sclerosing Cholangitis, primary biliary cirrhosis Primary Biliary Cholangitis, and Sjögren's syndrome Primary Sjögren's Syndrome.

Symptoms

• Upper abdominal pain that radiates to the back with possibly associated nausea and vomiting; weight loss, jaundice.
• The pain is caused by increased ductal pressure and by neuritis.
• Within approx. 8 years 50% of the patients develop endocrine and exocrine pacreatic insufficiency manifested as steatorrhoea, weight loss and diabetes Pancreatic Insufficiency.

Diagnosis

Conservative treatment

• The patient has to give up alcohol use and smoking immediately and completely.
• Treatment of diabetes
  • Insulin doses should often be small (hypoglycaemia tends to develop easily).
• Small meals are of benefit in cases of pain and steatorrhoea.
• Low-fat diet, no fibre (inhibits pancreatic enzymes), enzyme substitution and, in exceptional cases, also MCT-oil
• Appropriate analgesics
• Acute attack in chronic pancreatitis
  • Treated primarily as a mild acute pancreatitis, see Acute Pancreatitis
  • Conservative treatment, moderate rehydration
  • Analgesics
• Recurrent severe pain and complications, like pseudocysts, are indications for endoscopic or surgical treatment in chronic pancreatitis.

Indications for specialized care consultation

• Confirmation of diagnosis (CT)
• Recurrent bouts of severe pain
  • Treatment in a hospital: ERCP and stenting / surgical treatment if endoscopic treatment fails or is inadequate
• Suspected complications
  • Pancreatic pseudocyst
    • Symptoms: pain, bowel obstruction, biliary obstruction
    • Treatment: ERCP and stenting / endoscopic or operative pseudocyst-gastrostomy / pancreatic resection
  • Bleeding pancreatic pseudocyst or pseudoaneurysm
    • Treatment: endovascular coiling or operative treatment
  • Pancreatic fistulae
    • Treatment: endoscopic / operative
  • Infected pancreatic pseudocyst
    • Treatment: draining and antibiotics
  • Biliary obstruction
    • Treatment: ERCP and stenting