One of my favorite articles on Chronic Pancreatitis

[Guest guest]

Hi all,

I thought this overview might be of interest to all, especially our

new members. The web address for this information is:

http://www.uptodate.com/patient

info/topicpages/topics/23877k8.asp

This patient information sheet is for your general information and

is not designed to provide medical advice. You should contact

your physician or other healthcare provider, rather than

UpToDate and the physician authors of this sheet, with specific

questions about your treatment and care. Copyright 2002

UpToDate, Inc.

------------------------------------------------------------------------

Chronic pancreatitis

  INTRODUCTION

  WHAT ARE THE SYMPTOMS OF CHRONIC PANCREATITIS?

    • Abdominal pain

    • Symptoms of poor pancreatic function

    • Symptoms of complications

  WHAT CAUSES CHRONIC PANCREATITIS?

  HOW IS CHRONIC PANCREATITIS DIAGNOSED?

    • Blood tests

    • Stool tests

    • Imaging tests

      - X-rays

      - Ultrasound, computerized tomography (CT) scans, and

magnetic resonance imaging (MRI) scans

      - Endoscopic retrograde cholangiopancreatography (ERCP)

      - Endoscopic ultrasound

      - Magnetic resonance cholangiopancreatography (MRCP)

    • Pancreatic function tests

      - Secretin stimulation test

      - Bentiromide test

    • Tests for pancreatic cancer

  HOW IS CHRONIC PANCREATITIS TREATED?

    • Pain relief

      - Avoiding alcohol

      - Modifying meals

      - Non-narcotic analgesics

      - Pancreatic enzyme supplements

      - Narcotic analgesics

      - Fasting during short-term hospitalization

      - Nerve block

      - Treatments that widen the pancreatic ducts

      - Pancreatic lithotripsy

      - Other therapies

      - Surgery

    • Treatment of fat malabsorption and steatorrhea

      - Reducing fat intake

      - Lipase supplements

      - Medium chain triglycerides (MCTs)

  WHERE TO GET MORE INFORMATION

D Freedman, MD, PhD

  Associate Professor of Medicine

  Harvard Medical School

UpToDate performs a continuous review of over 270 journals

and other resources. Updates are added as important new

information is published. The literature review for UpToDate

version 10.1 is current through December 2001; this topic was

last changed on January 8, 2001.

This patient information sheet is for your general information and

is not designed to provide medical advice. You should contact

your physician or other healthcare provider, rather than

UpToDate and the physician authors of this sheet, with specific

questions about your treatment and care. Copyright 2002

UpToDate, Inc.

INTRODUCTION — The pancreas is an elongated organ that

lies in the back of the mid-abdomen (show figure 1). It is

responsible for producing digestive juices and certain

hormones, including insulin, the main hormone responsible for

regulating blood sugar.

Chronic pancreatitis refers to long-standing inflammation of the

pancreas that alters its normal structure and functions. People

with chronic pancreatitis typically have blocked areas in the ducts

that normally drain the digestive juices from the pancreas into

the intestines. They may also develop pancreatic stones (similar

to gallstones) within the ducts, which also contributes to the

blockage.

A hallmark of chronic pancreatitis is chronic mid-abdominal

pain. There may also be episodes in which the pain suddenly

worsens when the pancreas becomes suddenly inflamed (acute

pancreatitis). People with chronic pancreatitis can have difficulty

digesting fats contained in foods leading to weight loss, and

sometimes diarrhea. In severe cases, the pancreas can also

lose its ability to produce adequate amounts of insulin, leading

to diabetes mellitus.

People with chronic pancreatitis require ongoing medical care to

minimize their symptoms, to slow the progression of the

condition whenever possible, and to address any complications

that arise. In most cases, treatment controls but does not cure

the underlying problem.

Because the severity and course of chronic pancreatitis can vary

widely from person to person, the treatment of this condition is

individualized. It is therefore important to learn as much as you

can about chronic pancreatitis and to discuss the testing and

treatment options carefully with your doctor.

WHAT ARE THE SYMPTOMS OF CHRONIC PANCREATITIS? —

The most common symptoms of chronic pancreatitis are

abdominal pain and symptoms of poor pancreatic function

(called pancreatic insufficiency). In some cases, symptoms also

result from the complications associated with chronic

pancreatitis.

Abdominal pain — Abdominal pain is the hallmark symptom of

chronic pancreatitis. The pain usually occurs in the upper

abdomen, often radiates to the back, may be relieved by sitting

up or leaning forward, and may be associated with nausea and

vomiting. Because eating stimulates the pancreas, the pain is

often worse 15 to 30 minutes after a meal. During early chronic

pancreatitis, the pain may occur in isolated attacks, but over

time, it tends to become more continuous with periodic

flare-ups. However, the pain may follow different patterns in

different people, and about 20 percent of people with chronic

pancreatitis do not have any pain at all.

Symptoms of poor pancreatic function — Symptoms of poor

pancreatic function (pancreatic insufficiency) do not occur until

about 90 percent of pancreatic function has been lost. The

pancreas normally contributes to the digestion of different types

of food, the absorption of food breakdown products from the

digestive tract, and the metabolism of blood glucose (blood

sugar). Symptoms of poor pancreatic function may include

symptoms associated with fat malabsorption; significant fat

malabsorption results in steatorrhea, loose, greasy,

foul-smelling stools that are difficult to flush. Symptoms of poor

pancreatic function may also include glucose intolerance (high

blood glucose after consuming sugar and carbohydrates) and

diabetes. If pancreatic function is severely affected, a person

may also experience symptoms of vitamin and nutrient

deficiencies, including weight loss.

Symptoms of complications — Chronic pancreatitis can lead to a

variety of complications; these complications can have

symptoms of their own, but some of the symptoms mimic those

of pancreatitis. Complications can include formation of cyst-like

structures around the pancreas and blockage of the ducts that

drain the pancreas and gallbladder; if drainage from the

gallbladder is affected, a person may develop jaundice

(yellowing of the skin). Other possible complications include

collection of fluid in the abdominal or chest cavities, blood clots,

and aneurysm-like abnormalities of blood vessels. Chronic

pancreatitis can be associated with bouts of acute

pancreatitis—a sudden worsening of pancreatitis—particularly in

people who have abused alcohol and continue to drink. Chronic

pancreatitis is also associated with an increased risk of

pancreatic cancer.

WHAT CAUSES CHRONIC PANCREATITIS? — The majority of

cases of chronic pancreatitis are due to the following disorders:

  • Alcohol abuse (which accounts for most cases in the United

States and many other countries)

  • Hereditary pancreatitis

  • Ductal obstruction (eg, from trauma, stones, tumors, possibly

pancreas divisum, a developmental abnormality of the

pancreas)

  • Tropical pancreatitis (a rare disease)

  • Systemic disease such as systemic lupus erythematosus,

cystic fibrosis, possibly hyperparathyroidism

  • Idiopathic pancreatitis (ie, in which the cause is unknown)

  • Cystic fibrosis or mutations of the cystic fibrosis gene without

frank cystic fibrosis

HOW IS CHRONIC PANCREATITIS DIAGNOSED? — The

diagnosis of chronic pancreatitis can be difficult. The results of

many tests may actually be normal despite the presence of this

condition, especially during the first two to three years of the

condition. It can also sometimes be difficult to distinguish

chronic pancreatitis from acute pancreatitis.

Your doctor may recommend several different tests if your

medical history and symptoms suggest the presence of chronic

pancreatitis. These tests can determine the presence and

severity of chronic pancreatitis; alternatively, they may suggest

that symptoms are being caused by other conditions, such as an

ulcer, gallstones, irritable bowel syndrome, or pancreatic cancer.

Blood tests — Blood tests can detect digestive enzymes that

leak out of the pancreas into the bloodstream when the

pancreas is inflamed; the two most common tests are the

serum amylase test and the serum lipase test. However, levels

of these enzymes may be only slightly elevated in people with

chronic pancreatitis, and other routine blood tests are often

normal. The results of liver function tests may occasionally be

abnormal, suggesting that pancreatitis is interfering with

drainage from the gallbladder and indirectly affecting the liver.

Stool tests — Stool tests can detect steatorrhea, abnormal levels

of fat in a stool sample. The presence of high levels of fat

indicates fat malabsorption.

Imaging tests — Imaging tests provide information about the

structure of the pancreas, the ducts that drain the pancreas and

gallbladder, and the tissues surrounding the pancreas.

X-rays — X-rays of the abdomen may reveal deposits of calcium

in the pancreas. These deposits are present in about 30 percent

of people with chronic pancreatitis, and they are most common

in people who have alcoholic pancreatitis.

Ultrasound, computerized tomography (CT) scans, and

magnetic resonance imaging (MRI) scans — Ultrasound, CT

scans, and MRI scans may reveal calcium deposits in the

pancreas, dilation of the ducts that drain the pancreas and

gallbladder, enlargement of the pancreas, and collections of

fluid around the pancreas.

Endoscopic retrograde cholangiopancreatography (ERCP) —

ERCP outlines the system of ducts that drains the pancreas and

gallbladder. It is performed by having a patient swallow a tube

through which dye is injected into the bile and pancreatic ducts.

This test is usually used only if less invasive tests do not provide

enough information. ERCP is most often recommended for

people with suspected chronic pancreatitis who do not have

calcium deposits in the pancreas and who do not have an

abnormal stool test. However, ERCP results are normal in some

people with early chronic pancreatitis.

Endoscopic ultrasound — During endoscopic ultrasound, a tiny

ultrasound probe is advanced down the digestive tract to obtain

detailed information about the structure of the pancreas.

Endoscopic ultrasound can detect abnormalities in the texture of

pancreatic tissue, thickening of the walls of pancreatic ducts,

and dilation of the ducts.

Magnetic resonance cholangiopancreatography (MRCP) —

MRCP is a new test that is still being studied. This test may

occasionally be recommended for people with suspected

chronic pancreatitis who have narrowing of the digestive tract or

altered structure of the ducts that drain the pancreas and

gallbladder.

Pancreatic function tests — Several different tests can evaluate

specific functions of the pancreas. However, only a few of these

tests are routinely used because the other tests are not widely

available or are often normal during the first few years of chronic

pancreatitis.

Secretin stimulation test — The most commonly used pancreatic

function test is the secretin stimulation test. During this test, a

person is given an injection of secretin; normally, this hormone

prompts the gallbladder to secrete a substance called

bicarbonate. The contents of the digestive tract are sampled over

time to determine if the pancreas has secreted bicarbonate.

Bentiromide test — During the bentiromide test, a person is

asked to swallow a substance called bentiromide. Normally, a

pancreatic enzyme acts on this substance to produce a

byproduct, and this byproduct can then be detected in a urine

sample. The bentiromide test is performed only rarely in the

United States where other tests are more commonly used.

Tests for pancreatic cancer — Some of the tests for chronic

pancreatitis may also provide evidence for or against pancreatic

cancer, but it is sometimes difficult to distinguish between these

conditions. Blood levels of two tumor markers are often helpful.

Elevated blood levels of carcinoembryonic antigen (CEA) and CA

19-9 suggest that pancreatic cancer is the more likely cause of

symptoms. However, levels of these markers can be normal in

some people with pancreatic cancer.

HOW IS CHRONIC PANCREATITIS TREATED? — The goals of

treatment of chronic pancreatitis include pain relief, correction of

poor pancreatic function, and measures to manage

complications.

Pain relief — A variety of measures can help relieve the pain of

chronic pancreatitis. Simple measures may be sufficient early in

the course of the condition, whereas more extensive measures

may be needed after several years.

Avoiding alcohol — Avoiding alcohol is the single most important

thing that a person who developed pancreatitis due to alcohol

can do. Alcohol abstinence can improve pain while reducing the

risk of acute pancreatitis and the risk of dying.

Modifying meals — The pain of chronic pancreatitis often

lessens if a person eats smaller meals with a low fat content.

Non-narcotic analgesics — Early in the course of chronic

pancreatitis, non-narcotic analgesics—pain-relieving drugs that

are often available over the counter—usually control pain. These

drugs include nonsteroidal anti-inflammatory drugs (NSAIDs),

such as ibuprofen.

Pancreatic enzyme supplements — Pancreatic enzyme

supplements may alleviate pain by decreasing meal-associated

stimulation of the pancreas. These enzymes replace the

enzymes normally produced by the pancreas and therefore allow

the pancreas to " rest. " They are often recommended for people

with severe pain. However, these enzymes do not relieve pain in

all people.

Narcotic analgesics — Narcotic analgesics (such as oxycodone

and fentanyl) are powerful pain-relieving drugs that require a

prescription. These drugs are often recommended if pancreatic

enzymes fail to relieve pain. The short-term use of narcotic

analgesics can break the pain cycle in some people, but other

people may require long-term treatment with these drugs.

Long-term treatment is often achieved by using drug patches

that deliver a continuous dose of the drug. A major problem with

narcotic analgesics is that people can become dependent upon

them and thus crave them even when they do not have pain.

Thus, most doctors use them as sparingly as possible.

Fasting during short-term hospitalization — Fasting for several

days may alleviate the pain of chronic pancreatitis by eliminating

meal-associated stimulation of the pancreas. However, fasting

usually requires hospitalization so that a person can receive

nutrients in intravenous fluids.

Nerve block — During a nerve block, alcohol or steroids are

injected directly into the nerves that carry pain messages from

the pancreas; this injection blocks the transmission of pain

signals. A nerve block is usually reserved for severe pancreatic

pain that does not respond to other types of treatment. Nerve

blocks relieve pain in about 50 percent of people who undergo

the procedure, and many people require additional treatments

two to six months after the first treatment. The procedure also

carries certain risks that you should discuss carefully with your

doctor.

Treatments that widen the pancreatic ducts — Pain may be

caused by narrowing and persistent contraction of the pancreatic

ducts and the sphincter (muscle) that closes the duct shared by

the pancreas and gallbladder. One way to overcome a narrowing

is to place a tube into the narrowed area (stenting). During

stenting, a stiff plastic tube (called a stent) is placed inside the

pancreatic duct to hold it open. Preliminary studies suggest that

stents can relieve pain in people who have narrowing of the

pancreatic duct or pancreatic stones lodged in the duct.

However, many studies suggest that stenting is associated with

an increase in the structural abnormalities associated with

pancreatitis. This procedure also carries other risks that you

should discuss carefully with your doctor. Thus, it is probably

only useful for a small percentage of people with chronic

pancreatitis.

Pancreatic lithotripsy — Pancreatic lithotripsy refers to a

procedure in which shock waves are used to crush stones that

have become lodged in the pancreatic duct, thereby helping to

improve the blocked flow of digestive juices. The procedure is

being used most often in Europe. It is uncommonly used in the

United States where other methods of treatment are preferred.

Other therapies — Two new medical therapies are still being

evaluated for their ability to alleviate the pain of chronic

pancreatitis.

  • Octreotide — Preliminary studies suggest that high doses of

octreotide (a synthetic hormone related to the native hormone

somatostatin) relieve pain in people who have pancreatitis with

dilated pancreatic ducts.

  • Antioxidants — Ongoing studies will help determine if

antioxidants—substances that oppose tissue-damaging

substances—relieve the pain of chronic pancreatitis.

Surgery — Surgery is usually reserved for people with chronic

pancreatitis who have pain that does not respond to other

treatments. Three surgical procedures are available; two of

these procedures have been used for many years, whereas one

procedure (autologous islet transplantation) is still considered to

be experimental.

The optimal timing of surgery is debated. Some studies suggest

that early surgery slows the progression of chronic pancreatitis,

while others suggest that the condition progresses despite early

surgery. At this time, doctors usually recommend surgery for

people with chronic pancreatitis who have pain that does not

respond to other treatments and who have dilated pancreatic

ducts.

  • Decompression of pancreatic ducts — A surgical procedure

called pancreaticojejunostomy relieves obstruction of and

pressure in the pancreatic ducts and alleviates pain in about 80

percent of people. For unknown reasons, pain returns within one

year in some people who undergo this procedure.

  • Surgical removal of part of the pancreas — Surgical removal of

part of the pancreas relieves pain in some people with chronic

pancreatitis. This procedure is usually recommended for people

whose pancreatitis is confined to specific parts of the pancreas

because only limited amounts of the gland can be removed

without compromising its function.

  • Surgical removal of the pancreas and autologous islet cell

transplantation — Although treatments can compensate for most

functions of the pancreas if the pancreas is removed, it is most

difficult to compensate for the pancreas' insulin-producing

function. A somewhat experimental treatment of pancreatitis

entails surgical removal of the entire pancreas followed by

transplantation of the insulin-producing structures from the

gland (called islets). Because the islets are obtained from the

person's own pancreas, there is no chance of tissue rejection.

Preliminary studies suggest that this procedure relieves the pain

of chronic pancreatitis and that about 70 percent of people who

undergo this transplantation do not require insulin for at least

two years after the procedure.

Treatment of fat malabsorption and steatorrhea — Several

treatments are available for people who have fat malabsorption

and steatorrhea (excess fat in stools) as a result of chronic

pancreatitis. Treatment usually relieves the steatorrhea but does

not restore fat absorption to normal levels.

Reducing fat intake — Reducing the amount of dietary fat can

relieve the symptoms of steatorrhea. Restricting this intake to 20

grams per day or less often relieves greasy stools.

Lipase supplements — Oral supplements that contain the

enzyme lipase can reduce fat malabsorption and steatorrhea.

These supplements partially replace the lipase normally

produced by the pancreas. Three tablets of pancrealipase

(Viokase) taken with meals usually alleviates greasy stools.

Some people may have a poor initial response to lipase

supplements. Because acid inactivates the enzyme, the tablets

may become more effective if a person also takes

acid-suppressing drugs. Alternatively, encapsulated

preparations containing greater amounts of the enzyme may be

effective.

Medium chain triglycerides (MCTs) — Medium chain

triglycerides—a form of dietary fat—are more easily digested and

absorbed than the long chain triglycerides found in most diets.

MCTs are a good source of calories for people with chronic

pancreatitis who have weight loss and who have a poor

response to dietary modifications and pancreatic enzyme

supplements. The liquid supplement Peptamen contains MCTs;

doctors usually recommend one to three cans of this liquid daily.

An ongoing study is also evaluating whether or not this

supplement alleviates pain and improves overall nutritional

status in people with chronic pancreatitis.

WHERE TO GET MORE INFORMATION — Your doctor is the best

resource for finding out important information related to your

particular case. Not all patients with chronic pancreatitis are

alike, and it is important that your situation is evaluated by

someone who knows you as a whole person.

The discussion above is available on the internet in the Patient

Resource Center at UpToDate's home page

(www.UpToDate.com) where it will be updated as needed every

four months. Additional topics as well as selected

professional-level discussions written for physicians are also

available for those who would like more detailed information.

A number of other sites on the Internet have information about

chronic pancreatitis. Information provided by the National

Institutes of Health, national medical societies, and some other

well-established organizations are often reliable sources of

information, although the frequency with which their information

is updated is variable.

  • National Library of Medicine

   (http://www.nlm.nih.gov/medlineplus)

  • National Institute of Diabetes and Digestive and Kidney

Diseases

   (http://www.niddk.nih.gov/)

  • American Gastroenterological Association

   (http://www.gastro.org/)

  • National Pancreas Foundation

   P.O. Box 935

   Wexford, PA 15090-0935

   (http://www.pancreasfoundation.org)

------------------------------------------------------------------------

References

1 Ammann, RW, Akovbiantz, A, Largiader, F, Schueler, G. Course

and outcome of chronic pancreatitis. Gastroenterology 1984;

86:820.

2 Geenen, JE, Rolny, P. Endoscopic therapy of acute and chronic

pancreatitis. Gastrointest Endosc 1991; 37:377.

3 Layer, P, Yamamoto, H, Kalthoff, L, et al. The different courses

of early- and late-onset idiopathic and alcoholic pancreatitis.

Gastroenterology 1994; 107:1481.

4 Lowenfels, AB, Maisonneuve, P, Cavallini, G, et al. Pancreatitis

and the risk of pancreatic cancer. International Pancreatitis Study

Group. N Engl J Med 1993; 328:1433.

5 Mergener, K, Baillie, J. Chronic pancreatitis. Lancet 1997;

350:1379.

6 Okolo, PI 3rd, Pasricha, PJ, Kalloo, AN. What are the long-term

results of endoscopic pancreatic sphincterotomy? . Gastrointest

Endosc 2000; 52:15.

7 Steer, ML, Waxman, I, Freedman, SD. Chronic pancreatitis. N

Engl J Med 1995; 332:1482.

8 Warshaw, AL, Banks, PA, Fernàndez-del Castillo, C. AGA

Technical review on treatment of pain in chronic pancreatitis.

Gastroenterology 1998; 115:765.

I hope this information is helpful for all.

With love, hope and prayers,

Heidi

Heidi H. Griffeth

South Carolina

SC & SE Regional Rep.

PAI

Note: All comments or advice are personal opinion only, and

should not be substituted for professional medical consultation.