Chronic Pancreatitis

The term “chronic pancreatitis” refers to inflammation of the pancreas that lasts more than 6 months, and is associated with scarring and other permanent complications.  There are many causes of chronic pancreatitis, but all of the major causes seem to converge on the immune system, which is responsible for most of the organ damage.  Many lines of evidence suggest that premature activation of trypsinogen to become the active digestive enzyme trypsin, while it is still inside of the pancreas, is responsible for repeated injury and inflammation.   See “What is the Pancreas>Pathology-nonmalignant for micrographic pictures of chronic pancreatitis.

Causes of chronic pancreatitis:

  • Hereditary pancreatitis – caused by mutations in the trypsinogen gene (PRSS1)
  • Cystic fibrosis (CF) – caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR).
  • Atypical CF – caused my mild mutations in CFTR that may only affect the pancreas
  • Autoimmune pancreatitis – caused by the immune system attacking the pancreas
  • Severe acute pancreatitis – caused by destruction of the pancreas in a severe attack with pancreatic necrosis.
  • Alcohol and smoking.  These behaviors appear to be risk factors and usually do not cause chronic pancreatitis. However, if there is injury to the pancreas from another cause, alcohol consumption and smoking may cause rapid destruction of the pancreas – with the combined effect being much more potent than either one alone.

Complications of chronic pancreatitis.

Inflammation of the pancreas leads to progressive destruction of the three main cell types and also affects the nerves and other tissues.  The major complications include:

  • Recurrent acute inflammation
    • Progressive scarring
    • Splenic vein thrombosis
    • Inflammatory mass
  • Acinar cell destruction
    • Maldigestion of foods
    • Oil or fatty deposits in the stool
    • Cramping abdominal pain
    • Vitamin deficiencies
    • Malnutrition
    • Weight loss
  • Duct injury
    • Low bicarbonate secretion
    • Blockage of the duct with strictures or stones
    • Episodes of severe pain
    • Development of pseudocysts
  • Nerve inflammation
    • Continuous severe pain
    • Worsening inflammation of the gland
  • Islet cell injury
    • Glucose intolerance (high blood sugar)
    • Insulin dependent diabetes mellitus
  • DNA damage and release of growth factors
    • Risk of pancreatic cancer

Diagnosis

Experts have not come to an agreement of what defines early chronic pancreatitis.  However, the development of the complications listed above helps to confirm a diagnosis.  There is complete agreement on later stages with scarring, dilated pancreatic ducts, stone formation and pain.   The diagnosis is usually made on abdominal imaging studies such as a CT scan.  In some cases, the problem of on-going pain will direct the physician to use more sensitive or specific tests for chronic pancreatitis.  In addition, many patients have been diagnosed with chronic pancreatitis that do not have this problem at all, but rather a non-specific pain syndrome.

Treatment

The most important instruction for people who are diagnosed with chronic pancreatitis is DO NOT SMOKE!! Drinking alcohol is nearly as harmful, and both activities should be avoided.

Maldigestion is treated very well with pancreatic enzyme replacement therapy (PERT).  The FDA has recently ruled that PERT must meet FDA standards for drugs, resulting in the production of reliable products for treatment of maldigestion.

Pain is the most difficult problem to address.  There is reasonable concern for patiens developing narcotic addiction since the pain is often severe and continuous.  In extreme cases, part ofrall of the pancreas must be removed.  In some cases, the islet cells can be collected and placed into the liver to prevent the development of brittle diabetes.