Inflammation can be unpreventable but if your pancreas keeps getting persistent inflammation, you might have a condition known as chronic pancreatitis. First, let’s look at the anatomy of the pancreas.
The pancreas is an elongated, soft, flat, lobulated, light tan or pinkish in the coloured gland that lies on the posterior abdominal wall, more-or-less transversely. It is a retroperitoneal structure and possesses a very thin capsule.
The organ measures about 6 inches long and weighs about one-fifth of a pound. It is divided into head, neck, body and tail with the head being the broadest part of the pancreas and lying snugly within the C-curve of the duodenum.
The pancreas contains a tube-like structure called the main pancreatic duct, which runs from the tail to the head of the organ. This main duct of the gland is called the duct of wiring and it runs the length of the gland and usually joins with the termination of the common bile duct to form the ampulla of Vater that opens into the second part of the duodenum.
Also, an accessory pancreatic duct, the duct of Santorini, passes from the upper part of the head and opens into the duodenum at the minor papilla about 2 cm proximal to the opening of the major duct.
The primary functions of the pancreas are to make enzymes (amylase and lipase), which help break down food and also the production of insulin and glucagon, which control the body’s blood sugar level.
More than 95 per cent of the pancreas’s mass is made up of cells and tissues that produce pancreatic juices containing digestive enzymes such as amylase, lipase, elastase, and nucleases.
Each of these enzymes breaks down a specific type of substance; for instance, amylase breaks down carbohydrates, lipase breaks down fats, and elastase breaks down proteins.
The pancreatic juices, along with bile from the gallbladder empty into the small intestine at the duodenum, where they assist in digesting food.
Clusters of cells called the islets of Langerhans to make up much of the rest of the pancreas. These cell clusters release insulin, glucagon and other hormones that help control the body’s blood sugar level directly into the bloodstream.
Chronic pancreatitis results when the pancreas gets persistently inflamed.
What is chronic pancreatitis?
Pancreatitis refers to inflammation of the pancreas, the organ responsible for producing digestive enzymes and the hormone insulin that regulates blood sugar levels.
Chronic pancreatitis is therefore the persistent inflammation of the pancreas resulting in permanent structural damage, fibrosis and ductal stricture thus leading to a decline in the function of the pancreas (known as pancreatic insufficiency).
Causes of chronic pancreatitis
- Idiopathic
A large proportion of cases of chronic pancreatitis are idiopathic with an unknown cause.
- Stone and duct obstruction
It is believed that protein-rich plugs, which get calcified and eventually form stones within the pancreatic ducts cause duct obstruction.
If this obstruction stays for a long time, persistent inflammation results thus leading to fibrosis, pancreatic ductal distortion, strictures, and atrophy and if this is progressive over the years, atrophy and loss of functions result.
- Progression of acute pancreatitis
Repeated attacks of acute pancreatitis with associated necrosis over years, the healing process replaces the necrotic tissue with fibrotic tissue, leading to the development of chronic pancreatitis.
- Heavy alcohol consumption
Only a minority of people with sustained alcohol exposure ultimately develop chronic pancreatitis, suggesting that there are other co-factors required to trigger the overt disease.
- Cigarette smoking
Cigarette smoking is an independent, dose-dependent risk factor for developing chronic pancreatitis.
Signs and symptoms of chronic pancreatitis
Chronic pancreatitis may cause some of the same symptoms as acute pancreatitis and in addition:
- In chronic pancreatitis, pain is the most common symptom and is usually located in the epigastric area and is initially episodic but later tends to become continuous and sometimes disabling and spreads to the back and is common after food. Sitting up and leaning forward reduces pain in both acute and chronic pancreatitis.
- Unexplained weight loss.
- Foamy diarrhoea with visible oil droplets(steatorrhea)
- Diabetes (high blood sugar), if insulin-producing pancreas cells are damaged.
- Pancreatic insufficiency
Clinical manifestations of pancreatic insufficiency include flatulence, abdominal distention, steatorrhea, undernutrition, weight loss, and fatigue.
Investigating chronic pancreatitis
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Laboratory investigations
In chronic pancreatitis, pancreatic function tests are done and this can be either
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- Direct monitor
Here, the actual secretion of pancreatic exocrine products (bicarbonate and enzymes) is monitored. They are most useful in patients who have an earlier stage of chronic pancreatitis in whom imaging studies are not diagnostic.
Direct tests are cumbersome, time-consuming, and have not been well standardized but are still being done in only a few specialized centres.
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- Indirect monitor
In indirect monitoring, the secondary effects of the lack of pancreatic enzymes (e.g., fat Malabsorption) are monitored. They are less accurate in diagnosing earlier stages of chronic pancreatitis and involve blood or stool samples.
The serum trypsinogen test is inexpensive and is available through commercial laboratories.
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Imaging studies
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- Abdominal CT is typically recommended to exclude pancreatic cancer as the cause of pain. Abdominal CT can be used in detecting calcifications and other pancreatic abnormalities (e.g., pseudocyst or dilated ducts) but still may be normal early in the disease.
- Magnetic resonance imaging.
MRI coupled with magnetic resonance cholangiopancreatography (MRCP) is now frequently used for diagnosis and can show masses in the pancreas as well as provide more optimal visualization of ductal changes consistent with chronic pancreatitis.
Diagnosis of chronic pancreatitis
Diagnosis of chronic pancreatitis can be difficult because amylase and lipase levels are frequently normal due to significant loss of pancreatic function. Diagnosis relies on clinical assessment, imaging studies, and pancreatic function tests.
Treatment of Chronic Pancreatitis
Treatment can be divided into thus:
- Healthy lifestyle modifications
Vigorous efforts and appropriate referrals to encourage smoking cessation and alcohol abstinence should be made for patients with chronic pancreatitis in an effort to slow the disease progression as early as possible. Also, the consumption of a low-fat diet is advised, this helps reduce pancreatic enzyme secretions.
- Pain control
Pain control is the most challenging task in the management of patients with chronic pancreatitis. Adjunctive pain drugs, such as tricyclic antidepressants, gabapentin, pregabalin, and selective serotonin reuptake inhibitors, have been used alone or combined with opioids to manage chronic pain; the results are variable. Drug treatment of pain in chronic pancreatitis is often unsatisfactory.
- Pancreatic enzyme supplements
Pancreatic enzyme supplementation may reduce chronic pain by suppressing the release of cholecystokinin from the duodenum, thereby reducing the secretion of pancreatic enzymes. Enzyme therapy is more likely to be successful in patients with less advanced disease, in women, and patients with idiopathic pancreatitis than in patients with alcoholic pancreatitis. Although enzyme therapy may not provide substantial benefits in improving pain.
In patients with exocrine pancreatic insufficiency, malabsorption of fat is more severe than malabsorption of proteins and carbohydrates. Fat malabsorption also results in a deficit of fat-soluble vitamins (A, D, E, and K). Pancreatic enzyme replacement therapy (replacement of deficient hormones to treat pancreatic insufficiency) may be advised.
- Management of diabetes
The patient should be referred to an endocrine specialist for the management of diabetes. Insulin should be given cautiously because the coexisting deficiency of glucagon secretion by alpha cells of the pancreas can result in unopposed and prolonged hypoglycemia, which is the hallmark of pancreatogenic diabetes (type 3c diabetes). Oral hypoglycemic drugs rarely help treat diabetes caused by chronic pancreatitis.
- Management of other complications.
Treatable complications of chronic pancreatitis such as duodenal or biliary obstruction, which can cause similar symptoms, should be sought.
- Surgical management
- Percutaneous or endoscopic ultrasound-guided nerve blockade.
Celiac plexus block is a recommendation for refractory chronic pancreatitis pain by the European Society of Gastrointestinal Endoscopy (ESGE). Several studies have shown that EUS-guided CPB has a beneficial role in treating pain caused by chronic pancreatitis.
- Other surgical approaches:
Other surgical approaches include a partial resection such as:
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- Distal pancreatectomy (removal of the distal end of the pancreas especially for the extensive disease at the tail of the pancreas).
- Whipple procedure (for the extensive disease at the head of the pancreas).
- Pylorus-sparing pancreaticoduodenectomy (similar to a Whipple procedure).
- Duodenum-preserving pancreatic head resection (Beger procedure).
- Total pancreatectomy with autotransplantation of islets.
- Endoscopic therapy is aimed at decompressing a pancreatic duct obstructed by stricture, stones, or both and may provide pain relief in carefully selected patients with appropriate ductal anatomy.
Can one live without a pancreas?
Yes, though uncommon. Only those with pancreatic cancer, severe cases of chronic pancreatitis, or other diseases of the pancreas face the possibility of having to live without one. The procedure of removing the pancreas is called a pancreatectomy and it is rarely done, and more often than not, only part of the pancreas is removed.
In cases where the entire pancreas is removed, drugs that could help the body carry out the functions previously handled by the pancreas are prescribed. Without the pancreas, for example, one would develop diabetes and become dependent on insulin shots to regulate the blood sugar level) also, digestive enzymes to help break down your food are given as enzyme supplements
Complications of chronic pancreatitis
- Malabsorption
When lipase and protease secretions are reduced to less than 10% of the normal, the patient develops malabsorption characterized by viz:
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- The passing of greasy stools (Steatorrhea) or even oil droplets that float in water and are difficult to flush.
- Also, there could be malabsorption of fat-soluble vitamins (A, D, E, and K).
- Undernutrition.
- Weight loss.
- Glucose intolerance.
This may appear at any time, but overt diabetes (pancreatogenic diabetes or type 3c diabetes) usually occurs late in the course of chronic pancreatitis. Patients are also at risk of low blood sugar (hypoglycemia) because pancreatic alpha cells, which produce a counter-regulatory hormone called glucagon, are lost.
- Formation of pseudocysts
- Obstruction of the bile duct or duodenum.
- Disruption (disconnection) of the pancreatic duct (resulting in ascites and pleural effusion).
- Thrombosis of the splenic vein (can cause gastric varices).
- Pseudoaneurysms of arteries near the pancreas or pseudocyst
- Pancreatic cancer
Patients with chronic pancreatitis are at increased risk of pancreatic adenocarcinoma and this risk seems to be greatest for patients with hereditary and tropical pancreatitis.
Conclusion
Chronic pancreatitis is painful, a long-lasting condition which doesn’t go away. Once the pancreas is severely damaged, the pancreatic functions are lost, thus support to digest food and manage blood sugar is needed to avoid complications.
Please, consult your healthcare provider when you notice any of the symptoms described above.