Pancreatitis – Diagnosis, Symptoms, and Treatment

What is Chronic Pancreatitis?

Chronic pancreatitis is a medical condition characterized by long-term repetitive pancreatic injury and inflammation, ultimately resulting in pancreatic fibrosis and dysfunction. The most common cause is chronic alcohol use. The pancreas is a critical organ with both endocrine (hormonal) and exocrine (enzymatic) function. Islet cells in the pancreas generate essential hormones such as insulin and glucagon. The pancreas also releases digestive enzymes such as lipases, amylases, and proteases – these are essential for proper digestion and nutrition.

In chronic pancreatitis, the normal functions of the pancreas are impaired. Loss of insulin synthesis and secretion can result in diabetes mellitus. Decreased release of digestive enzymes may lead to impaired digestion and malabsorption. Chronic pancreatitis is associated with significantly high morbidity and mortality. It is a risk factor for pancreatic cancer and a common cause of death.

What Causes Chronic Pancreatitis?

The pancreas is a critical gastrointestinal organ that plays roles in both metabolism and digestion. Islet cells in the pancreas are hormone-producing cells that generate insulin and glucagon. Insulin and glucagon are critical regulators of blood glucose levels. The pancreas is also responsible for the production of digestive enzymes such as lipases (digest fat), amylases (digest sugar), and proteases (digest protein). The pancreas releases these enzymes into the pancreatic duct, which communicates with the common bile duct and empties into the small intestine. Here, digestive enzymes can interact with food that has been consumed and facilitate the breakdown of macromolecules for their absorption.

In chronic pancreatitis, these critical functions of the pancreas are disrupted. Chronic pancreatitis is most frequently caused by chronic alcohol use. Significant alcohol consumption can lead to pancreatic injury, resulting in acute inflammation of the pancreas – acute pancreatitis. Repetitive episodes of acute pancreatitis ultimately result in the replacement of normal pancreatic tissue with fibrotic scar tissue. The scar tissue tends to calcify, a diagnostic feature of chronic pancreatitis on abdominal imaging such as x-ray and CT scan. Shrunken, fibrotic pancreatic tissue is no longer functional. Consequently, patients with pancreatitis typically develop diabetes mellitus and malabsorption features such as weight loss and chronic diarrhea.

Causes of pancreatitis besides alcohol include genetic mutations (e.g., cystic fibrosis), ductal obstruction (e.g., gallstones), or systemic disease (e.g., hypertriglyceridemia, hyperparathyroidism).

How Common is Chronic Pancreatitis?

Chronic pancreatitis is a common medical problem that is frequently encountered in the primary care clinic. Advanced cases often require referral to a gastroenterology specialist, particularly if first-line and conservative measures are ineffective. Alcohol accounts for approximately 45% of chronic pancreatitis. About 5%-10% of alcoholics go on to develop chronic pancreatitis.

Worldwide, chronic pancreatitis incidence is estimated to be 2-23 cases per 100,000 people per year. In the United States, chronic pancreatitis leads to greater than 122,000 ambulatory care visits and more than 56,000 hospitalizations annually.

Signs and Symptoms

Features of chronic pancreatitis often include:

•         Abdominal pain
•         Nausea & vomiting
•         Anorexia
•         Weight loss
•         Chronic diarrhea
•         Malnutrition

Patients may develop complications such as diabetes mellitus and pancreatic cancer. The condition is associated with high morbidity and mortality – it is one of the leading causes of death.

Diagnosis

Chronic pancreatitis diagnosis is suggested based on symptoms, history, and physical examination but typically confirmed with laboratory and imaging studies. Your doctor will commonly order blood tests including lipase, amylase, CMP (comprehensive metabolic panel), CBC (complete blood cell count), thyroid function tests (TSH, free T4), and coagulation studies (PT/INR, PTT). They may obtain stool studies to evaluate for the presence of fecal fat.

Patients with acute pancreatitis often have elevated amylase and lipase – these are pancreatic enzymes released when the pancreas is inflamed. In chronic pancreatitis, the pancreas may not produce these enzymes in sufficient quantities due to fibrosis/scarring – therefore, patients often have low or normal amylase and lipase levels.

Your doctor will usually check your cholesterol and triglyceride levels and screen for diabetes. Also, prealbumin, vitamin B12, folate, and vitamin D levels will likely be obtained if you show signs of malnutrition.

CT scan of the abdomen is frequently obtained to search for causes of chronic abdominal pain, evaluate for chronic pancreatitis features, and assess for complications such as pancreatic cancer. Chronic pancreatitis typically appears as a shrunken pancreas with multiple calcifications.

Chronic Pancreatitis Treatment

The treatment of chronic pancreatitis involves preventing progression, pain control, and correction of pancreatic insufficiency. Patients are encouraged to avoid alcohol and tobacco use, as these are known risk factors for pancreatitis. They are also instructed to eat small meals and avoid diets high in fat as these can exacerbate abdominal pain.

Pancreatic enzyme supplements are typically required in patients that do not respond to the aforementioned conservative measures. These agents contain enzymes such as lipase, amylase, and protease. They are essential because they may reduce abdominal pain and the risk of malabsorption and nutritional deficiencies. The most commonly prescribed therapies include:

•       Pancreaze
•       Creon
•       Zenpep

 Pancreatic enzyme supplements are typically given with acid suppression therapy because the low pH and high acidity in the stomach inactivate these enzymes. Acid suppression therapy can include proton-pump inhibitors (PPIs) such as:

•       Prilosec (Omeprazole)
•       Protonix (Pantoprazole)
•       Prevacid (Lansoprazole)
•       Dexilent (Dexlansoprazole)

Histamine 2 receptor blockers such as Zantac (Ranitidine) and Pepcid (Famotidine) are sometimes used to substitute for proton pump inhibitors. These medications also work by reducing acid levels but may not be as effective as PPIs.

Pain is often controlled with opiate analgesics and nonsteroidal anti-inflammatory drugs (NSAIDS). Common examples of NSAIDS include Advil (ibuprofen) and Naprosyn (naproxen). Your doctor may also prescribe opiates in cases that are not responsive to the above measures. This can include medications such as:

•         Codeine
•         Vicodin (hydrocodone-acetaminophen)
•         Oxycontin (oxycodone-acetaminophen)

Patients with coexisting liver disease should avoid medications containing acetaminophen. Lyrica (pregabalin) may also be useful in some individuals. Patients with pain refractory to medical therapy may require specialized interventional procedures such as endoscopic therapy, lithotripsy, and occasionally surgery.

Chronic pancreatitis usually causes glucose intolerance and, in severe cases, can result in diabetes mellitus. Oral hypoglycemic agents such as Glucophage (Metformin) and occasionally insulin are necessary for such patients.

References:

1.     Rickels MR, Bellin M, Toledo FG, et al. Detection, evaluation and treatment of diabetes mellitus in chronic pancreatitis: recommendations from PancreasFest 2012. Pancreatology 2013; 13:336. - https://www.ncbi.nlm.nih.gov/pubmed/23890130
2.     Steer ML, Waxman I, Freedman S. Chronic pancreatitis. N Engl J Med 1995; 332:1482. - https://www.ncbi.nlm.nih.gov/pubmed/7739686
3.     Bang UC, Benfield T, Hyldstrup L, et al. Mortality, cancer, and comorbidities associated with chronic pancreatitis: a Danish nationwide matched-cohort study. Gastroenterology 2014; 146:989. - https://www.gastrojournal.org/article/S0016-5085(13)01847-7/fulltext