Chronic Pancreatitis Treatment

Chronic Pancreatitis

What is chronic pancreatitis?

Chronic pancreatitis is a medical condition characterized by long-term repetitive pancreatic injury and inflammation, which ultimately results in pancreatic fibrosis and dysfunction. The most common cause is chronic alcohol use. The pancreas is a critical organ that has both endocrine (hormonal) and exocrine (enzymatic) function. Islet cells in the pancreas generate important hormones such as insulin and glucagon. The pancreas also releases digestive enzymes such as lipases, amylases, and proteases – this 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 a significantly high morbidity and mortality. It is a risk factor for pancreatic cancer and a common cause of death. Due to the importance of this condition, it is critical that patients understand its causes, symptoms, and treatment. By the end of this article, you will have the answers to these essential questions:

  • What causes chronic pancreatitis?
  • How common is chronic pancreatitis?
  • What are the symptoms and signs of chronic pancreatitis?
  • How is chronic pancreatitis diagnosed?
  • How is chronic pancreatitis treated?

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 key 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 are able to interact with food that has been consumed, and facilitate the breakdown of macromolecules in order for them to be absorbed.

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, which is a diagnostic features 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 features of malabsorption 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, the incidence of chronic pancreatitis 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.

What are the symptoms and signs of chronic pancreatitis?

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.

How is chronic pancreatitis diagnosed?

The diagnosis of chronic pancreatitis 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 a 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 that are 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. In addition, 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 features of chronic pancreatitis, and asses for complications such as pancreatic cancer. Chronic pancreatitis typically appears as a shrunken pancreas with multiple calcifications.

How is chronic pancreatitis treated?

The treatment of chronic pancreatitis involves a combination of 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 important 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 as a substitute to 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 that is 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 in such patients.

Chronic Pancreatitis Patient Summary:

  • Chronic pancreatitis is characterized by long-term, repetitive pancreatic injury and inflammation, which ultimately results in pancreatic fibrosis and dysfunction.
  • The most common cause is chronic alcohol use.
  • In chronic pancreatitis, loss of insulin can result in diabetes mellitus. Decreased release of digestive enzymes may lead to impaired digestion and malabsorption.
  • The diagnosis is made based on history, physical examination, laboratory studies, and abdominal imaging. CT scan of the abdomen typically shows pancreatic calcifications.
  • Patients should avoid alcohol and tobacco. They should also eat small meals and avoid diets high in fat as these can exacerbate abdominal pain and diarrhea.
  • Pancreatic enzyme supplements are commonly prescribed, including Pancreaze, Creon, and Zenpep.
  • Pancreatic enzymes are typically given with proton-pump inhibitors, including Prilosec (omeprazole), Protonix (pantoprazole), and Prevacid (lansoprazole).
  • Histamine 2 receptor blockers such as Zantac (ranitidine) and Pepcid (famotidine) are sometimes used as a substitute to proton pump inhibitors.
  • Pain is often controlled with NSAIDS such as Advil (Ibuprofen) and Naprosyn (naproxen). Your doctor may also prescribe opiates such as Codeine, Vicodin (hydrocodone-acetaminophen), or Oxycontin (oxycodone-acetaminophen).
  • Lyrica (pregabalin) may also be useful in some individuals.
  • Hypoglycemic agents such as Glucophage (metformin) and occasionally insulin are necessary in patients with chronic pancreatitis complicated by diabetes mellitus.

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.
  2. Steer ML, Waxman I, Freedman S. Chronic pancreatitis. N Engl J Med 1995; 332:1482.
  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.

Popular Chronic Pancreatitis Medications

The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.