Chronic pancreatitis
Encyclopedia
Chronic pancreatitis
is a long-standing inflammation
of the pancreas
that alters its normal structure and functions. It can present as episodes of acute inflammation
in a previously injured pancreas
, or as chronic damage with persistent pain or malabsorption.
or steatorrhea
resulting from malabsorption of the fats in food. Diabetes is a common complication due to the chronic pancreatic damage and may require treatment with insulin. Some patients with chronic pancreatitis look very sick, while others don't appear to be unhealthy at all.
Considerable weight loss
, due to malabsorption
, is evident in a high percentage of patients, and can continue to be a health problem as the condition progresses. The patient may also complain about pain related to their food intake, especially those meals containing a high percentage of fats and protein. Some chronic pancreatitis patients do not experience pain while others suffer from constant, debilitating pain. Weight loss can also be attributed to a reduction in food intake in patients with severe abdominal pain.
In developed countries, the most common causes of chronic pancreatitis are alcohol and idiopathic.
Across the rest of the world malnutrition and associated dietary factors have been implicated. In a small group of patients chronic pancreatitis has been shown to be hereditary, inherited as an autosomal dominant condition with variable penetrance. Almost all patients with cystic fibrosis have established chronic pancreatitis, usually from birth. Cystic fibrosis gene mutations have also been identified in patients with chronic pancreatitis but in whom there were no other manifestations of cystic fibrosis.
Obstruction of the pancreatic duct because of either a benign or malignant process may result in chronic pancreatitis. Congenital abnormalities of the pancreatic duct, in particular pancreas divisum, have been implicated.″
and lipase
may or may not be moderately elevated in cases of chronic pancreatitis, owing to the uncertain levels of productive cell damage, though elevated lipase is the more likely found of the two. Amylase and lipase are nearly always found elevated in the acute condition along with an elevated CRP
inflammatory marker that is broadly in line with the severity of the condition. A secretin
stimulation test is considered the gold standard
functional test for diagnosis of chronic pancreatitis but not often used clinically. The observation that bi-carbonate production is impaired early in chronic pancreatitis has led to the rationale of use of this test in early stages of disease (sensitivity
of 95%). Other common tests used to determine chronic pancreatitis are faecal elastase measurement in stool, serum trypsinogen, Computed tomography (CT), ultrasound
, EUS, MRI
, ERCP and MRCP
. Pancreatic calcification
can often be seen on plain abdominal X-rays, as well as CT scans.
There are other non-specific laboratory studies useful in diagnosis of chronic pancreatitis. Serum bilirubin and alkaline phosphatase can be elevated, indicating stricturing of the common bile duct due to edema, fibrosis or cancer. When the chronic pancreatitis is due to an autoimmune process, elevations in ESR
, IgG4, rheumatoid factor
, ANA
and antismooth muscle antibody may be seen. The common symptom of chronic pancreatitis, steatorrhea
, can be diagnosed by two different studies: Sudan chemical staining of feces or fecal fat excretion of 7 grams or more over a 24hr period on a 100g fat diet. To check for pancreatic exocrine dysfunction, the most sensitive and specific test is the measurement of fecal elastase, which can be done with a single stool sample, and a value of less than 200 ug/g indicates pancreatic insufficiency.
may occur and need long term insulin therapy.
The abdominal pain can be very severe and require high doses of analgesic
s, sometimes including opiate
s. Disability and mood problems are common, although early diagnosis and support can make these problems manageable. Alcohol cessation and dietary modifications (low-fat diet) are important to manage pain and slow the calcific process. Recent research indicates smoking may be a high-risk factor.
. However, the outcome from 6 randomized trials has been inconclusive regarding pain reduction.
While the outcome of trials regarding pain reduction with pancreatic enzyme replacement is inconclusive, some patients do have pain reduction with enzyme replacement and since they are relatively safe, giving enzyme replacement to a chronic pancreatitis patient is an acceptable step in treatment for most patients. Treatment may be more likely to be successful in those without involvement of large ducts and those with idiopathic pancreatitis. Patients with alcoholic pancreatitis may be less likely to respond.
New and proven transplantation options prevent the patient from becoming diabetic following the surgical removal (resection) of their pancreas. This is achieved by transplanting back in the patient's own insulin-producing beta cells.
Pancreatitis
Pancreatitis is inflammation of the pancreas. It occurs when pancreatic enzymes that digest food are activated in the pancreas instead of the small intestine. It may be acute – beginning suddenly and lasting a few days, or chronic – occurring over many years...
is a long-standing inflammation
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
of the pancreas
Pancreas
The pancreas is a gland organ in the digestive and endocrine system of vertebrates. It is both an endocrine gland producing several important hormones, including insulin, glucagon, and somatostatin, as well as a digestive organ, secreting pancreatic juice containing digestive enzymes that assist...
that alters its normal structure and functions. It can present as episodes of acute inflammation
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
in a previously injured pancreas
Pancreas
The pancreas is a gland organ in the digestive and endocrine system of vertebrates. It is both an endocrine gland producing several important hormones, including insulin, glucagon, and somatostatin, as well as a digestive organ, secreting pancreatic juice containing digestive enzymes that assist...
, or as chronic damage with persistent pain or malabsorption.
Symptoms
Patients with chronic pancreatitis usually present with persistent abdominal painAbdominal pain
Abdominal pain can be one of the symptoms associated with transient disorders or serious disease. Making a definitive diagnosis of the cause of abdominal pain can be difficult, because many diseases can result in this symptom. Abdominal pain is a common problem...
or steatorrhea
Steatorrhea
Steatorrhea is the presence of excess fat in feces. Stools may also float due to excess lipid, have an oily appearance and be especially foul-smelling. An oily anal leakage or some level of fecal incontinence may occur. There is increased fat excretion, which can be measured by determining the...
resulting from malabsorption of the fats in food. Diabetes is a common complication due to the chronic pancreatic damage and may require treatment with insulin. Some patients with chronic pancreatitis look very sick, while others don't appear to be unhealthy at all.
Considerable weight loss
Weight loss
Weight loss, in the context of medicine, health or physical fitness, is a reduction of the total body mass, due to a mean loss of fluid, body fat or adipose tissue and/or lean mass, namely bone mineral deposits, muscle, tendon and other connective tissue...
, due to malabsorption
Malabsorption
Malabsorption is a state arising from abnormality in absorption of food nutrients across the gastrointestinal tract.Impairment can be of single or multiple nutrients depending on the abnormality...
, is evident in a high percentage of patients, and can continue to be a health problem as the condition progresses. The patient may also complain about pain related to their food intake, especially those meals containing a high percentage of fats and protein. Some chronic pancreatitis patients do not experience pain while others suffer from constant, debilitating pain. Weight loss can also be attributed to a reduction in food intake in patients with severe abdominal pain.
Causes
- Alcohol
- Tropical (nutritional)
- Hereditary
- Trypsinogen and inhibitory protein defects
- Cystic fibrosis
- Idiopathic
- Trauma
- Hypercalcaemia
- Calcific stones
In developed countries, the most common causes of chronic pancreatitis are alcohol and idiopathic.
Across the rest of the world malnutrition and associated dietary factors have been implicated. In a small group of patients chronic pancreatitis has been shown to be hereditary, inherited as an autosomal dominant condition with variable penetrance. Almost all patients with cystic fibrosis have established chronic pancreatitis, usually from birth. Cystic fibrosis gene mutations have also been identified in patients with chronic pancreatitis but in whom there were no other manifestations of cystic fibrosis.
Obstruction of the pancreatic duct because of either a benign or malignant process may result in chronic pancreatitis. Congenital abnormalities of the pancreatic duct, in particular pancreas divisum, have been implicated.″
Diagnosis
The diagnosis of chronic pancreatitis is typically based on tests on pancreatic structure and function, as direct biopsy of the pancreas is considered excessively risky. Serum amylaseAmylase
Amylase is an enzyme that catalyses the breakdown of starch into sugars. Amylase is present in human saliva, where it begins the chemical process of digestion. Food that contains much starch but little sugar, such as rice and potato, taste slightly sweet as they are chewed because amylase turns...
and lipase
Lipase
A lipase is an enzyme that catalyzes the formation or cleavage of fats . Lipases are a subclass of the esterases.Lipases perform essential roles in the digestion, transport and processing of dietary lipids in most, if not all, living organisms...
may or may not be moderately elevated in cases of chronic pancreatitis, owing to the uncertain levels of productive cell damage, though elevated lipase is the more likely found of the two. Amylase and lipase are nearly always found elevated in the acute condition along with an elevated CRP
C-reactive protein
C-reactive protein is a protein found in the blood, the levels of which rise in response to inflammation...
inflammatory marker that is broadly in line with the severity of the condition. A secretin
Secretin
Secretin is a hormone that controls the secretions into the duodenum, and also separately, water homeostasis throughout the body. It is produced in the S cells of the duodenum in the crypts of Lieberkühn...
stimulation test is considered the gold standard
Gold standard (test)
In medicine and statistics, gold standard test refers to a diagnostic test or benchmark that is the best available under reasonable conditions. It does not have to be necessarily the best possible test for the condition in absolute terms...
functional test for diagnosis of chronic pancreatitis but not often used clinically. The observation that bi-carbonate production is impaired early in chronic pancreatitis has led to the rationale of use of this test in early stages of disease (sensitivity
Sensitivity and specificity
Sensitivity and specificity are statistical measures of the performance of a binary classification test, also known in statistics as classification function. Sensitivity measures the proportion of actual positives which are correctly identified as such Sensitivity and specificity are statistical...
of 95%). Other common tests used to determine chronic pancreatitis are faecal elastase measurement in stool, serum trypsinogen, Computed tomography (CT), ultrasound
Medical ultrasonography
Diagnostic sonography is an ultrasound-based diagnostic imaging technique used for visualizing subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions...
, EUS, MRI
Magnetic resonance imaging
Magnetic resonance imaging , nuclear magnetic resonance imaging , or magnetic resonance tomography is a medical imaging technique used in radiology to visualize detailed internal structures...
, ERCP and MRCP
Magnetic resonance cholangiopancreatography
Magnetic resonance cholangiopancreatography is a medical imaging technique that uses magnetic resonance imaging to visualise the biliary and pancreatic ducts in a non-invasive manner...
. Pancreatic calcification
Calcification
Calcification is the process in which calcium salts build up in soft tissue, causing it to harden. Calcifications may be classified on whether there is mineral balance or not, and the location of the calcification.-Causes:...
can often be seen on plain abdominal X-rays, as well as CT scans.
There are other non-specific laboratory studies useful in diagnosis of chronic pancreatitis. Serum bilirubin and alkaline phosphatase can be elevated, indicating stricturing of the common bile duct due to edema, fibrosis or cancer. When the chronic pancreatitis is due to an autoimmune process, elevations in ESR
Erythrocyte sedimentation rate
The erythrocyte sedimentation rate , also called a sedimentation rate or Biernacki Reaction, is the rate at which red blood cells sediment in a period of 1 hour...
, IgG4, rheumatoid factor
Rheumatoid factor
Rheumatoid factor is an autoantibody most relevant in rheumatoid arthritis. It is defined as an antibody against the Fc portion of IgG. RF and IgG join to form immune complexes that contribute to the disease process...
, ANA
Anti-nuclear antibody
Anti-nuclear antibodies are autoantibodies directed against contents of the cell nucleus....
and antismooth muscle antibody may be seen. The common symptom of chronic pancreatitis, steatorrhea
Steatorrhea
Steatorrhea is the presence of excess fat in feces. Stools may also float due to excess lipid, have an oily appearance and be especially foul-smelling. An oily anal leakage or some level of fecal incontinence may occur. There is increased fat excretion, which can be measured by determining the...
, can be diagnosed by two different studies: Sudan chemical staining of feces or fecal fat excretion of 7 grams or more over a 24hr period on a 100g fat diet. To check for pancreatic exocrine dysfunction, the most sensitive and specific test is the measurement of fecal elastase, which can be done with a single stool sample, and a value of less than 200 ug/g indicates pancreatic insufficiency.
Treatment
The different treatment modalities for management of chronic pancreatitis are medical measures, therapeutic endoscopy and surgery. Treatment is directed, when possible, to the underlying cause, and to relieve pain and malabsorption. Insulin dependent diabetes mellitusDiabetes mellitus
Diabetes mellitus, often simply referred to as diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced...
may occur and need long term insulin therapy.
The abdominal pain can be very severe and require high doses of analgesic
Analgesic
An analgesic is any member of the group of drugs used to relieve pain . The word analgesic derives from Greek an- and algos ....
s, sometimes including opiate
Opiate
In medicine, the term opiate describes any of the narcotic opioid alkaloids found as natural products in the opium poppy plant.-Overview:Opiates are so named because they are constituents or derivatives of constituents found in opium, which is processed from the latex sap of the opium poppy,...
s. Disability and mood problems are common, although early diagnosis and support can make these problems manageable. Alcohol cessation and dietary modifications (low-fat diet) are important to manage pain and slow the calcific process. Recent research indicates smoking may be a high-risk factor.
Pancreatic Enzyme Supplementation
Replacement pancreatic enzymes are often effective in treating the malabsorption and steatorrheaSteatorrhea
Steatorrhea is the presence of excess fat in feces. Stools may also float due to excess lipid, have an oily appearance and be especially foul-smelling. An oily anal leakage or some level of fecal incontinence may occur. There is increased fat excretion, which can be measured by determining the...
. However, the outcome from 6 randomized trials has been inconclusive regarding pain reduction.
While the outcome of trials regarding pain reduction with pancreatic enzyme replacement is inconclusive, some patients do have pain reduction with enzyme replacement and since they are relatively safe, giving enzyme replacement to a chronic pancreatitis patient is an acceptable step in treatment for most patients. Treatment may be more likely to be successful in those without involvement of large ducts and those with idiopathic pancreatitis. Patients with alcoholic pancreatitis may be less likely to respond.
Surgery
Traditional Surgery for Chronic Pancreatitis tends to be divided into two areas - resectional and drainage procedures.New and proven transplantation options prevent the patient from becoming diabetic following the surgical removal (resection) of their pancreas. This is achieved by transplanting back in the patient's own insulin-producing beta cells.
External links
- VIDEO - Chronic Pancreatitis: Recent Advances and Ongoing Challenges, Jeffery B. Matthews, MD, speaks at the University of Wisconsin School of Medicine and Public Health (2007)
- Medical Information and Treatment of Chronic Pancreatitis