Pain in the upper part of the abdomen which goes to the backbone is often the first symptom of chronic pancreatitis. The word ‘chronic’ means a long-standing process and the word ‘pancreatitis’ suggests swelling of the pancreas. The pancreas is a soft gland, which is situated in the upper part of the abdomen, and performs the crucial function of digesting food and control of blood sugar. The pancreas secretes enzymes that are essential for the digestion of food. The pancreas has a central duct called the main pancreatic duct through which pancreatic enzymes reach the small intestine. Three essentials for the digestion of food required are bile which is secreted by the liver, pancreas enzymes, and small bowel enzymes. Pancreas also secretes hormones for the control of blood sugar. Insulin is such an important hormone, and a reduction in insulin function can lead to Diabetes mellitus.
What is chronic pancreatitis?
Chronic Pancreatitis is a long-standing, painful disease that results in a reduction in the size of the pancreas, dilatation of the pancreatic duct, and stone formation in the duct.
What causes chronic pancreatitis
Alcohol: Alcohol intake is the most common cause of chronic pancreatitis. Anybody consuming alcohol for a long time without good nutrition is at risk of pancreatitis and liver disease. If somebody consuming alcohol feels pain in the upper part of the abdomen, chronic pancreatitis should be suspected and a proper evaluation should be done.
Idiopathic: Certain subtle genetic mutations can also lead to chronic pancreatitis. Every single process in the human body is governed by genetic information. Sometimes this genetic information may be subtly altered which can lead to an inflammatory process and chronic pancreatitis.
Blockade of pancreas duct: Blockade in the duct of the pancreas by the tumor can also lead to chronic pancreatitis. In old age, tumors are a common cause of chronic pancreatitis.
Symptoms of chronic pancreatitis
The three most common symptoms of chronic pancreatitis are pain abdomen, diarrhea, and diabetes.
Pain abdomen: Pain in the upper part of the abdomen is the most common symptom of chronic pancreatitis. This pain may be persistent, occurring daily and after food intake. Sometimes, the patient may have severe attacks of pain abdomen which becomes normal between the attacks.
Diarrhea: Chronic pancreatitis leads to the shrinkage of the pancreas gland, and enzyme secretion is reduced. Reduced enzyme secretion leads to failure to digest the food leading to diarrhea. There may be an excess amount of oil or fat in the stool, giving it an oily appearance.
Diabetes: Shrinkage in the pancreas gland also lead to low level of insulin, and the blood sugar levels may go up.
How to diagnose and confirm the diagnosis of chronic pancreatitis
Once chronic pancreatitis is suspected, 4 tests are commonly used to diagnose chronic pancreatitis
Ultrasound abdomen: Ultrasound abdomen is the most common test, but gives limited information about the pancreas. In patients, with chronic pancreatitis, glands may become smaller in size, the duct of the pancreas may be dilated, and there may be stones in the pancreas duct. Ultrasonography can detect the dilated duct and stone in the pancreas. Sometimes, its difficult to evaluate the pancreas by ultrasonography.
Endoscopic ultrasonography (EUS): EUS is an ideal test to diagnose chronic pancreatitis. During EUS, a special endoscope that has an ultrasound probe on the tip is used for the evaluation of the pancreas. EUS is a painless test and is done under sedation. This test can be done on an OPD basis also.
CT and MRCP: CT and MRCP can also diagnose chronic pancreatitis, especially in advanced cases.
Treatment of chronic pancreatitis
Relief of pain: If the patient has severe pain, hospitalization should be done, and IV fluids are started, antibiotics are usually not required. Painkillers are also given, according to the severity of the pain.
In patients with less severe pain, treatment is started on an OPD basis. Firstly these patients are started on oral pancreatic enzymes, antioxidants, and painkillers. Medication that reduces the sensitivity of the nerves is also started. At the same time, the diet is modified to reduce the episodes of pain.
The next step is imaging of the pancreas by EUS or MRCP. There may be a stone in the duct of the pancreas or the duct may be dilated, which may require treatment. Stone in the pancreas duct can be removed by an endoscopic technique called ERCP. Larger stones can be broken by a special technique of pancreatoscopy with EHL/laser or ESWL. During ESWL, external waves are used for breaking the stones in the pancreas, and similar techniques have been used for breaking the kidney stones also. During Pancreatoscopy, the small endoscope is introduced in the duct of the pancreas, and stones are broken by EHL or laser. In patients with very large stones, surgery is performed to remove the stone. Multiple sessions of ERCP or ESWL may be required to completely remove the stones. If the test reveals dilated duct with a blockade in a duct of the pancreas, these patients are treated with ERCP or surgery. During surgery, plastic or stent is placed in the pancreas duct and is kept for 12 months, the stents may need to be replaced at regular intervals. In case of multiple strictures, or persistent strictures, surgery can be done. During surgery, the duct of the pancreas can be connected to the small intestine.
Diarrhea: In patients with diarrhea due to chronic pancreatitis, enzymes enzyme supplements are given along with the diet.
Diabetes: Oral medications and insulin are required to treat diabetes. Patients with chronic pancreatitis are at risk of low blood sugar also, so these patients must take small meals at regular intervals.
Complications of chronic pancreatitis
Pseudocyst: In many patients with chronic pancreatitis, fluid collection forms around the pancreas, and is called pancreatic pseudocyst. The pancreas pseudocyst can lead to chronic pain in patients with chronic pancreatitis. This cyst may be easily internally drained with the help of EUS guidance, a process known as EUS-guided cystogastrostomy. EUS Guided cystogastrostomy is a safe technique and does not require any skin incision.
Pancreatic mass: Many patients with chronic pancreatitis, can have mass in the pancreas gland. This mass is due to inflammation known as inflammatory mass or can be neoplastically known as neoplastic mass. This mass should be properly investigated with the help of EUS, CT scan, or blood test such as Ca 19-9 and is treated accordingly. The neoplastic or malignant mass may require surgery.
Jaundice: The duct of the liver known as the bile duct passes through the pancreas and is often compressed in patients with chronic pancreatitis, which leads to jaundice, yellow eyes, and urine, and raised bilirubin in the blood. This condition can be easily treated with ERCP and plastic or metal stent placement in the bile duct.
Vomiting: Swollen pancreas can lead to compression of the stomach, leading to vomiting. This condition can be easily treated with endoscopy or surgery.
What is the risk of cancer in chronic pancreatitis?
If proper care is taken risk of cancer is negligible. Patients who smoke or consume tobacco are at higher risk.
What is the life duration of the patient with chronic pancreatitis?
With proper care, a life span is equal to healthy persons in society.
What should be the lifestyle of patients with chronic pancreatitis?
Remember these 5 points
- Avoid alcohol, smoking, tobacco, and spicy food
- Early to bed, early to rise
- Take a diet rich in antioxidants, fruit, and vegetables
- Small frequent meals, avoid overeating
- Morning walk, 45 minutes a day, 5 days back, once the clinical condition is stable