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Chronic Pancreatitis

Chronic pancreatitis is the presence of inflammation in the pancreas that worsens over time, gradually causing permanent damage to the organ. It leads to an impairment in the exocrine as well as the endocrine functions of the pancreas.


Presentation

The symptoms of chronic pancreatitis exhibit episodes of severity occurring in intermissions, along with continuous pain. One of the major symptoms of this disease is epigastric abdominal pain that radiates to the back, probably due to the obstruction of the pancreatic duct. The severity of the pain may vary: sometimes it may require opiate analgesics whereas at other times, it may not be a problem. Other symptoms of the condition include nausea, vomiting, reduced appetite, exocrine and endocrine dysfunction. Exocrine dysfunction leads to weight loss, protein deficiency, diarrhea and steatorrhoea. Endocrine dysfunction leads to the development of secondary diabetes mellitus.

Weight Loss
  • There were no statistically significant differences in reported symptoms between patients with and without SIBO, with the exception of 'weight loss', with patients reporting weight loss more likely to have SIBO (P   0.047).[ncbi.nlm.nih.gov]
  • The lack or absence of pancreatic enzymes leads to an inadequate absorption of fat, proteins, and carbohydrates, causing steatorrhoea and creathorrhea which results in abdominal discomfort, weight loss, and nutritional deficiencies.[ncbi.nlm.nih.gov]
  • Here are some ways to differentiate the weight loss of chronic pancreatitis from weight loss associated with other medical conditions: Unintended weight loss is also one of the hallmark signs of cancer.[wikihow.com]
  • The weight loss occurs because the body does not secrete enough pancreatic enzymes to digest food, so nutrients are not absorbed normally, leading to malnutrition.[pancreasfoundation.org]
  • Symptoms of diabetes type 1 include increased hunger and thirst, frequent urination, weight loss, and fatigue.[en.wikipedia.org]
Wound Infection
  • The patient did very well with no pancreatic leak, wound infection, or delayed gastric emptying. She was discharged home on postoperative day 6, symptom free with no narcotic requirement.[ncbi.nlm.nih.gov]
Abdominal Pain
  • The abdominal pain had resolved completely and the patient remained normoglycemic after HPAT. We conclude that HPAT is a useful option for hemorrhagic pseudocyst of the pancreas head with severe abdominal pain of chronic pancreatitis.[ncbi.nlm.nih.gov]
  • Signs and symptoms include abdominal pain, malabsorption and diabetes mellitus Inflammation of the pancreas that is characterized by recurring or persistent abdominal pain with or without steatorrhea or diabetes mellitus.[icd9data.com]
  • Gradual loss of exocrine and endocrine function follows, along with clinical manifestations such as steatorrhoea, abdominal pain and diabetes.[ncbi.nlm.nih.gov]
  • pain with jaundice (22.4% vs 9.5%, P   .002) and pancreatic mass /- ductal dilatation (47% vs 27%, P[ncbi.nlm.nih.gov]
  • The patient complained of continuous upper abdominal pain. Her medical history included idiopathic chronic pancreatitis.[ncbi.nlm.nih.gov]
Vomiting
  • Nausea/Vomiting - Eating and drinking can make the pain of pancreatitis worse and often result in nausea and vomiting. Diarrhea - Inability to breakdown foods properly and poor eating/drinking habits may result in diarrhea and dehydration.[baylortransplant.com]
  • Abdominal pain, nausea, vomiting, decreased appetite, exocrine and endocrine dysfunction are some of the symptoms of chronic pancreatitis.[symptoma.com]
  • Other symptoms of chronic pancreatitis include: Nausea Vomiting (vomit may be yellowish, greenish or brownish) Diarrhea and oily bowel movements Trouble digesting food and poor growth Diabetes mellitus Jaundice (yellow discoloration of the skin) In some[cincinnatichildrens.org]
  • These symptoms include abdominal pain, nausea and vomiting, diarrhea or oil in your stool, weight loss, and fever. Diet changes Suggestions for dietary changes include the following: Eat a low-fat diet.[fairview.org]
  • Some people might feel sick and vomit. As the condition progresses, the painful episodes may become more frequent and severe. Eventually, a constant dull pain can develop in your tummy, between episodes of severe pain.[nhs.uk]
Nausea
  • Nausea/Vomiting - Eating and drinking can make the pain of pancreatitis worse and often result in nausea and vomiting. Diarrhea - Inability to breakdown foods properly and poor eating/drinking habits may result in diarrhea and dehydration.[baylortransplant.com]
  • Abdominal pain, nausea, vomiting, decreased appetite, exocrine and endocrine dysfunction are some of the symptoms of chronic pancreatitis.[symptoma.com]
  • These symptoms include abdominal pain, nausea and vomiting, diarrhea or oil in your stool, weight loss, and fever. Diet changes Suggestions for dietary changes include the following: Eat a low-fat diet.[fairview.org]
  • Chronic pancreatitis causes attacks of abdominal pain, nausea and vomiting that are worsened by eating or drinking, especially alcohol.[medicinenet.com]
  • Symptoms may include: Abdominal pain Nausea Vomiting Weight loss Diarrhea or oily stools At The Children's Hospital of Philadelphia, children with acute and chronic pancreatitis are evaluated and treated by doctors in the Division of Gastroenterology[chop.edu]
Diarrhea
  • Ten months after the onset of the first episode of pancreatitis the patient developed bloody diarrhea, mucus stools and biochemical findings of inflammation.[ncbi.nlm.nih.gov]
  • In many people who suffer from chronic pancreatitis, this chain of events results in severe diarrhea.[livehealthy.chron.com]
  • Symptoms that result from this dysfunction include fatty diarrhea and/or diabetes. What Causes Chronic Pancreatitis? There are several different causes of chronic pancreatitis.[trihealth.com]
  • Diarrhea - Inability to breakdown foods properly and poor eating/drinking habits may result in diarrhea and dehydration. Weight Loss - Caused by poor nutrition and inability of the pancreas to secrete sufficient enzymes to digest food.[baylortransplant.com]
  • The enzymes will help you digest food better, gain weight and reduce diarrhea. Avoid smoking and drinking alcoholic beverages, even if your pancreatitis is mild.[nlm.nih.gov]
Steatorrhea
  • Fats and nutrients are not absorbed properly, leading to loose, greasy stool known as steatorrhea. Weight loss even when eating habits and amounts are normal.[en.wikipedia.org]
  • Signs and symptoms include abdominal pain, malabsorption and diabetes mellitus Inflammation of the pancreas that is characterized by recurring or persistent abdominal pain with or without steatorrhea or diabetes mellitus.[icd9data.com]
  • However, it is possible to have control of pain and steatorrhea with medical, endoscopic, percutaneous or surgical treatment.[hopkinsmedicine.org]
  • Recognition and workup The diagnosis of chronic pancreatitis is obvious in an advanced case with typical features: upper abdominal pains with weight loss; steatorrhea; and, diabetes.[ddc.musc.edu]
  • Exocrine insufficiency may worsen over time, so one should be alert to ask the patient about worsening steatorrhea or weight loss.[clinicaladvisor.com]
Pancreatic Pain
  • KEYWORDS: Chronic pancreatitis; Co-incidence; Lifestyle factors; Liver cirrhosis; Pancreatic pain[ncbi.nlm.nih.gov]
  • Total pancreatectomy with intrahepatic autoislet transplantation (TP/IAT) is a definitive treatment for relentlessly painful chronic pancreatitis. Pain relief is reported to be achieved in approximately 80% of patients.[ncbi.nlm.nih.gov]
  • Abstract Pancreatic pain is the most frequent symptom of chronic pancreatitis (CP) and is difficult to treat.[ncbi.nlm.nih.gov]
  • During median follow-up of 10 years, 68 (76%) experienced pancreatic pain, but only 27 (30%) needed any invasive therapeutic intervention: 23% had endotherapy and 11% had pancreatic surgery.[ncbi.nlm.nih.gov]
  • RESULTS: The number of patients requiring opioids daily for pain control decreased from 16 (80%) prior to surgery to 2 (13%) 1 year after, with only 1 (6.5%) patient experiencing persistent phantom pancreatic pain.[ncbi.nlm.nih.gov]
Skin Lesion
  • Pancreatic panniculitis is a rare skin lesion in pancreatic disease patients. The purpose of this study is to report a case of chronic pancreatitis coexisting with multiple pseudocysts and pancreatic panniculitis.[ncbi.nlm.nih.gov]
Subcutaneous Nodule
  • The patient also developed subcutaneous nodules involving upper and lower limbs, hands, and lower abdomen bilaterally. The patient was diagnosed with pancreatic pseudocyst and pancreatic panniculitis resulted from chronic pancreatitis.[ncbi.nlm.nih.gov]

Workup

The diagnosis of chronic pancreatitis is not easy because the imaging scans and blood tests for this disease are not very specific. Blood tests are used to evaluate the levels of the pancreatic enzymes, the blood sugar and the functioning of the liver and the kidneys. Stool may also be tested for the presence of enzymes and fat. Pancreatic images are checked using computerized tomography, X-rays, magnetic resonance cholangiopancreatography and transabdominalultrasound [7] [8]. 

Pancreatic Calcification
  • calcifications, and pancreatic pseudocysts.[ncbi.nlm.nih.gov]
  • A 64-year-old man with recurrent acute pancreatitis was diagnosed as early CP and later progressed to definite CP with multiple pancreatic calcifications at the age of 69. The etiology of CP in this patient was thought to be idiopathic.[ncbi.nlm.nih.gov]
  • CT Diameter of the main pancreatic duct is greater than 5 mm in the head and 2 mm in the tail Most sensitive for demonstrating pancreatic calcifications Focal enlargement or atrophy of the pancreatic parenchyma Obliteration of the peripancreatic fat usually[learningradiology.com]
  • Of pancreatic calcification on abdominal imaging: Severe protein malnutrition. Hereditary pancreatitis. Hyperparathyroidism.[patient.info]
Pericardial Effusion
  • The diagnosis should be suspected if a patient presents with pericardial effusion on a background of chronic pancreatitis. Significantly raised amylase in the pericardial fluid offers an important clue for the diagnosis.[ncbi.nlm.nih.gov]
Hypertriglyceridemia
  • . • Systemic disease such as hypertriglyceridemia, possibly hyperparathyroidism • Autoimmune pancreatitis associated with rheumatological diseases such as systemic lupus erythematosus, Sjögren's syndrome and primary biliary cirrhosis.[cnn.com]
  • Hyperparathyroidism associated with chronic pancreatitis Chronic pancreatitis Hypercalcemia Chronic kidney disease Congenital conditions, such as pancreas divisum Ischemia — insufficient blood supply to the pancreas Hyperlipidemia — elevated blood fat levels Hypertriglyceridemia[uvahealth.com]
  • Prevention of Pancreatitis Gallstone Pancreatitis – surgical removal of the gall bladder Alcohol/tobacco induced Pancreatitis – strict abstinence from alcohol and/or tobacco Drug Induced Pancreatitis – avoid offending medication Hypertriglyceridemia[patients.gi.org]
  • Other causes of chronic pancreatitis are: hereditary disorders of the pancreas cystic fibrosis-the most common inherited disorder leading to chronic pancreatitis hypercalcemia-high levels of calcium in the blood hyperlipidemia or hypertriglyceridemia-high[gi.surgery.ucsf.edu]
  • […] gallstones or pancreatic stones cystic fibrosis, which is a hereditary disease that causes mucus to build up in your lungs genetics high blood levels of calcium, which is called hypercalcemia a high level of triglyceride fats in your blood, which is called hypertriglyceridemia[healthline.com]
Thrombocytosis
  • PDAC produces significant inflammatory response with resultant lymphopenia and thrombocytosis. The prognostic role of platelet-lymphocyte ratio (PLR) as a tumor marker has been defined.[ncbi.nlm.nih.gov]
Liver Biopsy
  • Magnetic resonance cholangiopancreatography revealed no new changes, and liver biopsy did not show progression of the periportal fibrosis.[ncbi.nlm.nih.gov]

Treatment

The treatment of chronic pancreatitis has to be started as soon as it is diagnosed. Delay in treatment may cause irreversible damage to the pancreas and lead to chronic pain that is difficult to treat. Most patients experience pain relief by the use of non-opioids like ibuprofen and acetaminophen along with antioxidants. An injection can block the celiac plexus preventing the nerves of the pancreas from reporting pain to the brain.

Surgical options are considered if medical options fail. Lateral pancreaticojejunostomy provides pain relief to nearly 80 percent of the patients. Pancreatic inflammation can also be removed by Whipple's procedure. Total pancreatectomy with islet auto-transplantation provides symptom relief. Antioxidant regimens consisting of a mixture of vitamin C and E, methionine and selenium are used reasonably in the management of oxidative stress in chronic pancreatitis [9].

Prognosis

The prognostic factors related to chronic pancreatitis are the diagnostic age, alcohol consumption, smoking and liver cirrhosis. The survival rate of the people with chronic pancreatitis in a study conducted at an international level was found to be 70% after 10 years of the disease, and 45% after the passage of 20 years. The risk of the development of pancreatic cancer was 4% after 20 years.

Common complications of the disease are the mechanical obstruction of the bile duct and the duodenum, and pseudocyst formation. A pseudocyst collects the pancreatic juice and encloses it within a granular or fibrous tissue. Pseudocysts develop in around 10% of the patients with chronic pancreatitis. Diabetes mellitus and pseudoaneurysm are the other complications of this disease [6].

Etiology

The main cause of chronic pancreatitis is metabolic. Some of the pathological reasons for this disease are intra-ductal obstruction by tumors or stones, toxic metabolites that release cytokines (from the pancreatic acinar cells), necrosis, fibrosis, oxidative stress, ischemia, alcohol consumption and autoimmune disorders. Obstruction of the flow of the pancreatic juice can be congenital or acquired.

Hereditary pancreatitis is an autosomal dominant disorder accounting for 1% of the cases. Cystic fibrosis, an autosomal recessive disorder, accounts for a small number of the cases of chronic pancreatitis. Autoimmune pancreatitis shows the clinical features of an enlarged pancreas, narrowed pancreatic duct, gamma globulin circulation and auto-antibody presence. Causes of the disease in nearly 30% of the cases are idiopathic. Some of the rare congenital causes include pancreas divisum and annular pancreas divisum. Blunt abdominal trauma, resulting from accidents, leads to acquired obstructive chronic pancreatitis. Other causes are hyperlipidemia, hypercalcemia, nutritional pancreatitis and medications [2] [3].

Epidemiology

It is estimated that in industrialized countries, only 3.5 to 10 among 100,000 people develop chronic pancreatitis. This disease mostly develops in the patients aged 30 to 40 years, more commonly in men than in women. It is estimated that every year approximately 87,000 cases of pancreatitis are reported in the hospitals of the United States. Alcohol stimulated disease is mostly seen in males, while idiopathic and hyperlipidemic induction of this disease is usually seen in females [4].

Sex distribution
Age distribution

Pathophysiology

Pancreatic fibrogenesis is a typical response to the injury. The deposition of the extracellular matrix and fibroblast proliferation in the pancreas involves a complex interplay of cytokines, growth factors and chemokines. When there is an injury in the pancreas, the release of the transforming growth factor beta and its local expression stimulates mesenchymal cell growth and increases the synthesis of extracellular matrix proteins like fibronectin, proteoglycans and collagens. There is evidence that chemokines are involved in the beginning and progress of chronic pancreatitis [5].

Prevention

As most of the cases of chronic pancreatitis are due to alcohol overuse, avoiding alcohol can reduce the risk for the development of chronic pancreatitis. The help of a healthcare professional may be needed in severe cases of alcohol dependence [10].

Summary

An inflammation in the pancreas that lasts for a short period is called acute pancreatitis and that which lasts for a longer period is termed chronic pancreatitis. With time, pancreatitis results in damage and scarring of the pancreas. Calcium stones that develop in the pancreas can block the outlet or the pancreatic duct which transfers the pancreatic enzymes and pancreatic juices to the gut. A reduction in the levels of pancreatic enzymes causes maldigestion, whereas a reduction in the pancreatic hormones impairs blood sugar regulation. Low levels of pancreatic enzymes lead to malnutrition due to poor absorption and the loss of a higher amount of fat in the stools. If the blood sugar level is not maintained within the normal limits, diabetes may result [1].

Patient Information

Pancreatic inflammation that has reached a stage of permanent damage to the tissue is termed as chronic pancreatitis. This disease leads to digestive disability and impaired synthesis of pancreatic enzymes.

Obstruction of the pancreatic duct, alcohol abuse and autoimmune disorders are some of the common causes of chronic pancreatitis. Abdominal pain, nausea, vomiting, decreased appetite, exocrine and endocrine dysfunction are some of the symptoms of chronic pancreatitis.

References

Article

  1. Mergener K, Baillie J. Chronic pancreatitis. Lancet 1997; 350:1379.
  2. Pezzilli R. Etiology of chronic pancreatitis: has it changed in the last decade?. World J Gastroenterol. Oct 14 2009;15(38):4737-40.
  3. Ammann RW, Muellhaupt B. The natural history of pain in alcoholic chronic pancreatitis. Gastroenterology 1999; 116:1132.
  4. Cahen DL, Gouma DJ, Nio Y, et al. Endoscopic versus surgical drainage of the pancreatic duct in chronic pancreatitis. N Engl J Med. Feb 15 2007;356(7):676-84.
  5. Del Prato S, Tiengo A. Pancreatic diabetes. Diabetes Reviews 1993; 1:260.
  6. 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.
  7. Schmidt G. Pancreas. In: Differential diagnosis in ultrasound: A teaching atlas, Georg Thieme Verlag, Stuttgart, Germany 2006. p.146.
  8. Luetmer PH, Stephens DH, Ward EM. Chronic pancreatitis: reassessment with current CT. Radiology 1989; 171:353.
  9. Singh VV, Toskes PP. Medical therapy for chronic pancreatitis pain. Curr Gastroenterol Rep 2003; 5:110.
  10. Maisonneuve P, Lowenfels AB, Müllhaupt B, et al. Cigarette smoking accelerates progression of alcoholic chronic pancreatitis. Gut 2005; 54:510.

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Last updated: 2018-06-22 03:02