Chronic Pancreatitis
Summary
Chronic Pancreatitis is a progressive, irreversible inflammatory condition leading to fibrosis and scarring of the pancreas. This results in the loss of both Exocrine function (Digestion) and Endocrine function (Insulin/Glucagon). Alcohol misuse accounts for 70-80% of cases in the West. The hallmark is chronic, disabling epigastric pain and malnutrition. [1,2]
Clinical Pearls
The "Burn Out" Phenomenon: In late-stage disease (>10 years), the pain often disappears ("burns out") because the fibrotic pancreas simply destroys its own nerve endings. However, by this point, the patient usually has brittle diabetes and severe malabsorption.
Creon Dosing: A common error is under-dosing Creon. Patients need 25,000 - 50,000 units per meal. One capsule is rarely enough. Tell them to take it during the meal, not before (acid deactivates it) or after (food is already gone).
Cancer Risk: Chronic pancreatitis increases the risk of pancreatic adenocarcinoma by 15-20 fold. If the pain pattern changes or weight loss accelerates, scan them.
Causes (TIGAR-O System)
- Toxic-Metabolic: Alcohol (70%), Smoking (accelerates damage), Hypercalcaemia.
- Idiopathic: Early onset vs Late onset.
- Genetic: CFTR (Cystic Fibrosis), SPINK1, PRSS1 (Hereditary Pancreatitis).
- Autoimmune (AIP): IgG4 related disease.
- Recurrent Acute Pancreatitis.
- Obstructive: Strictures, Tumour, Pancreas Divisum.
Mechanism
- Chronic inflammation leads to activation of Pancreatic Stellate Cells -> Fibrosis.
- Acinar cells (enzyme producers) atrophy first -> Exocrine Insufficiency.
- Islet cells (insulin producers) destruct later -> Type 3c Diabetes.
- Ductal calcification and stones form ("Chain of Lakes").
| Condition | Features |
|---|---|
| Chronic Pancreatitis | Radiates to back. Relieved by leaning forward. Steatorrhoea. |
| Pancreatic Cancer | Painless jaundice (head) or back pain (body). Cachexia. |
| Peptic Ulcer | Meal related pain. NSAID use. |
| Biliary Colic | RUQ pain. Meal triggered (fatty). |
| Gastroparesis | Vomiting. Early satiety. Diabetic history. |
The Classic Triad (End Stage)
- Calcification: Visible on X-ray/CT.
- Steatorrhoea: Pale, fatty, floating, foul-smelling stools.
- Diabetes: Type 3c.
Symptoms
Imaging
- CT Pancreas: Gold standard. Shows atrophy, calcifications, and ductal dilatation ("Chain of Lakes").
- MRCP: Better for visualizing biliary/pancreatic ducts.
- Endoscopic Ultrasound (EUS): Most sensitive for early changes ("Rose thorn" fibrosis).
Function Tests
- Faecal Elastase-1: Low (less than 200 mcg/g) indicates Exocrine Insufficiency.
- Why Elastase? It is not degraded by the gut, so stool levels reflect pancreatic output accurately.
- HbA1c: Screen for diabetes.
Management Algorithm
CHRONIC PANCREATITIS
(Pain + Weight Loss + Steatorrhoea)
↓
LIFESTYLE: STOP ALCOHOL (Crucial)
STOP SMOKING
↓
DIET & ENZYMES (Creon)
- High Calorie, Normal Fat (!)
- Creon 40,000-50,000U with meals
- Creon 25,000U with snacks
- PPI (prevents acid destroying Creon)
↓
PAIN CONTROL
- Paracetamol / NSAIDs
- Neuropathic (Amitriptyline/Pregabalin)
- AVOID OPIOIDS if possible (addiction)
↓
PAIN PERSISTS?
┌───────────┴───────────┐
ANATOMICAL PAIN ONLY
PROBLEM (No dilatation)
(Dilated duct/Stone) ↓
↓ COELIAC PLEXUS
ENDOSCOPY / SURGERY BLOCK (EUS)
(Stenting / Drainage) (Temporary)
↓
FREY'S PROCEDURE
(Coring out head)
1. Diet and Enzymes
- Previously, low fat diets were advised. This is WRONG. Patients are starving. They need a high fat/calorie diet, covered by adequate Enzyme Replacement Therapy (PERT).
- Creon/Pancrex: Contains Lipase/Amylase/Protease.
2. Surgery (Decompression)
- Lithotripsy: For large duct stones.
- Puestow Procedure: Longitudinal Pancreaticojejunostomy (filleting the duct open into the bowel) for dilated ducts.
- Frey's Procedure: Coring out the fibrotic head + Puestow.
- Splanchnicectomy: Nerve cutting for pain control.
3. Total Pancreatectomy with Islet Auto-Transplantation (TPIAT)
- Radical option. Remove entire pancreas. Isolate islet cells in lab. Inject them into the patient's liver portal vein so they still produce insulin.
- Pancreatic Pseudocyst: Fluid collection.
- Biliary Stricture: Jaundice.
- Duodenal Obstruction: Vomiting.
- Pancreatic Cancer.
- Osteoporosis: Due to Vit D malabsorption.
- Opioid Addiction.
- Reduced life expectancy (mostly due to smoking/alcohol related cancers and CVD).
- 10-year survival ~70%.
- Quality of life is often very poor due to chronic pain.
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| Chronic Pancreatitis | NICE NG104 (2018) | Offer PERT to all sympotmatic patients. Do not restrict fat. |
| Hape classification | UEG | United European Gastroenterology guidelines. |
Landmark Evidence
1. Low Fat Myth
- Studies confirm that restricting fat worsens malnutrition. The solution is MORE enzymes, not LESS fat.
What is Chronic Pancreatitis?
The pancreas is damaged and scarred, usually from long-term inflammation. It becomes hard and stops working properly.
Why does it hurt?
The scarring traps the nerves and blocks the tubes (ducts) that carry digestive juices. This builds up pressure, causing severe tummy and back pain.
What are the digestive problems?
The pancreas makes juices to digest food. Without them, food (especially fat) passes straight through you. This causes oily, smelly diarrhoea and weight loss because you aren't absorbing calories.
What can I do?
- Stop Drinking Alcohol: This is the single most important thing to stop the damage getting worse.
- Take Creon: You must take these enzyme capsules with every mouthful of food to carry out the digestion your pancreas can't do.
- Stop Smoking: Smoking speeds up the scarring.
Primary Sources
- NICE. Pancreatitis (Chronic) (NG104). 2018.
- Kleeff J, et al. Chronic pancreatitis. Lancet. 2017.
- Löhr JM, et al. United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis (HaPanEU). United European Gastroenterol J. 2017.
Common Exam Questions
- Diagnosis: "Test for exocrine function?"
- Answer: Faecal Elastase.
- Investigation: "Imaging for calcification?"
- Answer: CT (or plain Abdo X-ray).
- Complication: "Diabetic type?"
- Answer: Type 3c (Brittle, insulin dependent, risk of hypos as no Glucagon either).
- Management: "Vitamin deficiency?"
- Answer: Fat soluble vitamins (A, D, E, K).
Viva Points
- Autoimmune Pancreatitis: Type 1 (IgG4 related, older men, sausage pancreas, steroids work) vs Type 2 (IBD related).
- Chain of Lakes: Describe the appearance on MRCP (dilated duct with strictures).
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.