Chronic Pancreatitis

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | Referral

Definition

Chronic pancreatitis is a progressive inflammatory condition of the pancreas characterised by irreversible damage, fibrosis, and loss of exocrine and endocrine function.

Aetiology

Common causes include:

  • Alcohol misuse: most common cause in adults.
  • Idiopathic: no identifiable cause in a significant proportion of cases.
  • Genetic mutations: such as CFTR mutations (e.g., in cystic fibrosis).
  • Autoimmune pancreatitis.
  • Obstructive causes: pancreatic duct obstruction (e.g., stones, strictures, tumours).
  • Recurrent acute pancreatitis: leading to chronic changes over time.

Pathophysiology

Chronic inflammation and damage to the pancreas result in:

  • Fibrosis and calcification of the pancreatic tissue.
  • Atrophy of acinar cells, leading to reduced enzyme production.
  • Loss of endocrine function, resulting in diabetes mellitus in later stages.
  • Blockage of pancreatic ducts by strictures or stones, worsening inflammation.

Risk factors

  • Excessive alcohol consumption.
  • Recurrent episodes of acute pancreatitis.
  • Family history of pancreatitis.
  • Smoking.
  • Autoimmune diseases.
  • Gallstones (less common than in acute pancreatitis).

Signs and symptoms

Symptoms:

  • Recurrent or persistent epigastric pain radiating to the back.
  • Pain often worsened by eating or drinking.
  • Steatorrhoea (fatty stools) due to malabsorption.
  • Weight loss due to poor absorption of nutrients.
  • Diabetes mellitus in advanced disease.

Signs:

  • Tenderness in the epigastric region.
  • Signs of malnutrition (e.g., muscle wasting).
  • Jaundice if bile duct obstruction is present.

Investigations

  • Blood tests:
    • Amylase and lipase: could be normal or slightly raised.
    • Fasting glucose or HbA1c: to diagnose/rule out diabetes.
    • Serum calcium and triglycerides: to exclude other causes of pancreatitis.
  • Faecal elastase: a marker of pancreatic exocrine insufficiency.
  • Imaging:
    • Abdominal ultrasound: may show pancreatic calcifications or ductal dilatation.
    • CT scan: for identifying calcifications, ductal changes, or masses.
    • Magnetic Resonance Cholangio-pancreatography (MRCP) a form of MRI scan: to evaluate pancreatic ducts and exclude obstructive causes.
    • Endoscopic ultrasound (EUS): for detailed visualisation and tissue sampling if needed.

Management

1. Lifestyle Modifications:

  • Alcohol cessation: to slow disease progression and reduce pain.
  • Smoking cessation.

2. Pain Management:

  • Paracetamol or NSAIDs: for pain relief.
  • Opioids: for severe pain but use cautiously due to dependency risk.

3. Nutritional Support:

  • Pancreatic enzyme replacement therapy (PERT): for example Creon to aid digestion and reduce steatorrhoea.
  • Vitamin supplementation: fat soluble vitamins (A, D, E, K) if malabsorption is present.
  • High-calorie, low-fat diet with small, frequent meals.

4. Diabetes Management:

  • Regular monitoring of blood glucose levels.
  • Insulin therapy if pancreatic endocrine insufficiency occurs.

5. Endoscopic or Surgical Interventions:

  • ERCP: for removing pancreatic duct stones or stenting strictures.
  • Surgical drainage: indicated for large pseudocysts or refractory pain.
  • Pancreatectomy: for severe cases with unmanageable symptoms.

Referral

Refer to secondary care or specialist services for the following:

  • Severe pain unresponsive to medical management.
  • Signs of pancreatic duct obstruction or pseudocysts requiring intervention.
  • New-onset diabetes or significant malabsorption.
  • Suspected pancreatic cancer (urgent referral).
GastroenterologymypanotesChronic Pancreatitis