Chronic Pancreatitis

Normal pancreas: at left: picture of a computerised tomography (CAT Scan) with normal healthy organs; at right: diagrammic presentation
What is chronic pancreatitis?
Chronic pancreatitis is the chronic (long-term) inflammation of the pancreas.
Repetitive and long-lasting phases of inflammation lead to a progressive
destruction of healthy cells. These are replaced by scar tissue and, as a result, the
pancreas can no longer perform its functions fully.

1. The production of digestive enzymes, which are essential for breaking down food
for absorption into the body ceases. This leads to diarrhoea (often foul-smelling),
weight loss and vitamin deficiency.


 
 
  2. Also, as the pancreas's islet cells are destroyed, less or no insulin is manufactured,
the metabolizing of glucose is disrupted and diabetes mellitus develops.

The main symptom of chronic pancreatitis is severe pains in the upper abdomen.
These pains often radiate around to the patient's back and are probably caused by
changes in the pancreatic nerve tissue, and/or by blocked fluids in the pancreatic
ducts. This will bring about an ever-increasing pressure in the pancreas. Pains can
also be caused by the obstruction of processed foods in stomach and intestines or
massive bloating. Even strong medication can not always eliminate these severe pains.

 
 
 
 
 
 
 
 
 
 
Main duct of the pancreas. ERCP-pictures that show different stages of a chronic pancreatitis, increasing from top to bottom.
 
 
 
 
 
 
 
  What are the causes of chronic pancreatitis?
In the west, excessive alcohol consumption is the most common cause (80%) of chronic
pancreatitis. However, not all cases are due to chronic over-consumption. Patients
have varying degrees of alcohol tolerance, and in some cases the disease is triggered
when consuming relatively small amounts.

Besides alcohol, there are other important causes for the disease. These include
chronic gallstones, genetic defects, certain conditions in the pancreatic ducts (pancreas
divisum), medication and disorders of the metabolism. Sometimes, no particular cause
can be found.

 

 
  What are the most frequently encountered symptoms of chronic pancreatitis?
- Pains
- Bloating
- Diarrhea
- Weight loss
- Diabetes mellitus
 
  Pictures of a Chronic Pancreatitis
 
Picture of a computerised tomography (CAT Scan) or a sketch show a enlarged pancreatic
duct in the body of the pacnreas, with calcination.
 
This picture of a computerised tomography (CAT Scan) or the sketch show a cyste at the tail
of the pancreas.
 
  The Treatment of Chronic Pancreatitis
Treatment is determined by the patient's symptoms. Often, patients suffer from
almost unbearable pains in the upper abdomen. Alcohol consumption must be
discontinued as a first measure. Pancreatic enzyme supplements can then be taken,
alleviating the condition by suppressing pancreatic secretions (thus relieving the
pressure on the pancreas) and restoring the digestive process. If this does not
alleviate pains, medication should be the next option. Failing this, surgery must be
considered.

Fatty deposits in the stool and/or diarrhea are proof that the pancreas is not
producing sufficient digestive enzymes. These must be substituted with a regular
intake of an appropriate medication. The presence of the condition may also be
verified by a pancreatic enzyme (elastase) found in the patient's stool.

Fat content of the meal will determine how many capsules containing enzymes need
to be taken. To ensure that these have the desired effect it is often necessary to
inhibit the stomach's natural acid production with acid-blocking medication. It is also
vital to ensure the patient takes a sufficient amount of fat-soluble vitamins (A, D, E K).
In some severe cases, these may have to be injected. A blood test will show whether
this is necessary.

A rising blood sugar level is proof that not enough insulin is produced in the pancreas.
Dietary measures alleviate this condition in a few cases only. Usually patients need
to take additional doses of insulin on a regular basis to regulate blood sugar levels.

 
 
  Calcification (arrow) with a chronic pancreatitis.
 
  When is an operation required?
50% of patients with chronic pancreatitis will require surgery at some point. As the
procedures are very complicated, pancreatic surgery will usually be performed in
specialized clinics. There are several reasons where surgery is necessary:

1. Pain management is unsuccessful, even when using the most potent medication.

2. A chronically inflamed pancreas affects surrounding organs such as the duodenum
(constraint or blockage), the bile duct, the main pancreatic duct and blood vessels
behind the pancreas.

3. Suspicion that pancreatic cancer lies behind the condition.

Pseudo-cysts (cavities filled with fluids, caused by inflammation) are sometimes found.
Filled with pancreatic fluids, they are located next to or in the pancreas and will often
vanish without medical intervention. However, they can become enlarged and will
cause problems locally. They must be surgically removed or drained. The best time to
have the operation has to be discussed with an experienced pancreatic surgeon who
will determine the proper timing for surgery. A timely removal will restore the functions
of the pancreas (digestion, blood sugar control).

 
  What happens during surgery?
Pancreatic surgery is subdivided into 2 types: removal or draining. The nature of
the pathological changes in the pancreas will determine which is the preferred route.
When using surgical draining the physician opens the main pancreatic duct fully and
connects the pancreas to the small intestine. This enables pancreatic juices to flow
directly into the intestines. If a cyst is found, it is opened and connceted to the small
intestine and blocked fluids are released.

Often, recurring inflammations will have reduced organ function to such an extent
that this procedure will not permanently improve the condition. If pains persist,
damaged sections of the organ will be removed permanently.

The head (usually most severely affected) will be removed first. Surgeons will
proceed with utmost caution, removing only badly damaged tissue. Neighboring
organs such as the duodenum, gall ducts and stomach are not affected during the
operation.

In special circumstances removal of these organs may be necessary as well. The tail
piece of the pancreas may be removed if inflamed. This is done if possible spleen.
After removing damaged pancreatic tissue, a section of small intestine will be sewn
on to the remaining part of the pancreas, so digestive fluids can be released.

Pancreatic surgery is extremely demanding and technically difficult. It should
therefore only be performed by qualified surgeons in larger and specialized clinics.

 
  Part of my pancreas has been removed - what next?
Patients who have had part or the all of their pancreas removed experience a
reduction of pancreas function, depending on how much of the organ had to be
removed. This will cause the following deficiencies:

- Not enough pancreatic enzymes (digestive disorders)
- Insufficient insulin production (high blood-sugar levels)

These deficiencies can be compensated for by taking appropriate medication.

1. Pancreatic Enzyme Substitution
At present, drugs which substitute pancreatic enzymes are available. They must be
taken with all meals and snacks. Correct doses vary from patient to patient and are
determined by nature of food taken and by symptoms present in the patient. Bloated
feelings and diarrhoea with excess fatty substances can be addressed and handled
with these drugs. More capsules need to be taken with main meals than with
snacks. Enzymes must be in direct contact with food in order to be effective and
6-12 capsules per day are needed. The doses may vary significantly and are
governed by the nature of the drug (amount of enzymes contained in one capsule)
and the remaining function of the pancreas.

Substitute enzymes are readily absorbed into the body and patients do not suffer
any side-effects. In very rare cases, the drug can cause an allergic reaction.

2. Insulin Substitution
If a pancreatic disorder or surgery has caused high blood sugar levels, patients will
require some form of blood sugar level correction. Initially, and if levels are not
severely elevated, this can be achieved by dietary measures and with medication
which influence blood glucose levels. However, insulin treatment may be
necessary if the amount on insulin producing cells in the pancreas has been reduced
significantly. Treatment can be tailor-made to the requirements of the individual
patient, as a variety of insulin types are now available. Thus, the patient's nutritional
preferences can be respected. The goal of any such treatment is the well-being of
the patient and efficient management of blood sugar levels. In this manner, doctors
can avoid severe damage over the short and longer term. Close supervision by a GP or
specialist is required in the initial phase of the treatment.

 
  My spleen has been removed - what next?
Sometimes the spleen is removed during pancreatic sugery.

It is quite possible to live without a spleen. The spleen plays a certain role in the
human immune system. If it is removed, a person is more susceptible to bacterial
infections. To provide protection against infection after removal of the spleen, the
patient should be given certain inoculations after the operation. According to current
guidelines, these inoculations should be repeated every 3 to 5 years. In addition, the
patient should always seek medical help if he contracts a serious infection, and tell
the doctor that he or she no longer has a spleen. The doctor can then decide
whether treatment with antibiotics is required.

The removal of the spleen can also lead to a build-up of blood platelets (thrombo-
cytes). It is important to have this situation regularly monitored. If the number of
platelets is too high, this can lead to the thickening of the blood and a possible
thrombosis. If the level is too high, your doctor will prescribe a temporary course of
medication to thin the blood, in order to reduce the risk of thrombosis.