Chronic pancreatitis

Long-term alcohol misuse is behind around 7 out of every 10 cases of chronic pancreatitis. This is because heavy drinking over a number of years can repeatedly damage the pancreas.

Less common causes include:

• smoking
• a problem with the immune system, causing it to attack the pancreas
• an inherited genetic mutation disrupting the functions of the pancreas

In as many as 3 out of 10 people with the condition, the cause cannot be identified; this is known as "idiopathic" chronic pancreatitis.

Read more about the causes of chronic pancreatitis.

Who's affected

Chronic pancreatitis can affect people of any age, but it is most common in middle-aged men between 45 and 54 years old.

Causes of chronic pancreatitis

Most cases of chronic pancreatitis are linked to drinking excessive amounts of alcohol over a long period of time.

However, in up to 3 out of 10 people with the condition, the cause cannot be identified; this is known as "idiopathic" chronic pancreatitis.

Alcohol consumption

Heavy drinking over many years can cause repeated episodes of acute pancreatitis. Acute pancreatitis is usually a short-term condition, but it can come back again and again if you continue to drink alcohol.

Over time, this repeated inflammation causes permanent damage to the pancreas, resulting in chronic pancreatitis.

Anyone who drinks alcohol regularly has an increased risk of chronic pancreatitis, although only a minority go on to develop the condition.

Read more about alcohol misuse.

Problems with the immune system

Rare cases of chronic pancreatitis happen because of a problem with the immune system, which causes it to attack the pancreas. This is known as "autoimmune pancreatitis," and it is not entirely clear why it happens.

Many people with autoimmune pancreatitis also have other conditions caused by the immune system attacking healthy tissue. These include ulcerative colitis or Crohn's disease, both of which cause inflammation inside the digestive system.

Genetics

Some cases of chronic pancreatitis are inherited. This is thought to be caused by mutations, or alterations, in a number of genes, including genes called PRSS1 and SPINK-1. These mutations disrupt the normal working of the pancreas.

Genetic mutations may also play a role in how alcohol affects your pancreas. Evidence suggests that certain genetic mutations make the pancreas more vulnerable to the harmful effects of alcohol.

Certain mutations of the CFTR gene, which is responsible for cystic fibrosis, are also thought to cause chronic pancreatitis in a small number of cases.

Other causes

Several other rare causes of chronic pancreatitis have also been identified, including:

• injury to the pancreas
• blocked or narrowed openings (ducts) of the pancreas
• smoking
• radiotherapy to the abdomen (tummy)

Chronic pancreatitis usually can only be confirmed by taking scans of the pancreas.

Your doctor will first ask about your symptoms and may do a simple physical examination. If chronic pancreatitis is suspected, you will be referred for further tests, which are usually done at your local hospital. These may include:

• a stool sample test
• an ultrasound scan, which uses sound waves to build up a picture of the inside of your pancreas
• a computerised tomography (CT) scan, which uses a series of X-rays to build a more detailed, three-dimensional image of the pancreas
• an endoscopic ultrasonography
• a magnetic resonance cholangiopancreatography, known as MRCP

Endoscopic ultrasonography

For this test, a thin, flexible telescope called an endoscope is passed through your mouth towards your stomach. An ultrasound probe attached to the tip of the endoscope can get close to the pancreas and take very accurate pictures of it.

You will usually be given a sedative to help you stay relaxed during the procedure.

MRCP

An MRCP involves injecting a substance called a contrast agent, which makes your pancreas and nearby organs, such as the gallbladder and liver, show up clearly on a magnetic resonance imaging (MRI) scanner.

An MRI scanner uses magnetic fields and radio waves to build a detailed image of the inside of your body.

MRCP is particularly useful for checking whether gallstones may be contributing to your symptoms.

Biopsy

The symptoms of chronic pancreatitis can sometimes look very similar to those of pancreatic cancer. So if you have symptoms such as jaundice (yellowing of the skin and the whites of the eyes) along with weight loss, your doctor may recommend a biopsy to rule out pancreatic cancer.

A biopsy involves taking a small sample of cells from the pancreas and sending it to a laboratory, where it is examined under a microscope for cancerous cells.

This sample is usually taken with a long, thin needle passed through your abdomen, guided towards the affected area using an ultrasound or CT scan. In some cases, the sample can instead be taken during an endoscopic ultrasonography.

In most cases of chronic pancreatitis, there is no specific treatment that can reduce the inflammation or repair the damage already done to the pancreas.

Treatment mainly focuses on lifestyle changes and medicines to relieve pain. Surgery is sometimes needed to treat severe, long lasting pain that does not respond to painkillers.

That said, the pain can be difficult to treat and can seriously affect your quality of life.

People who do not smoke cigarettes and avoid drinking alcohol tend to experience less pain and live longer than those who continue to drink and smoke after they are diagnosed.

Read more about treating chronic pancreatitis.

Treating chronic pancreatitis

Treatment for chronic pancreatitis aims to help control the condition and reduce any symptoms.

Lifestyle changes

If you are diagnosed with chronic pancreatitis, your doctor will recommend some changes to your daily habits and routine.

Surgery

Surgery can be used to treat severe pain in people with chronic pancreatitis. Depending on the exact cause of your pain, there are a variety of surgical techniques that may be used.

Endoscopic surgery

Patients who have stones in the opening of their pancreas, known as the pancreatic duct, may benefit from endoscopic surgery along with a treatment called lithotripsy.

Lithotripsy involves using shock waves to break the stone into smaller pieces. An endoscope, which is a long, thin, flexible tube with a light source and a video camera at one end, is then used to pass surgical instruments into the pancreatic duct so the pieces can be removed.

This treatment may improve pain to some extent, but the benefit may not be permanent.

Pancreas resection

In cases where specific parts of the pancreas are inflamed and causing severe pain, these parts can be surgically removed. This type of surgery is called a pancreas resection.

Pancreas resection can also be used if endoscopic treatment has not worked.

The technique used for pancreas resection depends on exactly which parts need to be removed. For example, some techniques involve removing the gallbladder along with parts of the pancreas.

The different surgical techniques tend to work about equally well in terms of reducing pain and preserving the function of the pancreas, although some of the more complex techniques carry a higher risk of complications, such as infection and internal bleeding. Simpler procedures carry a lower risk of complications and usually allow for faster recovery.

It is worth discussing the pros and cons of the appropriate pancreas resection techniques with your surgical team before making a decision.

Total pancreatectomy

In the most serious cases of chronic pancreatitis, where the pancreas has been extensively damaged, it may be necessary to remove the entire pancreas. This is known as a total pancreatectomy.

A total pancreatectomy can be very effective in treating pain. However, you will no longer be able to produce the insulin your body needs. To get around this problem, doctors sometimes use a relatively new technique called autologous pancreatic islet cell transplantation, or APICT.

During APICT, the islet cells responsible for producing insulin are removed from your pancreas before it is surgically taken out.

These islet cells are mixed with a special solution, which is then injected into your liver. If the procedure is successful, the islet cells settle in your liver and begin producing insulin there.

In the short term, APICT appears to work well, but you may still need additional insulin treatment in the long run. You can see guidelines from the National Institute for Health and Care Excellence, known as NICE, about autologous pancreatic islet cell transplantation for more information.

Avoiding alcohol

The most important thing you can do is to stop drinking alcohol, even if it isn’t the cause of your condition. This helps to prevent further damage to your pancreas and may help to reduce the pain.

If you continue to drink alcohol, it’s likely that you’ll experience debilitating pain and you’ll be more likely to die from a complication of chronic pancreatitis.

Some people with chronic pancreatitis caused by alcohol consumption have a dependency on alcohol and require additional help and support to stop drinking. If this applies to you, talk to your GP about getting help to stop drinking.

Treatment options for alcohol dependence include:

• one-to-one counselling
• self-help groups – such as Alcoholics Anonymous
• a medication called acamprosate that can help to reduce cravings for alcohol

Read more about treating alcohol misuse.

Stopping smoking

If you smoke, you should stop. Smoking can speed up the progress of chronic pancreatitis, making it more likely that your pancreas will lose its function.

It’s recommended that you use an anti-smoking treatment, such as nicotine replacement therapy (NRT) or bupropion (a medication used to reduce cravings for cigarettes). People who use these types of treatments have a much greater success rate in permanently stopping smoking than those who try to quit using willpower alone.

If you want to give up smoking, it’s a good idea to start by visiting your GP. They’ll be able to give you help and advice about quitting and can refer you to an NHS Stop Smoking support service.

These services offer the best support for people who want to give up smoking. Studies show you are 4 times more likely to give up smoking if you do it through the NHS.

Read more about stopping smoking.

Dietary changes

As chronic pancreatitis can affect your ability to digest certain foods, you may need to change your diet.

Your GP may be able to provide you with appropriate dietary advice, or may refer you to a dietitian, who will draw up a suitable dietary plan.

A low-fat, high-protein, high-calorie diet with fat-soluble vitamin supplements is usually recommended, but don’t make changes to your diet without consulting a health professional.

Enzyme supplements

You may be given pancreatic enzyme supplements, which is medication containing an artificial version of the enzymes produced by your pancreas. These supplements may help to improve the effectiveness of your digestive system.

Side effects of pancreatic enzyme supplements can include diarrhoea, constipation, nausea, vomiting and stomach pains.

Talk to your GP if you’re experiencing troublesome side effects, as your dosage may need to be adjusted.

Steroid medication

If you have chronic pancreatitis caused by problems with your immune system, treatment is relatively straightforward. The inflammation affecting the pancreas can usually be relieved using steroid medication (corticosteroids).

However, taking corticosteroids for a long time can cause side effects, such as osteoporosis and weight gain.

Pain relief

Pain relief is an important part of the treatment of chronic pancreatitis. At first, mild painkillers will be used, but more powerful ones will be needed if these don’t work.

Mild painkillers

In most cases, the first painkiller used is paracetamol or a non-steroidal anti-inflammatory drug (NSAID), such as ibuprofen.

Taking NSAIDs on a long-term basis can increase your risk of developing stomach ulcers, so you may be prescribed an additional medication called a proton pump inhibitor (PPI) to protect against this.

Stronger painkillers

If NSAIDs or paracetamol prove to be ineffective in controlling your pain, it’s likely that you’ll need an opiate-based painkiller, such as codeine or tramadol. Side effects of these types of medication can include constipation, nausea, vomiting and drowsiness.

The side effect of constipation can be particularly troublesome if you need to take an opiate-based painkiller on a long-term basis. You may be prescribed a laxative to help relieve your constipation.

See the page on treating constipation for more information.

If you feel drowsy after taking an opiate-based painkiller, avoid driving and using heavy tools or machines.

Severe pain

If you experience an attack of very severe pain, you may need a stronger opiate-based painkiller, such as morphine or pethidine. These have similar side effects to opiate-based painkillers.

Long-term use of these stronger opiate-based painkillers isn’t usually recommended, because there’s a high risk of addiction. Therefore, if you have persistent severe pain, surgery is usually recommended.

In some cases, an additional medication called amitriptyline may be recommended. Amitriptyline was originally designed to treat depression, but it can help to relieve pain in some people.

If medication isn’t effective, severe pain can sometimes be temporarily relieved for a few weeks or months using a procedure called a nerve block. This is an injection that blocks the pain signals from the pancreas.

Severe episodes

If the inflammation of your pancreas suddenly gets worse, you may need a short stay in hospital for treatment.

This may involve having fluids delivered directly into a vein, and oxygen supplied through tubes into your nose.

Read more about treating acute pancreatitis.

Living with ongoing pain can wear you down mentally as well as physically. If chronic pancreatitis is leaving you feeling stressed, anxious or low, it is worth talking to your doctor about it.

Diabetes is a common complication, affecting around a third of people with chronic pancreatitis. It develops when the pancreas is damaged and can no longer produce enough insulin.

People with chronic pancreatitis also face a higher risk of pancreatic cancer.

Here is more on the possible complications of chronic pancreatitis.

Complications of chronic pancreatitis

Complications are fairly common with this condition, and they usually come from either living with long-term pain or from damage to the pancreas itself.

Psychological effects of chronic pancreatitis

Any long-term health condition, especially one that brings recurring or constant pain, can take a toll on your emotional wellbeing. The International Association for the Study of Pain found that as many as 94% of people with chronic pancreatitis live with pain.

One study of people with the condition found that about one in seven had some form of psychological or emotional difficulty, such as stress, anxiety or depression.

Do speak to your doctor if you are struggling emotionally. There are effective treatments that can ease stress, anxiety and depression. Joining a support group for people with chronic pancreatitis can also help, since talking to others facing the same condition often eases feelings of isolation and stress.

Diabetes

Around a third of people with chronic pancreatitis go on to develop diabetes, usually many years after their diagnosis. In fact, it is not unusual for 20 years to pass before diabetes appears.

Diabetes develops once the pancreas is no longer able to produce insulin, the chemical the body needs to turn glucose into energy. The main symptoms to watch for are:

• feeling very thirsty
• needing to urinate often, especially at night
• extreme tiredness
• weight loss and muscle wasting (loss of muscle bulk)

If you develop diabetes as a result of chronic pancreatitis, you will likely need regular insulin injections to make up for what your body can no longer produce on its own.

Pseudocysts

Pseudocysts, fluid filled sacs that form on the surface of the pancreas, are another common complication, affecting around 1 in 10 people with chronic pancreatitis.

Often, pseudocysts cause no symptoms at all and are only picked up during a CT (computerised tomography) scan. In some people, though, they can cause:

• bloating
• indigestion
• a dull ache in the abdomen

If the pseudocysts are small and symptom free, treatment may not be needed, since they usually go away on their own. Treatment is generally recommended when symptoms are present or when a pseudocyst grows larger than 6cm (2.3 inches) across, since larger ones carry a risk of bursting, which can lead to internal bleeding or infection.

Treatment usually involves draining the fluid from the cyst, either by inserting a needle through the skin or through an endoscopy, where a thin flexible tube (an endoscope) is passed down the throat so tiny tools can drain the fluid away.

In some cases, part of the pancreas is removed using laparoscopic, or keyhole, surgery, known as a laparoscopic distal pancreatectomy. You can read the guidelines on this procedure from the National Institute for Health and Care Excellence (NICE).

Pancreatic cancer

Chronic pancreatitis does raise the risk of pancreatic cancer, though the increase is relatively small. For example, out of every 100 people with chronic pancreatitis, only 1 or 2 will go on to develop pancreatic cancer.

The early symptoms of pancreatic cancer closely resemble those of chronic pancreatitis, including jaundice, abdominal pain and weight loss.