Chronic pancreatitis

Chronic pancreatitis is a condition where the pancreas becomes permanently damaged by inflammation. The pancreas is a small organ behind the stomach and below the ribcage. Chronic pancreatitis is different from acute pancreatitis, where the inflammation lasts only a short time.

The most common symptom is repeated episodes of abdominal (tummy) pain, and the pain can be severe. Other symptoms tend to appear as the damage to the pancreas gets worse, such as passing greasy, foul-smelling stools.

Always see a doctor if you have severe pain. It's a warning sign that something is wrong, and with chronic pancreatitis you shouldn't wait it out.

Long-term alcohol misuse causes around 7 out of every 10 cases of chronic pancreatitis. Heavy drinking over a number of years can damage the pancreas again and again, and that's how the condition develops.

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 chronic pancreatitis, the cause cannot be found. Doctors call this 'idiopathic' chronic pancreatitis.

Chronic pancreatitis can affect people of any age. It's most common in middle-aged men, especially those between 45 and 54.

In most cases of chronic pancreatitis, there's no specific treatment that reduces the inflammation or repairs the damage to the pancreas.

Treatment mainly rests on lifestyle changes and medicine to relieve the pain. Sometimes surgery is needed for severe chronic pain that doesn't respond to painkillers.

Even so, the pain of chronic pancreatitis can be hard to treat, and it can seriously affect your quality of life.

People who don't smoke cigarettes and who avoid drinking alcohol tend to have less pain and live longer than those who keep drinking and smoking after they've been diagnosed.

Living with chronic pain strains the mind as well as the body. If you're feeling stressed, anxious or depressed because of chronic pancreatitis, speak to your doctor.

Diabetes is a common complication of chronic pancreatitis, and it affects about a third of people with the condition. It happens when the pancreas is damaged and can no longer produce insulin.

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

The most common symptom of chronic pancreatitis is repeated episodes of abdominal (tummy) pain. Digestion problems may come on later.

The pain usually starts in the middle or left side of the abdomen, and it can sometimes travel along your back. People describe it as a burning or shooting pain that comes and goes. In some cases an episode can last for several hours or even days.

Some people also have nausea and vomiting while the pain is there. As chronic pancreatitis gets worse, the painful episodes may become more frequent and more severe.

The pain sometimes comes after a meal, but often there's no trigger at all.

In time, a constant mild to moderate pain can develop in the abdomen between the episodes of severe pain. This is most common in people who keep drinking alcohol after they've been diagnosed with chronic pancreatitis.

Some people who stop drinking alcohol and stop smoking find that their pain becomes less severe.

Sometimes the pancreas stops making the digestive juices that help break down food. This usually happens many years after the first symptoms of chronic pancreatitis appeared.

Without these juices, your digestive system finds it hard to break down fats and certain proteins. Your stools can become particularly smelly and greasy, and they may be difficult to flush down the toilet.

You may also have:

• weight loss
• loss of appetite
• jaundice (yellowing of the skin and eyes)
• symptoms of diabetes, such as feeling very thirsty, urinating frequently and feeling very tired
• ongoing nausea and vomiting

If you have severe pain, see your doctor. Pain like this is a warning sign that something is wrong, so don't put it off.

See your doctor too if you notice symptoms of jaundice. Jaundice can have causes other than pancreatitis, but it usually means something is wrong with your digestive system.

You should also see a doctor if you have persistent vomiting.

Most cases of chronic pancreatitis are linked to drinking too much alcohol over a long time. But in up to 3 out of 10 people with the condition, doctors can't find the cause. This is known as "idiopathic" chronic pancreatitis.

Drinking heavily over many years can cause repeated episodes of acute pancreatitis. Acute pancreatitis is usually short-term, but it can come back if you keep drinking alcohol.

Each time the pancreas becomes inflamed, it takes some damage. Over time this adds up to permanent damage, and the result is chronic pancreatitis.

Anyone who drinks alcohol regularly has a higher risk of chronic pancreatitis, though only a minority of them go on to develop it.

In a small number of cases, chronic pancreatitis happens because of a problem with the immune system, which turns on the pancreas and attacks it. This is called autoimmune pancreatitis, and doctors don't know exactly why it happens.

Many people with autoimmune pancreatitis also have other conditions where the immune system attacks healthy tissue. These include ulcerative colitis and Crohn's disease, and both of them cause inflammation inside the digestive system.

Some cases of chronic pancreatitis run in families. This is thought to happen because of mutations (alterations) in a number of genes, including the ones called PRSS1 and SPINK-1. These mutations disrupt the normal working of the pancreas.

Genes may also play a part in how alcohol affects your pancreas. The evidence suggests that certain mutations leave the pancreas more open to the harmful effects of alcohol.

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

Doctors have identified a few other rare causes of chronic pancreatitis. These include:

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

Chronic pancreatitis can usually only be diagnosed by scans of the pancreas. Your doctor will ask about your symptoms and may do a simple physical examination. If they suspect chronic pancreatitis, they'll send you for further tests.

These tests are usually done in your local hospital and may include:

• requesting a stool sample
• an ultrasound scan, where sound waves are used to build up a picture of the inside of your pancreas
• a computerised tomography (CT) scan, where a series of X-rays are taken to build up a more detailed, three-dimensional image of the pancreas
• an endoscopic ultrasonography
• a magnetic resonance cholangiopancreatography or MRCP

In endoscopic ultrasonography, the doctor passes a thin, flexible telescope (an endoscope) through your mouth and down towards your stomach. A small ultrasound probe is attached to the tip of the endoscope, so it can get close to the pancreas and take very accurate pictures of it.

You'll usually be given a sedative to help you relax during the procedure.

For an MRCP, you're given an injection of a substance called a contrast agent. It makes your pancreas and the organs around it, such as the gallbladder and liver, show up very clearly on a magnetic resonance imaging (MRI) scanner.

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

An MRCP is a useful way to check whether gallstones may be adding to your symptoms.

Chronic pancreatitis can sometimes cause symptoms that look very much like pancreatic cancer. So if you have jaundice (yellowing of the skin and whites of the eyes) and weight loss, your doctor may suggest a biopsy to rule out pancreatic cancer.

In a biopsy, a small sample of cells is taken from the pancreas and sent to a laboratory. There it is checked under a microscope for cancerous cells.

The sample can be taken with a long, thin needle passed through your abdomen. An ultrasound scan or CT scan can guide the needle towards the tumour. Another way is to take the biopsy during an endoscopic ultrasonography.

Treatment for chronic pancreatitis is meant to keep the condition under control and ease the symptoms you have.

If you're diagnosed with chronic pancreatitis, your doctor will recommend some changes to your lifestyle.

The most important thing you can do with chronic pancreatitis is stop drinking alcohol, even if alcohol isn't what caused your condition. Stopping helps prevent further damage to your pancreas, and it may help reduce the pain.

If you keep drinking, you're likely to have debilitating pain, and you're more likely to die from a complication of chronic pancreatitis.

Some people whose chronic pancreatitis is caused by alcohol have a dependency on it and need extra help and support to stop. If that sounds like you, talk to your doctor about getting help.

Treatment options for alcohol dependence include:

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

If you smoke, you should stop. Smoking can speed up the progress of chronic pancreatitis, which makes 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 medicine used to reduce cravings for cigarettes). People who use these treatments have a much greater success rate in stopping smoking for good than those who try to quit on willpower alone.

If you want to give up smoking, a good first step is to visit your doctor.

Chronic pancreatitis can change how well your body digests certain foods, so you may need to change what you eat.

Your doctor may be able to give you the right dietary advice, or may send you to a dietitian, who will draw up a plan that suits you. A diet that is low in fat, high in protein and high in calories, together with fat-soluble vitamin supplements, is usually recommended. But please don't change your diet without talking to a health professional first.

Your doctor may give you pancreatic enzyme supplements. These are medicines that contain an artificial version of the enzymes your pancreas makes, and they may help your digestive system work better in chronic pancreatitis.

The side effects can include diarrhoea, constipation, nausea, vomiting and stomach pains. If any of these become troublesome, talk to your doctor, because your dosage may need to be adjusted.

If your chronic pancreatitis is caused by a problem with your immune system, treatment is fairly simple. Steroid medicine (corticosteroids) can usually relieve the inflammation in the pancreas.

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

Easing the pain is a big part of treating chronic pancreatitis. Doctors usually start with mild painkillers, and if those don't work, you will need stronger ones.

For most people with chronic pancreatitis, the first painkiller is paracetamol or a non-steroidal anti-inflammatory drug (NSAID), such as ibuprofen.

If you take NSAIDs for a long time, your risk of stomach ulcers goes up. So your doctor may also prescribe a medicine called a proton pump inhibitor (PPI) to protect your stomach.

If NSAIDs or paracetamol don't control your chronic pancreatitis pain, you'll probably need an opiate-based painkiller, such as codeine or tramadol. These medicines can cause constipation, nausea, vomiting and drowsiness.

Constipation can be particularly troublesome if you have to take an opiate-based painkiller over a long period. Your doctor may prescribe a laxative to help relieve it.

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

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

Using these stronger painkillers for a long time isn't usually recommended, because there's a high risk of addiction. So if your severe pain keeps coming back or doesn't go away, surgery is usually recommended.

In some cases, a further medicine called amitriptyline may be recommended. It was first made to treat depression, but it can help to relieve pain in some people.

If medicine isn't working, a procedure called a nerve block can sometimes ease severe pain for a few weeks or months. It's an injection that blocks the pain signals coming from the pancreas.

If the inflammation in your pancreas suddenly gets worse, you may need to stay in hospital for a short time for treatment. You may be given fluids straight into a vein, and oxygen through tubes placed in your nose.

Treatment for this kind of sudden flare is the same as for acute pancreatitis.

Surgery can help when people with chronic pancreatitis have severe pain. Which operation is used depends on exactly what is causing your pain, and there are several different techniques your surgeon may choose from.

People with chronic pancreatitis who have stones in the pancreatic duct (the narrow channel that drains the pancreas) may benefit from endoscopic surgery along with a treatment called lithotripsy.

Lithotripsy uses shock waves to break the stone into smaller pieces. Then an endoscope is used to pass surgical instruments into the pancreatic duct and take the pieces out. An endoscope is a long, thin, flexible tube with a light and a video camera at one end.

This treatment may ease the pain to some extent, but the relief may not last.

When only certain parts of the pancreas are inflamed and causing severe pain, those parts can be removed by surgery. This operation is called a pancreas resection, and it is one of the treatments for chronic pancreatitis. Doctors may also suggest it if endoscopic treatment hasn't worked.

Which technique is used depends on exactly which parts need to be removed. Some techniques, for example, take out the gallbladder along with parts of the pancreas.

The different techniques tend to work equally well at reducing pain and preserving the function of the pancreas. But the more complex ones carry a higher risk of complications, such as infection and internal bleeding. Simpler procedures have a lower risk of complications and usually mean a faster recovery.

Before you decide, talk through the pros and cons of the suitable techniques with your surgical team.

In the most serious cases of chronic pancreatitis, the pancreas has been badly damaged, and the doctor may need to remove all of it. This operation is called a total pancreatectomy.

A total pancreatectomy can be very effective at treating pain. But afterwards your body can no longer make the insulin it needs. To get around this, a relatively new technique called autologous pancreatic islet cell transplantation (APICT) is sometimes used.

In APICT, the islet cells that make insulin are taken out of your pancreas before the pancreas itself is removed by surgery.

The islet cells are then mixed with a special solution and injected into your liver. If the procedure works, the islet cells stay in your liver and start to produce insulin.

In the short term, APICT appears to work well, but in the long term you may still need extra insulin treatment. For more information, you can read the guidelines from the National Institute for Health and Care Excellence (NICE) on autologous pancreatic islet cell transplantation.

Complications are fairly common in chronic pancreatitis. They usually come from living with long-term pain, or from damage to the pancreas itself.

Living with a long-term health condition can take a toll on your emotional and psychological health, especially when it brings pain that keeps coming back or never really goes away. The International Association for the Study of Pain found that up to 94% of people with chronic pancreatitis experience pain.

One study of people living with chronic pancreatitis found that one in seven had some kind of psychological or emotional problem, such as stress, anxiety or depression.

If you're having these difficulties, see your doctor. There are effective treatments that can help ease the symptoms of stress, anxiety and depression.

Joining a support group for people with chronic pancreatitis may help too. Talking to others who have the same condition can often reduce feelings of isolation and stress.

About a third of people with chronic pancreatitis go on to develop diabetes. It usually comes many years after the original diagnosis, and it's not unusual for 20 years to pass first.

Diabetes develops when your pancreas can no longer make insulin, which is a chemical the body uses to break glucose down into energy. The main symptoms are:

• feeling very thirsty
• going to the toilet a lot, particularly at night
• extreme tiredness
• weight loss and muscle wasting (loss of muscle bulk)

If you develop diabetes because of chronic pancreatitis, you'll probably need regular insulin injections to make up for the lack of natural insulin in your body.

Pseudocysts are another common complication of chronic pancreatitis. These are sacs of fluid that develop on the surface of your pancreas, and they're thought to affect around 1 in 10 people with chronic pancreatitis.

In many cases, pseudocysts don't cause any symptoms and are only found during a computerised tomography (CT) scan. In some people, though, they can cause the following symptoms:

• bloating
• indigestion
• dull abdominal pain

If the pseudocysts are small and not causing any symptoms, you may not need treatment, because they usually disappear on their own.

Treatment is usually recommended if you have symptoms or the pseudocysts are larger than 6cm (2.3 inches) in diameter. Larger pseudocysts are at risk of bursting open, which could cause internal bleeding or trigger an infection.

Pseudocysts can be treated by draining the fluid out of the cyst. One way is to insert a needle through your skin and into the cyst. Another is to use an endoscopy, where a thin, flexible tube called an endoscope is passed down your throat and tiny tools are used to drain away the fluid.

Sometimes pseudocysts are treated by removing part of the pancreas using laparoscopic or "keyhole" surgery. This is known as a laparoscopic distal pancreatectomy. The National Institute for Health and Care Excellence (NICE) has published guidelines on laparoscopic distal pancreatectomy.

Chronic pancreatitis raises your risk of getting pancreatic cancer, but the extra risk is fairly small. It's estimated that for every 100 people with chronic pancreatitis, only 1 or 2 will develop pancreatic cancer.

The first symptoms of pancreatic cancer are usually much the same as those of chronic pancreatitis. These include jaundice, abdominal pain and weight loss.