Surgery

Chronic pancreatitis

Chronic pancreatitis

Chronic pancreatitis is a long-standing inflammation of the pancreas that results in destruction, fibrosis, alters the organ's normal structure and functions, resulting in irreversible changes. It can present as repeated episodes of acute inflammation in a previously injured pancreas, or as chronic damage with persistent pain or malabsorption. This different from acute pancreatitis where in the changes are reversible.

Signs and symptoms

  • Upper abdominal pain: Upper abdominal pain which increases after drinking or eating, lessens when fasting or sitting and leaning forward. Some people may not suffer pain.
  • Nausea and vomiting.
  • Steatorrhea: Frequent, oily, foul-smelling bowel movements as a result of damage to enzyme secretig cells of the pancreas. Fats and nutrients are not absorbed properly, leading to loose, greasy stool known as steatorrhea. This can also lead to malnutrition.
  • Weight loss
  • Diabetes type 1

Causes

Among the causes of chronic pancreatitis are the following:

  • Alcohol
  • Autoimmune disorders
  • Intraductal obstruction
  • Idiopathic pancreatitis
  • Tumors
  • Ischemia
  • Calcific stones

The relationship between etiologic factors, genetic predisposition, and the pace of disease progression requires further clarification, though recent research indicates smoking may be a high-risk factor to develop chronic pancreatitis.[5] In a small group of patients chronic pancreatitis has been shown to be hereditary. Almost all patients with cystic fibrosishave established chronic pancreatitis, usually from birth. Cystic fibrosis gene mutations have also been identified in patients with chronic pancreatitis but in whom there were no other manifestations of cystic fibrosis. Obstruction of the pancreatic duct because of either a benign or malignant process may result in chronic pancreatitis.

Pathophysiology

The mechanism of chronic pancreatitis viewed from a genetic standpoint indicates early onset of severe epigastric pain beginning in childhood. It is an autosomal dominant disease, chronic pancreatitis disease is identified in the cationic trypsinogen gene PRSS1, and mutation, R122H. R122H is the most common mutation for hereditary chronic pancreatitis with replacement of arginine with histidine at amino acid position 122 of the trypsinogen protein. There are, of course, other mechanisms – alcohol, malnutrition, smoking – each exhibiting its own effect on the pancreas.

Treatment

The different treatment options for management of chronic pancreatitis are medical measures, therapeutic endoscopy and surgery.Treatment is directed, when possible, to the underlying cause, and to relieve pain and malabsorption. Insulin dependent diabetes mellitus may occur and need long term insulin therapy. The abdominal pain can be very severe and require high doses of analgesics, sometimes including opiates. Alcohol cessation and dietary modifications (low-fat diet) are important to manage pain and slow the calcific process. Antioxidants may help but it is unclear if the benefits are meaningful.

Pancreatic enzymes

Pancreatic enzyme replacement is often effective in treating the malabsorption and steatorrhea associated with chronic pancreatitis. Treatment of CP consists of administration of a solution of pancreatic enzymes with meals. Some patients do have pain reduction with enzyme replacement and since they are relatively safe, giving enzyme replacement to a chronic pancreatitis patient is an acceptable step in treatment for most patients. Treatment may be more likely to be successful in those without involvement of large ducts and those with idiopathic pancreatitis.

Surgery

Surgery to treat chronic pancreatitis tends to be divided into two areas – resectional and drainage procedures. Among the reasons to opt for surgery are if there is a pseudocyst, fistula, ascites, or a fixed obstruction.