Chronic pancreatitis
and Carola Felchner, science journalistDr. med. Julia Schwarz is a freelance writer in the medical department.
More about the expertsCarola Felchner is a freelance writer in the medical department and a certified training and nutrition advisor. She worked for various specialist magazines and online portals before becoming a freelance journalist in 2015. Before starting her internship, she studied translation and interpreting in Kempten and Munich.
More about the experts All content is checked by medical journalists.Chronic pancreatitis is a recurrent inflammation of the pancreas. In up to 80 percent of cases, it is caused by excessive alcohol consumption. Typical symptoms include belt-shaped upper abdominal pain, weight loss, indigestion, and impaired blood sugar regulation. Here you can read everything you need to know about chronic pancreatitis.
ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. K86
Chronic pancreatitis: description
Chronic pancreatitis is a constantly recurring inflammation of the pancreas. As a result, the diseased organ is less and less able to perform its tasks - i.e. to produce digestive enzymes and important hormones (such as insulin). This increasingly restricts the quality of life of those affected. In addition, chronic pancreatitis significantly reduces life expectancy.
In Germany, 1,500 to 8,000 people are newly diagnosed with chronic pancreatitis every year. The disease often occurs in the 3rd and 4th decades of life. Long-term alcohol consumption is usually the cause. Chronic pancreatitis rarely develops in childhood. Then a genetic component often plays a role.
Chronic pancreatitis: symptoms
Chronic pancreatitis often begins insidiously and progresses slowly. Initially, the symptoms are often only mild to moderate: As with acute pancreatitis, a typical symptom of the chronic form is epigastric pain radiating into the back or shoulders in a belt shape. They often appear during or after eating and can last for days. In a late stage of the disease, however, patients often no longer feel any pain in the upper abdomen.
In addition to the pain, chronic pancreatitis can trigger symptoms such as loss of appetite, nausea and vomiting. The patients lose weight. In addition, greasy, foul-smelling bowel movements occur.
The further the chronic pancreatitis progresses, the more the production of digestive enzymes for fat digestion is impaired. The increasing lack of pancreatic enzymes means that fat-soluble vitamins (A, D, E, K) can no longer be adequately absorbed from food. This triggers vitamin deficiency symptoms: night blindness (deficiency in vitamin A), tiredness and gait disorders (deficiency in vitamin E), a tendency to bleeding (deficiency in vitamin K) and soft bones (osteomalacia due to deficiency in vitamin D).
In the advanced stages of chronic pancreatitis, the production of hormones for regulating blood sugar is also reduced: insulin (lowers the blood sugar level) and glucagon (increases the blood sugar level). As a result, the patient develops diabetes (diabetes mellitus).
Chronic pancreatitis: causes & risk factors
In 80 percent of cases, chronic pancreatitis is caused by excessive alcohol consumption (alcohol abuse). The alcohol directly damages the pancreatic tissue and weakens the immune system. Alcohol inhibits the release of the messenger substance interferon, which normally stimulates the immune system. Chronic pancreatitis can also be triggered by the following factors:
Genetically determined (hereditary pancreatitis)
In the case of hereditary pancreatitis, the pancreas becomes inflamed in childhood. A genetic defect leads to an altered structure and function of an endogenous substance that activates the digestive enzymes: trypsinogen. The digestive enzymes are activated in the pancreas and not in the small intestine. They “digest” the pancreatic tissue, which causes an inflammatory reaction.
Patients with cystic fibrosis are also more likely to suffer from chronic pancreatitis because the thick mucus prevents the pancreatic secretion from draining normally.
Medication
Drugs can also cause chronic pancreatitis. These include beta blockers, diuretics, ACE inhibitors, estrogens and anti-epileptics. Similar to alcohol, the drugs damage pancreatic tissue, causing it to become inflamed.
Excess of calcium in overactive parathyroid glands
The parathyroid gland produces the parathyroid hormone, which regulates the level of calcium in the blood. It mobilizes calcium from the bones to help raise calcium levels in the blood. When there is an excess of parathyroid hormone, the excess calcium reacts with the digestive enzymes in the pancreas. Stones form, which can cause chronic pancreatitis.
Excess triglycerides (hypertriglyceridemia)
An excess of certain blood lipids (triglycerides) with values> 1000 mg / dl also causes chronic pancreatitis in rare cases. The exact mechanism behind this is not yet clearly known. It is believed that cleavage of the triglycerides (with the help of lipase) produces free fatty acids, which cause inflammation of the pancreatic cells.
Autoimmune pancreatitis
Autoimmune pancreatitis is a rare form of chronic pancreatitis. The body increasingly produces antibodies that attack its own pancreatic tissue. A single cortisone therapy is sometimes sufficient for healing without further therapeutic measures having to be taken.
Chronic pancreatitis: examinations & diagnosis
If you suspect chronic pancreatitis, contact your general practitioner or a specialist in internal medicine and gastroenterology. The exact description of your complaints and any previous illnesses provides the doctor with valuable information about your state of health (anamnesis discussion). The doctor could ask the following questions:
- Where exactly does it hurt you? Is the pain radiating?
- Does the pain occur after eating?
- How Much Alcohol Do You Drink? Do you have an alcohol addiction?
- Have you noticed shiny, greasy diarrhea?
- Have you ever had pancreatitis?
- Have you ever been found to have elevated blood lipid levels or elevated calcium levels in an examination?
- Do you take any medicine?
Physical examination
The doctor will ask you to lie down and free your upper body so that they can examine you. Chronic pancreatitis leads to belt-shaped upper abdominal pain in most people affected, which can radiate into the back and possibly into the chest. The doctor will first listen to the abdomen with the stethoscope. He will then carefully palpate the abdomen, paying attention to any pain.
Blood test
In the case of an acute flare-up of inflammation, the pancreatic enzymes in the blood may be increased. The fat-splitting pancreatic enzyme lipase is increasingly released into the blood. The carbohydrate-splitting enzyme amylase and the protein-splitting enzyme elastase can also be increased. However, digestive enzyme levels in the blood are not elevated in all patients with chronic pancreatitis.
Stool examination
The enzyme elastase produced by the pancreas is released into the intestine and excreted undigested. If the pancreas does not work properly, correspondingly smaller amounts of elastase reach the intestine - the elastase level in the stool also falls accordingly. If chronic pancreatitis is suspected, the doctor will measure the elastase concentration in the stool as part of a stool examination. This examination is considered to be the method of choice for diagnosing chronic pancreatitis.
If the concentration is less than 200 micrograms per gram of stool, there is damage to the exocrine pancreatic function. Above an elastase-1 concentration of less than 100 micrograms per gram of stool, the dysfunction is classified as severe.
In addition, the amount of fat and the digestive enzyme chymotrypsin in the stool can be determined. Increased fat excretion and reduced chymotrypsin concentration in the stool also indicate a dysfunction of the pancreas and thus chronic pancreatitis.
Imaging procedures
To diagnose chronic pancreatitis, an ultrasound examination of the abdomen (abdominal sonography), magnetic resonance imaging (MRI), or computed tomography (CT) should be performed. With the help of the imaging measures, the extent of the tissue damage can be assessed. With the help of endoscopic retrograde cholangio-pancreatography (ERCP) it can be clarified whether a tumor in the area of the pancreatic or bile duct is the cause of the symptoms.
Ultrasound examination
Due to the recurring attacks of inflammation, the pancreatic tissue scars over time and calcifications form. An ultrasound examination of the abdomen (abdominal ultrasound) can provide the first clues. If such calcifications are present, this is considered evidence of chronic pancreatitis. Since the pancreas lies behind other organs in the abdomen, it can often not be optimally represented by an ultrasound examination. In this case, the doctor uses other imaging methods such as computed tomography, magnetic resonance tomography or ERCP.
Computed tomography and magnetic resonance imaging
If chronic pancreatitis is suspected, computed tomography (CT) provides a detailed picture of the pancreas. Magnetic resonance tomography (MRT) also enables an even more precise visual representation. Chronic pancreatitis typically shows up in the pictures as a calcification of the pancreatic tissue as well as a change in the pancreatic duct or so-called pancreatic pseudocysts. Pancreatic tumors can also be detected using these two methods.
Endoscopic Cholangio-Pancreatography (ERCP)
Since chronic pancreatitis can eventually lead to a tumor (pancreatic carcinoma), endoscopic retrograde cholangiopancreatography (ERCP) is performed in many cases. For ERCP, the doctor slices a small tube down the esophagus into the stomach and further down the duodenum. In this way, he can precisely inspect the joint duct of the pancreas and bile and possibly recognize the cause of the chronic pancreatitis. He then injects an X-ray contrast medium into the duct. This allows the ducts of the pancreas and bile as well as any obstacles to flow (for example a tumor) to be made visible in an X-ray image.
Chronic pancreatitis: treatment
The most important measure for chronic pancreatitis is the absolute and permanent abstinence from alcohol. Only abstinence prevents further inflammation and thus a continuous destruction of the pancreatic tissue. You should definitely seek professional help for alcohol withdrawal, as very few people manage to remain abstinent on their own. At least for people who are physically dependent on alcohol, the first step is detoxification in a clinic, in which the physical withdrawal symptoms are overcome under medical supervision and, if necessary, with medical support. This is followed by further suitable measures. This includes outpatient or inpatient addiction therapy to get the psychological dependence on alcohol under control, and visiting self-help groups that support the process.
People with chronic pancreatitis need to pay extra attention to their diet. Some have lost a lot of weight due to the disease and need to build up their physical reserves again. However, it is important how and what the patients eat: Ideally, the portions should be small and contain little carbohydrates and fat. To break down carbohydrates, the body needs amylase from the pancreas - which should be spared. Oily foods, on the other hand, are often very poorly tolerated due to the lack of secretion production in chronic pancreatitis and cause flatulence and fatty stools. Fats with medium-chain fatty acids (MCT) such as those found in coconut fat and palm kernel oil or in special dietary foods are better tolerated. They do not have to be broken down by enzymes to be absorbed into the intestine.
In addition, the symptoms of chronic pancreatitis can be relieved with the help of medication and surgical procedures.
Chronic pancreatitis - drugs
In the case of an acute flare-up of inflammation, pain therapy corresponds to that of an acute form of pancreatitis. Patients are given opioids for pain relief in the form of buprenorphine or pethidine. In addition, patients can take the fat-splitting enzyme lipase with meals in the form of tablets. This relieves the digestive discomfort.
Some patients suffer from deficiency in fat-soluble vitamins (vitamins A, D, E, K) due to fat digestion disorder. They are administered directly into the blood through the muscle. This is how the bowel can be bypassed.
In patients with severe chronic pancreatitis, the pancreas is often so badly damaged that they can no longer regulate the blood sugar balance - they develop diabetes. In that case, patients will also need insulin therapy.
Chronic pancreatitis - surgical procedure
Chronic pancreatitis often results in calcifications, which can cause stones in the pancreatic duct or narrow it. With the help of a special endoscopic method, the endoscopic cholangio-pancreatography (ERCP), the joint duct of the bile and pancreas can be enlarged again. To do this, the doctor puts a small tube into the pankread duct. Then a small balloon is inflated over this, which stretches the passage again. In some cases, a small tube (stent) is also inserted to prevent re-narrowing. Doctors can use electric shock waves to break stones in the pancreatic duct to improve drainage.
Chronic pancreatitis: course & prognosis
The prognosis of chronic pancreatitis depends on how pronounced concomitant diseases such as alcohol addiction are and how consistently the recommended therapeutic measures are followed. In the long term, chronic pancreatitis causes tissue changes that can cause various complications such as pancreatic pseudocysts, blood clots in the splenic vein or the portal vein. At an advanced stage, chronic pancreatitis also increases the risk of developing pancreatic cancer.
Chronic pancreatitis - prognosis
Chronic pancreatitis usually lasts for several years and is usually associated with other diseases. Although it is rarely fatal itself, the life expectancy of the patient is significantly reduced due to the often severe accompanying and secondary diseases. Chronic alcohol consumption, which occurs in 80 percent of those affected, drastically reduces life expectancy. If the chronic pancreatitis has led to a functional impairment of the pancreas, those affected often suffer from chronic diarrhea and the associated weight loss. Being underweight weakens the entire organism, making those affected more susceptible to infections. Complications are also more likely to occur. About 50 percent of patients with chronic pancreatitis die within ten to 15 years.
Chronic pancreatitis - complications
Chronic pancreatitis is associated with tissue damage in the long term. This increases the risk of the following complications. This includes:
Pancreatic pseudocysts
The inflammatory tissue changes can cause so-called pancreatic pseudocysts to form. These are encapsulated accumulations of fluid that are surrounded by wound healing tissue and collagen fibers. Compared to real cysts, however, the accumulations of fluid are not enclosed by a real wall. Pancreatic pseudocysts can resolve on their own within six weeks. In some cases, however, they become infected or tear apart. If the patient suffers from symptoms, a small tube is usually surgically applied so that the contents of the pseudocyst can be continuously drained.
Splenic vein and portal vein thrombosis
Severe, chronic pancreatitis can squeeze the splenic vein or portal vein due to the calcifications and structural changes and thus lead to blood clots (thrombosis) in these vessels. Depending on the size of the clot, the blood can back up in the portal vein that leads to the liver. This is especially true if the patient has cirrhosis of the liver due to long-term alcohol consumption. Increased blood pressure develops in the portal vein, which can cause water to accumulate in the abdomen (ascites). In addition, the congestion of blood in front of the liver can cause so-called collateral circuits to form, through which the blood flows from the portal vein directly back to the right heart.
Pancreatic cancer
As a late complication of chronic pancreatitis, pancreatic carcinoma can develop in an advanced stage. Due to the permanent inflammation, the dying cells in the pancreatic tissue have to be constantly replaced. In addition, the healthy cells divide much more frequently than usual. Errors can occur with each division - in the worst case the cell can degenerate. Such cells no longer have sufficient repair mechanisms of their own and then divide exponentially - a tumor develops. Chronic pancreatitis should therefore be recognized and treated early.
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