Chronic Pancreatitis

What chronic pancreatitis does

The pancreas has two jobs:

• Exocrine: making digestive enzymes that flow into the intestine to break down fat, protein and carbohydrate.
• Endocrine: making insulin and glucagon to control blood sugar.

In chronic pancreatitis, repeated inflammation replaces healthy tissue with scar tissue. The ducts may narrow, dilate and fill with stones (calcifications). As damage progresses, the pancreas loses its ability to produce enzymes (exocrine pancreatic insufficiency) and insulin (diabetes). Unlike acute pancreatitis, which usually heals, chronic damage is permanent.

Symptoms

Pain

Pain is the main symptom for most people:

• in the upper middle belly, often spreading straight through to the back
• may be constant or come in attacks lasting hours to days
• often worse after eating, especially fatty meals, or after alcohol
• may ease when sitting up and leaning forward

In some people, pain lessens over many years as the gland "burns out", while digestive and sugar problems increase.

Digestion problems

When enzyme output falls below about 10% of normal:

• steatorrhea: pale, bulky, oily, foul-smelling stools that are hard to flush
• diarrhea, bloating and gas
• weight loss despite eating normally
• deficiencies of vitamins A, D, E and K, and osteoporosis

Diabetes

Type 3c (pancreatogenic) diabetes develops in many people over time. It can cause unpredictable blood sugars because glucagon is also reduced.

Causes and risk factors

The TIGAR-O classification groups causes:

Alcohol use disorder and smoking are the most important modifiable risk factors; smoking independently speeds disease progression.

Diagnosis

1. History and examination: pain pattern, alcohol and smoking, family history, weight.
2. Imaging: - CT scan: shows calcifications, duct dilation and atrophy; often the first test. - MRI with MRCP: shows the ducts in detail, including early changes. - Endoscopic ultrasound (EUS): sensitive for early disease and for sampling suspicious masses.
3. Pancreatic function tests: fecal elastase (low in exocrine insufficiency).
4. Blood tests: blood sugar and HbA1c, vitamin levels, calcium, triglycerides, IgG4, and liver tests.
5. Genetic testing: for young patients or those with a family history or no obvious cause.

Lipase and amylase blood levels are often normal in chronic pancreatitis, so they are not reliable for diagnosis.

Treatment

Remove the triggers

• Stop drinking alcohol completely. Support programs and medicines for alcohol dependence improve success.
• Stop smoking. This slows progression and reduces cancer risk.

Pain management

• acetaminophen (paracetamol) and NSAIDs as first steps, following medical advice
• nerve pain medicines such as pregabalin
• careful, limited use of opioids if needed, under close supervision
• treatment of duct stones or strictures by endoscopy (ERCP), sometimes with shock wave lithotripsy
• nerve blocks for selected patients
• surgery: drainage procedures, partial pancreas removal, or total pancreatectomy with islet autotransplantation in selected cases

Pancreatic enzyme replacement therapy (PERT)

Enzyme capsules taken at the start of every meal and snack replace missing digestive enzymes. They reduce fatty stools, improve weight and vitamin absorption, and may ease pain in some. The dose is adjusted to meal size and symptoms. An acid-reducing medicine is sometimes added to help the enzymes work.

Nutrition

• eat regular, smaller meals; you do not usually need a very low-fat diet if enzymes are adequate
• supplements of vitamins A, D, E and K as needed
• bone density testing and treatment for osteoporosis
• dietitian support for weight loss

Diabetes care

Blood sugar checks at least yearly. Treatment often starts with metformin and may need insulin. Hypoglycemia can be more severe because glucagon is low.

Complications

• pseudocysts (fluid collections)
• bile duct or duodenal narrowing causing jaundice or vomiting
• splenic vein thrombosis and bleeding
• diabetes and malnutrition
• osteoporosis
• pancreatic cancer: risk is increased, especially in hereditary pancreatitis and smokers

Outlook

Chronic pancreatitis is lifelong, but stopping alcohol and smoking slows progression and improves pain. Enzyme replacement and diabetes care manage digestive and sugar problems effectively. Life expectancy is reduced on average, mainly due to continued alcohol use, smoking-related disease, infections and cancer; people who stop drinking and smoking do considerably better.

Frequently asked questions

What are the symptoms of chronic pancreatitis?

The main symptoms are upper belly pain that often spreads to the back and worsens after eating, weight loss, and pale, greasy, foul-smelling stools. Over time, many people develop diabetes. Some have little pain but notice weight loss and digestive changes.

What causes chronic pancreatitis?

Heavy alcohol use and smoking cause most adult cases. Other causes include genetic mutations, recurrent acute pancreatitis, autoimmune pancreatitis, high calcium or triglycerides, and blockage of the pancreatic duct. In some people no cause is found.

Can chronic pancreatitis be cured?

No. The damage is permanent. But stopping alcohol and smoking slows progression, and pain control, enzyme capsules and diabetes treatment manage symptoms. Some people need endoscopic procedures or surgery.

What should I eat with chronic pancreatitis?

Eat regular, smaller balanced meals and take enzyme capsules with every meal and snack. Avoid alcohol completely. You usually do not need a very low-fat diet if your enzymes are working. A dietitian can help with vitamins and weight.

What is the life expectancy with chronic pancreatitis?

It varies widely. Life expectancy is reduced on average, largely because of continued alcohol use and smoking, which also raise cancer risk. People who stop drinking and smoking and follow treatment can live for many decades.