Asked by Carolyne, Massachusetts
Could you give me a brief outline of chronic pancreatitis? My husband has recently been diagnosed with this, yet the doctors tell us all the time it will get better when in fact it is getting worse. Thank you.
Dr. Otis Brawley
Chief Medical Officer,
American Cancer Society
Chronic pancreatitis is a progressive inflammation in the pancreas that results in permanent structural damage of the organ. Pancreatitis can lead to impairment of digestive enzyme production by the pancreas and, in severe cases, to lack of insulin production.
Lack of insulin production can lead to a form of diabetes that must be treated with insulin. Chronic pancreatitis is different from acute pancreatitis, in that the latter is usually nonprogressive and often occurs as one painful episode. However, there can be some overlap.
Recurrent attacks of acute pancreatitis can lead to chronic pancreatitis over a period of years. Chronic pancreatitis can be asymptomatic, with occasional painful flares, while acute pancreatitis is almost always painful.
Most chronic pancreatitis is caused by:
• Alcohol abuse
• Genetic causes (mutations in the cystic fibrosis gene, hereditary pancreatitis)
• Obstructions of the bile ducts because of gallstones, malformations, trauma or tumors.
• Tropical pancreatitis, which is poorly understood and rarely seen outside of India.
• Systemic disease such as hypertriglyceridemia, possibly hyperparathyroidism
• Autoimmune pancreatitis associated with rheumatological diseases such as systemic lupus erythematosus, Sjögren's syndrome and primary biliary cirrhosis.
Studies show that one can decrease the risk of painful flare-ups by consuming small meals low in fat and maintaining good hydration. Abstinence from alcohol is important even among those whose pancreatitis is not caused by alcohol.
Drugs to lower gastric acidity are also useful. This can be either an H2 receptor blocker such as ranitidine or a proton pump inhibitor such as omeprazole. These drugs reduce the inactivation of the supplemental pancreatic enzymes from gastric acid.
Treatment of chronic pancreatitis can also be aimed at its cause. Ductal stones can be treated with sound wave therapy (lithotripsy) or by endoscopic or surgical removal. Malformed bile ducts can sometimes be surgically corrected. Very rarely, surgical removal of the pancreas is performed. Patients with rheumatologic or systemic illnesses often improve when their illness is brought under control.
When there is an acute flare-up of pain from chronic pancreatitis, it is common to rest the pancreas. One can minimize pancreatic digestive activity by first not feeding the patient for several days.
Giving pancreatic enzyme supplementation with meals is another form of pancreatic rest. Both may reduce pain and irritation, but analgesics are often needed. Common pain medications are the opioids or drugs designed to reduce neuropathic pain such as amitriptyline or nortriptyline. Occasionally, nerve blocks are used to treat frequently recurring pain.
Special attention needs to be paid to nutrition in patients who have long-term chronic pancreatitis. These patients have difficulty absorbing fat. As a result, they do not absorb enough calories, nor do they absorb fat-soluble vitamins. After a long period, there will be deficiencies in fat-soluble vitamins (A, D, E, K and B-12).
They will need vitamin injections and may need to be fed medium-chain triglycerides (MCTs) for additional calories. MCTs are less likely to cause a flare, compared with long-chain triglycerides.
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