Chronic pancreatitis is a condition where the pancreas (a small organ located behind the stomach and below the ribcage) becomes permanently damaged from inflammation.
It’s different to acute pancreatitis, where the inflammation is only short-term.
The most common symptom of chronic pancreatitis is repeated episodes of abdominal (tummy) pain, which can be severe.
Other symptoms tend to develop as the damage to the pancreas progresses, such as producing greasy, foul-smelling stools.
When to seek medical advice
Always visit your GP if you’re experiencing severe pain – it’s a warning sign that something is wrong.
Why it happens
Long-term alcohol misuse is responsible for around 7 out of every 10 cases of chronic pancreatitis. This is because heavy drinking over a number of years can repeatedly damage the pancreas.
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 the condition, the cause cannot be identified – this is known as ‘idiopathic’ chronic pancreatitis.
Who’s affected
Chronic pancreatitis can affect people of any age, but is most common in middle-aged men aged between 45 and 54.
How it’s treated
In most cases of chronic pancreatitis, there’s no specific treatment to reduce the inflammation and repair the damage to the pancreas.
Treatment mainly focuses on lifestyle changes and medication to relieve the pain. Surgery is sometimes needed to treat severe chronic pain that doesn’t respond to painkillers.
However, the pain can be difficult to treat and can seriously affect your quality of life.
People who don’t smoke cigarettes and avoid drinking alcohol tend to experience less pain and live longer than those who continue to drink and smoke after receiving a diagnosis.
Complications
Living with chronic pain can cause mental as well as physical strain. It’s important to speak to your GP if you’re experiencing stress, anxiety or depression caused by chronic pancreatitis.
Diabetes is a common complication of chronic pancreatitis and affects about a third of people with the condition. It occurs when the pancreas is damaged and unable to produce insulin.
People with chronic pancreatitis also have an increased risk of developing pancreatic cancer.
Symptoms of chronic pancreatitis
The most common symptom of chronic pancreatitis is repeated episodes of abdominal (tummy) pain. Eventually, there may also be digestion problems.
The pain usually develops in the middle or left side of the abdomen and can sometimes travel along your back. It’s been described as a burning or shooting pain which comes and goes, but can last for several hours or days, in some cases.
Some people also experience symptoms of nausea and vomiting during the pain. As chronic pancreatitis progresses, the painful episodes may become more frequent and severe.
Although the pain sometimes occurs after eating a meal, there’s often no trigger.
Eventually, a constant mild to moderate pain can develop in the abdomen in between episodes of severe pain. This is most common in people who continue to drink alcohol after being diagnosed with chronic pancreatitis.
Some people who stop drinking alcohol and stop smoking may experience a reduction in the severity of their pain.
Advanced chronic pancreatitis
Additional symptoms can occur when the pancreas loses its ability to produce digestive juices, which help to break down food in the digestive system. The pancreas usually only loses these functions many years after the original symptoms started.
The absence of digestive juices makes it difficult for your digestive system to break down fats and certain proteins. This can cause your stools to become particularly smelly and greasy, and make them difficult to flush down the toilet.
You may also experience:
- 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
When to seek medical advice
Always visit your GP if you’re experiencing severe pain, as this is a warning sign that something is wrong.
You should also visit your GP if you develop symptoms of jaundice. Jaundice can have a range of causes other than pancreatitis, but it’s usually a sign that there’s something wrong with your digestive system.
You should also visit your GP if you develop persistent vomiting.
Causes of chronic pancreatitis
Most cases of chronic pancreatitis are associated with drinking excessive amounts of alcohol over a long period of time.
However, in up to 3 out of 10 people with the condition, the cause can’t be identified – known as ‘idiopathic’ chronic pancreatitis.
Alcohol consumption
Heavy drinking over many years can cause repeated episodes of acute pancreatitis. Acute pancreatitis is usually a short-term condition, but it can recur if you continue to drink alcohol.
Over time, repeated inflammation causes permanent damage to the pancreas, resulting in chronic pancreatitis.
Anyone who regularly consumes alcohol has an increased risk of chronic pancreatitis, although only a minority develop the condition.
Problems with the immune system
Rare cases of chronic pancreatitis are the result of a problem with the immune system, which causes it to attack the pancreas. This is known as ‘autoimmune pancreatitis’ and it’s not clear exactly why it happens.
Many people with autoimmune pancreatitis also have other conditions caused by the immune system attacking healthy tissue. These include ulcerative colitis or Crohn’s disease, both of which cause inflammation inside the digestive system.
Genetics
Some cases of chronic pancreatitis are inherited. This is thought to be caused by mutations (alterations) in a number of genes, including genes called PRSS1 and SPINK-1. These mutations disrupt the normal working of the pancreas.
Genetic mutations may also have a role in the effect of alcohol on your pancreas. Evidence suggests that certain genetic mutations make the pancreas more vulnerable to the harmful effects of alcohol.
Certain mutations of the CFTR gene, responsible for cystic fibrosis, are also thought to cause chronic pancreatitis in a small amount of cases.
Other causes
Several other rare causes of chronic pancreatitis have also been identified, including:
- injury to the pancreas
- blocked or narrowed openings (ducts) of the pancreas
- smoking
- radiotherapy to the abdomen (tummy)
Diagnosing chronic pancreatitis
Chronic pancreatitis can usually only be diagnosed by carrying out scans of the pancreas.
Your GP will ask about your symptoms and may carry out a simple physical examination, but they’ll refer you for further tests if they suspect chronic pancreatitis.
These tests are usually carried out 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
Endoscopic ultrasonography
During an endoscopic ultrasonography, a thin, flexible telescope (endoscope) is passed through your mouth and towards your stomach. An ultrasound probe attached to the tip of the endoscope is able to 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.
MRCP
An MRCP involves injecting you with a substance known as a contrast agent that makes your pancreas and surrounding organs, such as the gallbladder and liver, show up very clearly on a magnetic resonance imaging (MRI) scanner.
An MRI scanner is a type of imaging system that uses magnetic fields and radio waves to build up a detailed image of the inside of your body.
An MRCP is a useful way of checking whether gallstones may be contributing to your symptoms.
Biopsy
Sometimes, the symptoms of chronic pancreatitis can be very similar to pancreatic cancer. Therefore, if you have symptoms such as jaundice (yellowing of the skin and whites of the eyes) and weight loss, a biopsy may be recommended to rule out a diagnosis of pancreatic cancer.
A biopsy involves taking a small sample of cells from the pancreas and sending it to a laboratory, so it can be checked under a microscope for the presence of cancerous cells.
A biopsy can be taken using a long, thin needle that’s passed through your abdomen. The needle can be guided towards the tumour using an ultrasound scan or CT scan. Alternatively, a biopsy can be taken during an endoscopic ultrasonography.
Treating chronic pancreatitis
Treatment for chronic pancreatitis aims to help control the condition and reduce any symptoms.
Lifestyle changes
If you’re diagnosed with chronic pancreatitis, some lifestyle changes will be recommended.
Avoiding alcohol
The most important thing you can do is to stop drinking alcohol, even if it isn’t the cause of your condition. This helps to prevent further damage to your pancreas and may help to reduce the pain.
If you continue to drink alcohol, it’s likely that you’ll experience debilitating pain and you’ll be more likely to die from a complication of chronic pancreatitis.
Some people with chronic pancreatitis caused by alcohol consumption have a dependency on alcohol and require additional help and support to stop drinking. If this applies to you, talk to your GP about getting help to stop drinking.
Treatment options for alcohol dependence include:
- one-to-one counselling
- self-help groups – such as Alcoholics Anonymous
- a medication called acamprosate that can help to reduce cravings for alcohol
Stopping smoking
If you smoke, you should stop. Smoking can speed up the progress of chronic pancreatitis, making 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 medication used to reduce cravings for cigarettes). People who use these types of treatments have a much greater success rate in permanently stopping smoking than those who try to quit using willpower alone.
If you want to give up smoking, it’s a good idea to start by visiting your GP.
Dietary changes
As chronic pancreatitis can affect your ability to digest certain foods, you may need to change your diet.
Your GP may be able to provide you with appropriate dietary advice, or may refer you to a dietitian, who will draw up a suitable dietary plan.
A low-fat, high-protein, high-calorie diet with fat-soluble vitamin supplements is usually recommended, but don’t make changes to your diet without consulting a health professional.
Enzyme supplements
You may be given pancreatic enzyme supplements, which is medication containing an artificial version of the enzymes produced by your pancreas. These supplements may help to improve the effectiveness of your digestive system.
Side effects of pancreatic enzyme supplements can include diarrhea, constipation, nausea, vomiting and stomach pains.
Talk to your GP if you’re experiencing troublesome side effects, as your dosage may need to be adjusted.
Steroid medication
If you have chronic pancreatitis caused by problems with your immune system, treatment is relatively straightforward. The inflammation affecting the pancreas can usually be relieved using steroid medication (corticosteroids).
However, taking corticosteroids for a long time can cause side effects, such as osteoporosis and weight gain.
Pain relief
Pain relief is an important part of the treatment of chronic pancreatitis. At first, mild painkillers will be used, but more powerful ones will be needed if these don’t work.
Mild painkillers
In most cases, the first painkiller used is paracetamol or a non-steroidal anti-inflammatory drug (NSAID), such as ibuprofen.
Taking NSAIDs on a long-term basis can increase your risk of developing stomach ulcers, so you may be prescribed an additional medication called a proton pump inhibitor (PPI) to protect against this.
Stronger painkillers
If NSAIDs or paracetamol prove to be ineffective in controlling your pain, it’s likely that you’ll need an opiate-based painkiller, such as codeine or tramadol. Side effects of these types of medication can include constipation, nausea, vomiting and drowsiness.
The side effect of constipation can be particularly troublesome if you need to take an opiate-based painkiller on a long-term basis. You may be prescribed a laxative to help relieve your constipation.
If you feel drowsy after taking an opiate-based painkiller, avoid driving and using heavy tools or machines.
Severe pain
If you experience an attack of very severe pain, you may need a stronger opiate-based painkiller, such as morphine or pethidine. These have similar side effects to opiate-based painkillers.
Long-term use of these stronger opiate-based painkillers isn’t usually recommended, because there’s a high risk of addiction. Therefore, if you have persistent severe pain, surgery is usually recommended.
In some cases, an additional medication called amitriptyline may be recommended. Amitriptyline was originally designed to treat depression, but it can help to relieve pain in some people.
If medication isn’t effective, severe pain can sometimes be temporarily relieved for a few weeks or months using a procedure called a nerve block. This is an injection that blocks the pain signals from the pancreas.
Severe episodes
If the inflammation of your pancreas suddenly gets worse, you may need a short stay in hospital for treatment.
This may involve having fluids delivered directly into a vein, and oxygen supplied through tubes into your nose.
Surgery
Surgery can be used to treat severe pain in people with chronic pancreatitis. Depending on the exact cause of your pain, there are a variety of surgical techniques that may be used.
Endoscopic surgery
Patients with stones in the opening of their pancreas (the pancreatic duct) may benefit from endoscopic surgery and a treatment called lithotripsy.
Lithotripsy involves using shock waves to break the stone into smaller pieces. An endoscope (a long, thin flexible tube with a light source and a video camera at one end) is then used to pass surgical instruments into the pancreatic duct so the pieces can be removed.
This treatment may improve pain to some extent, but the benefit may not be permanent.
Pancreas resection
In cases where specific parts of the pancreas are inflamed and causing severe pain, these parts can be surgically removed. This type of surgery is called a pancreas resection.
Pancreas resection can also be used if endoscopic treatment is ineffective.
The technique used for pancreas resection depends on exactly which parts need to be removed. For example, some techniques involve removing the gallbladder, along with parts of the pancreas.
The different surgical techniques tend to have the same levels of effectiveness in terms of reducing pain and preserving the function of the pancreas, although some of the more complex techniques have an increased risk of complications, such as infection and internal bleeding. Simpler procedures have a lower risk of complications and usually have faster recovery times.
Discuss the pros and cons of the appropriate pancreas resection techniques with your surgical team before making a decision.
Total pancreatectomy
In the most serious cases of chronic pancreatitis, where the pancreas has been extensively damaged, it may be necessary to remove the entire pancreas. This is known as a total pancreatectomy.
A total pancreatectomy can be very effective in treating pain. However, you’ll no longer be able to produce the insulin that’s needed by your body. To overcome this problem, a relatively new technique called autologous pancreatic islet cell transplantation (APICT) is sometimes used.
During APICT, the islet cells responsible for producing insulin are removed from your pancreas, before your pancreas is surgically removed.
The islet cells are mixed with a special solution, which is injected into your liver. If the APICT procedure is successful, the islet cells remain in your liver and begin to produce insulin.
In the short term, APICT appears to be effective, but you may need additional insulin treatment in the long term. See guidelines from the National Institute for Health and Care Excellence(NICE) about autologous pancreatic islet cell transplantation for more information.
Complications of chronic pancreatitis
Complications of chronic pancreatitis are relatively common and usually caused by living with chronic pain or damage to the pancreas.
Psychological effects of chronic pancreatitis
Any chronic health condition, particularly one causing recurring or constant pain, can have an adverse effect on your emotional and psychological health. 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 people had some sort of psychological or emotional problem, such as stress, anxiety or depression.
Contact your GP if you’re experiencing psychological and emotional difficulties. Effective treatments are available to help improve the symptoms of stress, anxiety and depression.
Joining a support group for people with chronic pancreatitis may also help. Talking to other people with the same condition can often help to reduce feelings of isolation and stress.
Diabetes
Around a third of people with chronic pancreatitis develop diabetes, usually many years after receiving their diagnosis (it’s not unusual for 20 years to pass before diabetes occurs).
Diabetes develops when your pancreas is no longer able to produce insulin (a chemical the body uses to break glucose down into energy). The main symptoms of diabetes 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 to have regular insulin injections to compensate for the lack of natural insulin in your body.
Pseudocysts
Another common complication of chronic pancreatitis is pseudocysts (sacs of fluid which develop on the surface of your pancreas). 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 detected during a computerized tomography (CT) scan. However, in some people, pseudocysts can cause the following symptoms:
- bloating
- indigestion
- dull abdominal pain
If the pseudocysts are small and not causing any symptoms, there may be no need for treatment, because they usually disappear on their own.
Treatment is usually recommended if you’re experiencing 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. This can be done by inserting a needle through your skin and into the cyst. Alternatively, an endoscopy may be used. This is 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.
Pancreatic cancer
Chronic pancreatitis increases your risk of developing pancreatic cancer. However, the increased risk is relatively small. For example, it’s estimated that for every 100 people with chronic pancreatitis, only 1 or 2 will develop pancreatic cancer.
The most common initial symptoms of pancreatic cancer are much the same as chronic pancreatitis. They include jaundice, abdominal pain and weight loss.