Thoracic / Chest

Chronic Pancreatitis

Definition

Pain caused by chronic inflammation of the pancreas.

Aetiology

In 70-80% of patients, chronic pancreatitis is related to alcohol abuse. The mechanism regarding how alcohol causes pancreatitis is not yet clear.  A high number of alcoholics do not develop pancreatitis. Genetic factors may play a role here.

In one-third of patients with chronic pancreatitis, alcohol is not the cause. Hereditary, autoimmune, metabolic and trophic factors may also be a cause.

In 50% of patients with chronic pancreatitis, causal aetiology is found. In the remaining patients, this is known as idiopathic chronic pancreatitis.

Pain is an important symptom in chronic pancreatitis. In the pathogenesis of the pain, nociceptive, neuropathic and neural inflammatory mechanisms play a role.

Signs and symptoms

In 20% of chronic pancreatitis patients, long pain-free periods can occur. In contrast, acute pancreatitis is always painful. Patient complains of diarrhoea, difficulty of washing away smelly stools, and weight loss.

Steatorrhoea can lead to a deficiency of fat-soluble vitamins (A, D, E, K) and vitamin B12. Moreover, chronic pancreatitis can lead to insulin-dependent diabetes mellitus (DM). This usually occurs late in the course of the disease.

Patients with calcification of the pancreas have a greater risk of developing diabetes. Since glucagon production is disturbed in chronic pancreatitis, the accompanying diabetes has a greater risk of hypoglycaemia. Diabetic ketoacidose and nephropathy are seldom seen, in contrast to neuropathy and retinopathy.

In case of pain, patients with chronic pancreatitis have typical epigastria pain radiating to the thoracic spine. About 20-30 minutes after a meal, this pain can increase and nausea and vomiting can co-exist.  Two pain patterns can be distinguished in chronic alcoholic pancreatitis. In Type I, pain is episodic with pain-free intervals lasting from weeks to years. In Type II, persistent pain with exacerbations is present, necessitating hospitalisation.

Diagnostics

Physical Examination

Pressure pain in the epigastria region only is found in chronic pancreatitis. Fever and a palpable mass suggest that the course of the chronic pancreatitis (pseudo-cyst) has complications.

Additional Somatic Diagnostics

In chronic pancreatitis, exocrine function of the pancreas is frequently affected earlier and more seriously than endocrine function.

  • Routine laboratory tests do not play an important role in the diagnosis of chronic pancreatitis, since amylase, lipase and inflammatory markers may be perfectly normal or often only slightly increased. Determination of elastase and fat excretion in the stools may exhibit impaired exocrine function.
  • Glucose/HbA1c blood tests are important for endocrine pancreas function.
  • In chronic pancreatitis, exocrine function of the pancreas is frequently affected earlier and more seriously than endocrine function.
  • The diagnosis is made by means of imaging techniques, such as ultrasound, CT scan, MRI scan and endoscopic ultrasound.
  • Ultrasound and CT scan can show abnormalities of the parenchyma of the pancreas, such as calcifications, pseudocysts and tumours.
  • MRI (MRCP) is important in evaluating abnormalities of the pancreas duct, such as strictures, dilatations and intra-ductal concrements.
  • Endoscopic ultrasound can be helpful when there is any doubt, by taking a biopsy of the pancreas.
  • RAND-36 (quality of life)
  • VAS-Pain (maximal, minimal, actual, average/week)
  • PCS (catastrophising)
  • HADS (fear and depression)

Additional Psycho-cognitive Diagnostics

Multidisciplinary Treatment

Whether or not somatic treatment is indicated is based on the pain diagnosis. Based on the findings of the pain questionnaires, additional diagnostics and/or multidisciplinary treatment comprising various non-somatic treatments may be necessary.

Non-somatic Treatment

Somatic Treatment

First of all, any secondary complications should be treated (cysts, duodenal obstruction).

Pharmacological treatments:

  • According to the WHO three-step ladder
  • Long-acting opioids
  • Fast-acting opioids if necessary
  • Laxatives
  • Co-analgesics gabapentine

Interventional Pain Treatment