What does it do? Chronic Pancreatitis. What is the Pancreas? How is it diagnosed? How can chronic pancreatitis be treated?

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1 In association with: Primary Care Society for Gastroenterology INFORMATION ABOUT Chronic Pancreatitis What is the Pancreas? What does it do? What is chronic pancreatitis? What causes chronic pancreatitis? What symptoms do you get? How is it diagnosed? How can chronic pancreatitis be treated?

2 What is the pancreas? The pancreas is part of the digestive system. It lies high up in the upper half of the abdomen behind the stomach and in front of the spine. It is a solid flat gland about nine inches long, salmon pink in colour and shaped like a comma. The larger end is the head and the smaller end is the tail; in between is the body of the pancreas. The head is attached to the first part of the small intestine (duodenum), where all the food enters from the stomach. The tube (bile duct), which carries bile from the liver to the intestines, passes through the head of the pancreas where it is joined by the tube carrying the pancreatic digestive juices. The main blood vessels of the intestines go under the pancreas. The pancreas has two main functions. It produces digestive juice (enzymes which help to digest food) and insulin (a hormone which balances the sugar in your blood). The digestive juice flows into the duodenum and mixes with the food and bile to digest food. It also produces other hormones, which help with digestion and bicarbonate to balance the acid from the stomach. What is chronic pancreatitis? Chronic pancreatitis is the result of damage to the pancreas. Damage to the pancreas can result from a number of different causes see below. These can each result in inflammation of the pancreas, which results in scarring, fibrosis, and sometimes the development of calcium deposits in the gland. The scarring can result both in reducing insulin production from the pancreas and a reduction in enzyme production. This can result in failure to absorb fats or proteins. The scarring can result in different problems in different people. In some people, nerves can get irritated, causing pain. In others, the scarring can result in acute attacks of inflammation. In other people, the scarring can produce a lump in the pancreas, which can cause narrowing of the end of the pipe between the liver and the bowel (the bile duct). This can result in jaundice. In other patients, the inflammation can produce cysts on the pancreas (pseudocysts). Sometimes, scarring can cause a narrowing in the drainage tube from the pancreas (the pancreatic duct stricture). Insulin production can drop causing diabetes. What causes chronic pancreatitis? There are many causes of chronic pancreatitis but in the UK, most are associated with alcohol intake. Alcohol is toxic to the pancreas and some people are more susceptible to damage from alcohol than others. Other causes include a follow-on of damage from acute pancreatitis, some patients develop chronic pancreatitis because of an inherited tendency related to trypsinogen and inhibitory protein defects. Other causes include cystic fibrosis, following trauma and auto-immune problems; in some people who develop chronic pancreatitis, the cause is not understood. What symptoms do you get? Chronic pancreatitis causes two main problems. These are chronic pain and pancreatic insufficiency, which means a reduced ability of the pancreas to produce insulin and enzymes that help to digest fats. There are a number of other problems. Reduction in insulin production, which can lead to diabetes. Reduction in enzyme secretion fat malabsorption. This causes motions to become pale and bulky and frequently difficult to flush away. The result is weight loss. Chronic pain. This is usually felt in the upper abdomen and back and can vary from mild to very severe and unremitting. Recurrent flare-ups of acute inflammation. This can result in sudden onset of upper abdominal pain, vomiting and inflammation. Cyst formation. Sometimes, damage to the pancreas can produce cysts on the pancreas (pseudocysts). Blockage of the bile duct causing jaundice. Blockage of the duodenum causing vomiting. 2 3

3 How is it diagnosed? The diagnosis of chronic pancreatitis is based on typical clinical features such as the presence of fat malabsorption causing weight loss and characteristic upper abdominal and back pain. Sometimes, these are not present and people can present with recurrent attacks of acute inflammation. The diagnosis is usually confirmed with tests. These can include imaging such as ultrasound and CT scans. CT scans can reveal various features such as calcification within the pancreas, a lump in the pancreas, dilatation of the pancreatic duct or cyst formation. Other tests can be helpful to confirm the diagnosis and look more closely into the effects of chronic pancreatitis. These tests include endoscopic ultrasound scanning or magnetic resonance scanning of the pancreas, which can look for narrowing in the pancreatic duct. There are also tests, which measure the amount of fat that is not being absorbed in the gut. How can chronic pancreatitis be treated? The treatment for chronic pancreatitis depends on which problems the chronic pancreatitis is causing, and this can be very different in different patients. Treatment is directed whenever possible to correction of the underlying cause, to relieve pain and correct fat malabsorption and reverse weight loss. Diabetes may occur and will need treatment with drugs or insulin. The abdominal pain can be quite severe and require treatment with either simple pain killers or sometimes opiates. To reverse the fat malabsorption, replacement pancreatic enzyme capsules are available. Endoscopic Procedures Sometimes, an endoscope can be used to widen areas of narrowing in the pancreas or to remove stones which can, in a few patients, result in symptom improvement. Surgery Surgery is available in specialised centres for some suitable patients. Two types of operation are commonly employed. These sometimes involve removing the most affected part of the pancreas or other operations which involve draining the affected pancreas straight into another part of the bowel. These operations will not help everybody but typically, good results are obtained in six or seven out of ten patients. Other operations are sometimes required to correct the complications of chronic pancreatitis such as cyst formation. Cysts sometimes need draining which can be done both surgically and endoscopically depending on the suitability of the cyst. What research is needed Further research is needed on effective pain control in chronic pancreatitis and in better controlling the fat malabsorption that occurs. Research into the cyclical process of inflammation and fibrosis is needed - if this could be controlled it might be possible to prevent the progressive destruction of the pancreas. It is also important to find out why some people who drink alcohol are affected but others who seemingly drink similar amounts have no problems. 4 5

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