What is chronic pancreatitis and how is it treated?
Pancreatitis is a medical term that means the inflammation of the pancreas. The process can be acute or chronic. In acute form, the normal function of the pancreas can restore with timely treatment. In chronic form, acute periods alter with remission but over time, the function of the pancreas worsens.
Short information about pancreatitis
According to the latest data, the prevalence of chronic pancreatitis in Europe is 25-26 cases on 100,000 of people. In the US, it is 50 people per 100,000. The incidence of chronic pancreatitis has doubled over the past 30 years around the world.
In the majority of cases, the disease develops at the age of 35-50 years. The first stage of the disease can last up to 10 years and is distinguished by the alteration of remissions and flare-ups. The main complaint during this stage is pain in the left side of the abdomen.
The second stage is distinguished by the impaired bowel function and body mass loss while pains become less intense. The complications of the disease can develop at any stage. One of them is the entering of the digestive enzymes in the blood which causes severe intoxication.
Types of chronic pancreatitis
Chronic pancreatitis is a whole group of inflammatory pancreatic diseases of various origins. In this disease, the functioning structures of the organ are replaced by connective tissue (fibrosis).
The generally accepted international classification of chronic pancreatitis TIGAR-O helps to understand the causes of the disease, according to which the following types are distinguished:
- Toxic (metabolic), which is associated with alcohol and tobacco abuse; with hypercalcemia and hyperparathyroidism, leading to an increase in the concentration of calcium in the blood plasma; with chronic renal failure, as well as with the action of medications and toxins.
- Idiopathic, is associated with fatty degeneration of the pancreas and the replacement of normal organ tissue with adipose (fat) tissue.
- Hereditary form of the disease is a result of an inborn pancreas defect.
- Autoimmune, which can be accompanied by other autoimmune diseases or develop on its own.
- Chronic pancreatitis results from recurrent and severe acute pancreatitis. This category includes radiation pancreatitis (caused by radiation) and ischemic pancreatitis caused by vascular diseases.
- Obstructive pancreatitis can be caused by a tumor or a cyst of the duodenum, a complication of endoscopic procedures, and others.
In chronic pancreatitis, patients complain of acute abdominal pain, more often in the left side, spreading to the back. The pain is worse after eating and is partially relieved when sitting or leaning forward. Pain is observed in 80–90% of patients. In 10–20% of cases, chronic pancreatitis proceeds without pain. Intoxication is manifested in nausea, vomiting, general weakness, fever, and decreased appetite also occurs. The stool is mushy, oily, and contains undigested food particles.
Certain types of pancreatitis can be almost asymptomatic for the patient, but digestive disorders are still present. For example, heaviness in the lower part of the stomach, slight numbness in this area after eating or drinking alcohol.
With a decrease in the functional activity of the pancreas by more than 90%, a pronounced exocrine insufficiency occurs. It is characterized by a violation of the processes of digestion and absorption in the intestine, as well as the development of bacterial overgrowth in the small intestine. This leads to steatorrhea (excretion of excess fat in the feces) and flatulence. In 30–52% of patients, this condition may be accompanied by weight loss.
Causes of chronic pancreatitis
The main causes of pancreatic inflammation are associated with an unhealthy lifestyle and heredity.
Although alcohol is the cause of 60–70% of chronic pancreatitis cases, the term toxic pancreatitis does not necessarily mean chronic alcoholism or the effects of alcohol abuse. Heredity and other causes, including the sex of the patient, can play a basic role. Smoking is one of the factors that enhance the effects of alcohol. The results of a number of studies prove that the importance of tobacco smoking for the development of the disease may be more significant than the effect of alcohol.
Progression of the disease
Mortality after the initial diagnosis of chronic pancreatitis is up to 20% during the first 10 years. More than 50% of patients die 20 years after the diagnosis. The causes of death are complications associated with exacerbations of pancreatitis, concomitant digestive disorders and infections. The risk of pancreatic cancer in chronic pancreatitis increases 3.6 times.
In cases where hereditary pancreatitis is involved, symptoms usually appear before the age of 20. The disease has a rapid course. This increases the risk of developing such a malignant tumor as adenocarcinoma.
Diagnostics of chronic pancreatitis
It is quite difficult to diagnose chronic pancreatitis at an early stage. The initial diagnosis can be facilitated by the set of tests and examinations:
- A general blood test to detect signs of inflammation by the number of leukocytes, an increase in the erythrocyte sedimentation rate (ESR) and other indicators.
- Biochemical blood test to determine the level of pancreatic enzymes, assess nutritional status.
- Analysis of urine to determine the presence of amylase.
- Ultrasound of the abdominal organs to detect changes in the pancreas and other organs of the gastrointestinal tract.
- Gastroscopy to assess the involvement of the stomach and duodenum in the inflammatory process.
- Coprogram (feces analysis) allows assessing the quality of absorption of nutrients by the body.
- Radiography of the abdominal organs to detect pancreatic calcification and intraductal stones.
- Functional tests (secretin-cholecystokinin test, Lundh's test, and so on).
How is chronic pancreatitis treated?
Like diagnostics, the tactics of treating this disease requires an integrated approach. The therapy is aimed at normalizing and restoring the functions of the pancreas.
Chronic pancreatitis requires adherence to diet, drug therapy, and in some cases, surgery. The methods of treatment can differ from patient to patient since chronic pancreatitis can have various causes and differ in degrees of intoxication.
As for acute pancreatitis attack, you should immediately take the patient to a hospital for a qualified examination. And for the next three days, hunger, complete rest in a horizontal position, clean air and cold are needed (you can apply a heating pad with ice to the stomach area and ventilate the room).
Taking medications for chronic pancreatitis is aimed at eliminating several problems:
For this, periodic or course use of non-narcotic painkillers is prescribed, for example, with the active substance paracetamol. If it is ineffective, narcotic analgesics are prescribed (due to the high risk of dependence, they should be taken for no more than two weeks). The active substance Tramadol is preferred (the daily dose should not exceed 800 mg). Pregabalin, anticonvulsant and anxiolytic medication used to treat neuropathic pain can be also used as it additionally has an anti-anxiety effect, which may have a positive effect on some patients.
Typically, if pain worsens after a meal, doctors recommend taking analgesics 30 minutes before meals to minimize pain. If this dependence is not observed, drugs are taken after meals in order to reduce the risk of damage to the gastric mucosa.
Surgical intervention is required in the case when pain cannot be stopped for three months, in case of disability, which significantly reduces the quality of life, or in case of complications of chronic pancreatitis that require surgical intervention, as well as if pancreatic cancer is suspected.
Surgical treatments for chronic pancreatitis are direct and indirect. Indirect methods include operations on the biliary tract, and gastrointestinal tract. The direct ones include drainage of cysts, removal of stones, and resection of the gland.
Surgical treatment of chronic pancreatitis is indicated in the following cases:
- A complicated form of the disease, accompanied by obstructive jaundice;
- Acute pain that does not disappear with long-term conservative treatment;
- The occurrence of a cyst or a tumor.
There is no scientifically grounded "pancreatic" diet. Therefore, an individual approach to the problem in order to expand the diet (in combination with enzyme replacement therapy) to prevent nutritional deficiencies, is required. Of course, fried, smoked, salty, spicy dishes and coarse vegetable fiber, strong tea, coffee, cocoa, sweet carbonated drinks, mushrooms, baked goods should be excluded. Ideally, a patient's diet should not differ in composition and quantity from that of a healthy person.
Mineral waters are also indicated. The diet should be fractional - five to six, sometimes eight times a day. A high protein and carbohydrate content in food is desirable, if this does not increase pain, nausea, heartburn, and other dyspeptic symptoms. With exocrine pancreatic insufficiency, fat restriction is necessary to the extent required in a particular case. Oftentimes, unrefined vegetable fats should not be limited, but they should be moderately and evenly distributed throughout the day.
During an exacerbation, fasting may be prescribed for two to four days.
Prevention of chronic pancreatitis
Treatment of chronic pancreatitis in a hospital and on an outpatient basis will not give a long-term effect without further prevention.
To save life and reduce serious complications, a patient with chronic pancreatitis must completely stop drinking alcohol and quit smoking. This is recommended regardless of the cause of the disease, the usual consumed dose of alcohol and the daily amount of cigarettes smoked. This rule applies to all patients with chronic pancreatitis, regardless of the duration of alcohol intake and smoking. In addition, patients who do not consume alcohol benefit from more effective pain-relief therapy.
It is also important to timely treat diseases of the biliary tract, stomach and duodenum, and adhere to proper nutrition. These measures will allow for chronic pancreatitis to extend the period of remission.
Treatment of chronic pancreatitis requires a serious revision of lifestyle and habits from a person. Certain categories of patients should be under constant supervision in connection with the risk of adenocarcinoma. We are talking about people over 60 years old, patients with hereditary pancreatitis, as well as those who have blood relatives with thyroid cancer.
Post by: Natalie Keller, M.D. General Health Centre, Minneapolis, Minnesota
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