Chronic pancreatitis is a fibrotic disease of the pancreas that is characterised by recurrent episodes of abdominal pain, and gastrointestinal symptoms and signs of malabsorption. In some patients, involvement of the islet cells also results in diabetes.
Patients with chronic pancreatitis present with recurrent episodes of epigastric abdominal pain that radiates into the back. These episodes of pain occur over a prolonged period and, in alcohol-related pancreatitis, initially occur after bouts of heavy wrinking. However, as the disease progresses, episodes of pain also occur independently of alcohol consumption. In due course, the pain may be constant, with more severe attacks occurring intermittently. The pain at its worst is very debilitating because the patient often cannot find a position of comfort and needs high doses of parenteral analgesia for relief. The disease may be associated with varying degrees of malabsorption characterised by steatorrhoea and weight loss. In addition, symptoms and signs of diabetes may develop.
The diagnosis is made on the characteristic presentation plus confirmatory radiological investigations. Serological tests, in particular serum amylase, may be entirely normal in chronic pancreatitis. A plain abdominal X-ray may reveal calcification in the region of the pancreas. This may be confirmed by CT scanning, which may also show direct dilatation and atrophy of the pancreas. The most specific investigation is an ERCP. In patients with moderate to severe pancreatitis, changes will be demonstrated in the pancreatic duct. These changes include stricture formation and duct dilatation. Pancreatic calculi may also be demonstrated. The only useful test of pancreatic function is the measurement of faecal fat content to determine whether the patient has significant steatorrhoea. This is usually done by collecting faeces for 3 days and measuring the fat content of the faeces in the laboratory. An abnormal amount of faecal fat supports the diagnosis of malabsorption. A number of other tests of pancreatic enzyme function have been developed, but all are invasive and require prolonged study, thus making their indication of low value.
Chronic pancreatitis is one of the most difficult abdominal conditions to treat as there is no specific treatment for the ongoing chronic inflammatory disease and treatment is largely aimed at the symptoms and complications. For alcoholic patients, it is crucial that they abstain from alcohol consumption; otherwise no other form of treatment will be effective. It is important to realize that in alcoholic patients, the epigastric pain experienced after heavy drinking may not be solely due to pancreatitis and may be caused by alcoholic gastritis. Therefore, antacid therapy and treatment with gastric acid suppressing medication is important. The role of surgery in the treatment of chronic pancreatitis is limited and confined to those patients in whom it can be demonstrated that the cause is nonalcoholic or who have abstained from alcohol. Because pain is the major symptom of chronic pancreatitis, measures that aim to alleviate this are usually taken. Administration of oral pancreatic enzyme replacement medication reduces the hormone drive on the pancreas and may assist in the control of pain, in addition to appropriate oral analgesics. The pancreatic enzyme replacement therapy will also treat the steatorrhoea and assist with the treatment of malabsorption.