Chronic pancreatitis / Diseases / EXPERT Clinic

Chronic pancreatitis (CP) is a long-term inflammatory disease of the pancreas, with manifestations in the form of irreversible changes in the structure of the organ, which cause pain and/or a persistent decrease in its function.

The pancreas performs important functions:

secretion of most digestive enzymes
production of insulin (a hormone whose deficiency develops diabetes mellitus)

There is a worldwide trend toward an increase in the incidence of acute and chronic pancreatitis, more than doubling over the past 30 years.

Reasons for the development of pancreatitis

The most common cause of chronic pancreatitis is alcohol consumption, and the quality and raw materials from which the drink is made do not matter.

Other reasons

Toxins and metabolic factors:
smoking
increased calcium levels in the blood (develops in patients with a tumor of the parathyroid glands)
overeating and eating fatty foods
protein deficiency in food
effects of medications and toxins
chronic renal failure
Blockage of the pancreatic duct:
due to dysfunction of the sphincter of Oddi
blocking of the duct by a tumor, cysts
post-traumatic scars of the pancreatic ducts (complication of endoscopic procedures: papillosphincterotomy, stone removal, etc.)
Pathology of the gallbladder and biliary tract.
Pathology of the duodenum.
Consequences of acute pancreatitis.
Autoimmune mechanisms.
Heredity (gene mutations, 1-antitrypsin deficiency, etc.).
Helminths.
Insufficient oxygen supply to the pancreas due to atherosclerosis of the vessels supplying blood to this organ.
Congenital anomalies of the pancreas.
Idiopathic chronic pancreatitis (the cause cannot be determined).

Symptoms of pancreatitis

abdominal pain: usually the pain is localized in the epigastrium and radiates to the back, increasing after eating and decreasing when sitting or bending forward
nausea, vomiting
diarrhea, steatorrhea (fatty stool), increased stool volume
bloating, rumbling in the stomach
weight loss
weakness, irritability, especially on an empty stomach, sleep disturbance, decreased performance
the symptom of “red drops” is the appearance of bright red spots on the skin of the chest, back and abdomen.

If such symptoms appear, it is recommended to undergo examination to exclude chronic pancreatitis.

Complications of chronic pancreatitis

If left untreated, possible complications of chronic pancreatitis include:

diabetes
vitamin deficiency (mainly A, E, D)
increased bone fragility
cholestasis (with and without jaundice)
inflammatory complications (inflammation of the bile ducts, abscess, cyst, etc.)
subhepatic portal hypertension (fluid accumulation in the abdominal cavity, enlarged spleen, dilation of the veins of the anterior abdominal wall, esophagus, liver dysfunction)
effusion pleurisy (fluid accumulation in the membranes of the lungs)
compression of the duodenum with the development of intestinal obstruction
pancreas cancer.

First aid for an attack of pancreatitis

To reduce pain, you can use a heating pad filled with cold water. It needs to be applied to the abdominal area, namely to the epigastric region (the area under the xiphoid process, corresponding to the projection of the stomach onto the anterior abdominal wall). This allows you to reduce the intensity of pain, slightly reduce swelling and inflammation.

The patient must comply with the hospital regime. This will reduce blood flow to the organ, and therefore reduce inflammation.

Eating is prohibited. The digestion process can cause more severe pain, nausea and vomiting. And the diet will reduce the production of enzymes that increase the inflammatory response and pain. You need to fast for 3 days. You can drink clean water without gases.

It is imperative to call a doctor for an examination, even if the patient is not exactly sure that this is an attack of acute pancreatitis. As we already know, this pathology can subside and then rapidly recur. At this time, you can take a painkiller to reduce discomfort.

Severity of chronic pancreatitis

There are three degrees of severity of chronic pancreatitis:

Mild degree

exacerbations are rare (1-2 times a year), short-lived
moderate pain
no weight loss
no diarrhea, no fatty stools
Coprological examination of stool is normal (no neutral fat, fatty acids, soaps)

With mild severity of chronic pancreatitis, long courses of medication are usually not required, since lifestyle changes and giving up bad habits often prevent relapses.

Average degree

exacerbations 3-4 times a year, occur with prolonged pain syndrome
There may be an increase in amylase and lipase in the blood
periodic loose stools, greasy stools
there are changes in the coprogram

With moderate severity of chronic pancreatitis, a strict diet, longer courses of therapy, and constant supervision by the attending physician are necessary.

Serious condition

frequent and prolonged exacerbations with severe, prolonged pain syndrome
frequent loose stools, fatty stools
loss of body weight, up to exhaustion
complications (diabetes mellitus, pseudocysts, etc.)

In severe cases of chronic pancreatitis, constant maintenance therapy, stronger medications and a strict diet are required. Often, patients need careful monitoring not only by a gastroenterologist, but also by doctors of other specialties (endocrinologist, surgeon, nutritionist). Emerging exacerbations, as well as complications of the disease, pose a threat to the patient’s life and, as a rule, are an indication for hospitalization.

The presence of chronic pancreatitis, regardless of severity, requires immediate consultation with a doctor, since without treatment and lifestyle changes, the process will steadily progress.

Treatment Basics

The approach to treating pancreatitis varies depending on the form of the disease. In acute severe form of pancreatitis, when there is pain and constant vomiting, the patient is hospitalized. In case of a chronic disease and in the absence of relapses, hospitalization is not required; doctors fight the cause of the disease with the help of drugs.

Acute pancreatitis on a CT image. Photo: Hellerhoff / (Creative Commons Attribution-Share Alike 3.0 Unported license)

After admission to the hospital with acute pancreatitis, the patient is not fed, as a rule, for the first 48 hours. A tube is inserted into the stomach to remove its contents. If there are complications (bleeding, acute intestinal obstruction, suppuration, etc.), the patient is referred for surgery.

Next, the doctor prescribes various medications to reduce the load on the gland, reduce pain and prevent the development of infection.

With pancreatitis, control of the production of pancreatic digestive enzymes is vital. Lack of oral nutrition in the first week after the attack is over is the most effective way of such control. Therefore, parenteral nutrition is used, that is, intravenous infusion through a dropper, or enteral nutrition, in which nutritional mixtures are administered through a tube.

Pancreatitis can occur with a complication in the form of death of part of the pancreas or the entire organ (pancreatic necrosis). In this case, doctors adhere to a conservative method of treatment with the help of medications. In case of infected pancreatic necrosis, the use of antibiotics is mandatory. If conservative treatment does not help and the patient progresses to multiple organ failure, suppuration, pancreatic necrosis or pancreatic cancer, surgery is prescribed.

At the first stage, doctors prefer to minimize surgical intervention in the body. First, puncture and drainage of the pancreas and retroperitoneum are performed. To do this, using small incisions, special tubes (drains) are inserted inside, which remove excess liquid and wash the cavity with special solutions.

In case of a more severe condition of the patient and widespread damage to the gland, they resort to alternative treatment tactics, which include:

laparotomy, that is, external drainage, in which incisions are made in the abdominal wall,
resection of the gland or removal of it entirely.

Removing the gland is an extreme measure; it is resorted to in a situation where the organ can no longer be restored. It is possible to live without a gland, but you will have to artificially maintain its functions: take insulin, enzyme preparations and follow a very strict diet.

How to cope with an attack of pancreatitis?

The main task when severe pain occurs is to provide the gland with cold, hunger and peace. You should not eat anything and consult a doctor immediately. To relieve inflammation, you need to put a cold compress on your stomach.

Diagnosis of pancreatitis

The EXPERT Clinic has an algorithm for diagnosing chronic pancreatitis, which includes:

Laboratory methods:

A clinical and biochemical blood test is performed (of particular importance is the level of pancreatic enzymes in the blood - amylase, lipase)
coprogram - the presence of certain substances in the stool (fats, soaps, fatty acids, etc.) is assessed. Normally, they should be absent, but in chronic pancreatitis, due to insufficient production of enzymes by the gland to break down these substances, they remain undigested and are detected in the feces
fecal elastase is an enzyme of the pancreas, the level of which decreases when it is not working enough
in certain cases, it is important to determine cancer markers
If a hereditary genesis of the disease is suspected, a genetic examination of the patient is carried out.

Instrumental studies

Ultrasound of the abdominal cavity. Signs of inflammation of the pancreatic tissue, the presence of stones in the ducts, calcifications, cysts, and tumors of the pancreas are assessed. Additionally, changes in other organs of the gastrointestinal tract are determined to exclude complications of the disease, as well as concomitant pathologies.

Elastography of the pancreas.
Allows you to determine whether there is fibrosis (hardening) of the pancreas, which is a criterion for the severity of structural changes in the organ. Ultrasound with elastography of a healthy pancreas
FGDS. Visualization of the duodenum is necessary to assess the presence of inflammation in it, as well as indirect signs of pancreatitis. It is necessary to exclude inflammation and pathological formations (tumor, diverticulum) in the area of the large duodenal nipple (through it, pancreatic secretions enter the duodenum; when it is blocked, the outflow of this secretion is disrupted, which leads to inflammation of the gland tissue). Visualization of the stomach and esophagus is necessary to exclude erosions, ulcers, and inflammation in them. Pathological changes in these organs are often combined with chronic pancreatitis, being mutually aggravating conditions.

Additionally, CT and MRI of the abdominal cavity with cholangiography and RCHP may be prescribed. They are necessary to confirm the diagnosis, and are also prescribed if there is a suspicion of the presence of pathological formations in the pancreas, blockage of the gland ducts with a stone, tumor or cyst.

Drugs

The main task in the treatment of pancreatitis is to get rid of the cause that caused the inflammation and prevent the onset of complications. Therefore, doctors prescribe a whole course of tablets that should help the digestive system cope with the malfunction (Fig. 3).

Figure 3. To treat pancreatitis, medications of different directions of action are used. Source: MedPortal

Antispasmodics for pancreatitis

Antispasmodics are prescribed to relieve pain and muscle spasms. They can be administered intramuscularly or intravenously. The main ones include those containing drotaverine, mebeverine, pinaverium bromide, m-anticholinergics (metocinium iodide, atropine).

Enzymes and antienzyme drugs for pancreatitis

With pancreatitis, the gland is unable to produce enzymes necessary for digestion. Therefore, the patient must receive them from outside. In addition, the introduction of enzymes allows the gland to reduce their production and rest. Enzymes are prescribed only in the absence of exacerbation. They are divided into those that contain pancreatin (with and without bile components), and those that contain only components of plant origin (simethicone, chymopapain).

In acute pancreatitis, intoxication of the body occurs. Enzymes accumulate in the pancreas and, instead of going further to the duodenum, enter the blood. Anti-enzyme drugs are used to cleanse the body and relieve stress on the pancreas. They are drunk in the first 5 days from the onset of the disease. The main active ingredient of such drugs is aprotinin.

Important! Enzyme preparations must be taken with every meal. The enzyme preparation, its dosage and duration of treatment are determined only by the doctor. Under no circumstances should you take enzymes for acute pain. Such pain indicates worsening inflammation in the pancreas. Taking enzymes in this case will lead to increased intraductal pressure, which in the future will lead to blockage of blood vessels and necrosis.

Antacids

Hydrochloric acid, which is contained in gastric juice, triggers the work of the pancreas. The more of this acid, the more actively the iron works. With pancreatitis, increased activity of the organ leads to pain and complications. Antacids are used to reduce acidity in the stomach. They contain algeldate and magnesium hydroxide, which neutralize stomach acid. Doctors give preference to drugs in liquid form.

Antisecretory

Antisecretory drugs reduce the production of hydrochloric acid, which is contained in gastric juice. Its excessive amount leads to the fact that the alkaline pancreatic secretion is not able to neutralize the acidity of the environment. It is the alkaline environment that provides the best conditions for digestion, so its restoration is one of the tasks in the fight against pancreatitis. Another function of such drugs is to have a cytoprotective effect. They increase the secretion of protective mucus, increase blood flow to the digestive system and promote scar healing.

H2 blockers

These are antihistamine antisecretory agents. Their action is aimed at preventing the excitation of H2 receptors, which stimulate the work of all glands: salivary, gastric, pancreas. They reduce the acidity of gastric juice, delay the production of hydrochloric acid and pepsin, which breaks down protein. These include drugs containing famotidine, ranitidine, etc.

Proton pump inhibitors

Medicines whose purpose is to block the work of the proton pump located in the gastric mucosa and thereby reduce the acidity of the stomach by reducing the production of hydrochloric acid. The same acid that is necessary for digestion, but in large quantities leads to gastritis, and then to ulcers. Such drugs are benzimidazole derivatives. This includes drugs containing omeprazole, pantoprazole, lansoprazole, etc.

Treatment of pancreatitis

The main treatment for chronic pancreatitis is diet and giving up bad habits, lifestyle changes, as well as medications:

drugs that reduce the production of hydrochloric acid by the stomach (proton pump inhibitors)
enzyme preparations
antispasmodics
in the presence of pain - analgesics, NSAIDs; if the pain is extremely severe and is not eliminated by these drugs, narcotic analgesics are prescribed.

It is necessary to identify during the initial examination the pathology of other organs of the gastrointestinal tract (cholelithiasis, chronic cholecystitis, gastritis, duodenitis, peptic ulcer, hepatitis, bacterial overgrowth syndrome, intestinal dysbiosis, kidney disease, etc.), since these diseases may be the cause and/or aggravating factors of chronic pancreatic inflammation. In this case, treatment of other gastrointestinal diseases is necessary. The decision on the urgency and procedure for treating a particular concomitant disease is made by the attending physician.

If medications taken by a patient for other diseases may contribute to the development of the disease, the issue of replacing medications is decided.

All types of drug therapy should be prescribed and monitored by a gastroenterologist.

If any mechanical obstruction to the outflow of bile is detected, surgical treatment is indicated for the patient.

Forecast

Chronic pancreatitis is a serious disease. However, if you follow the recommendations of the supervising physician for the prevention of exacerbations (compliance with dietary recommendations, preventive courses of treatment, etc.), chronic pancreatitis proceeds “calmly”, without frequent exacerbations and has a favorable survival prognosis.

If the diet is violated, alcohol intake, smoking and inadequate treatment, degenerative processes in the gland tissue progress and severe complications develop, many of which require surgical intervention and can be fatal.

Prevention and recommendations

Prevention is based on eliminating risk factors that provoke the disease:

timely treatment of diseases that provoke pancreatitis
eliminating the possibility of chronic intoxication that contributes to the development of this disease (industrial, as well as alcoholism)
ensuring a balanced diet and daily routine.

Nutrition for chronic pancreatitis

For pancreatitis, all dishes are made from lean meat and fish - and then only in the boiled version. Fried foods are prohibited. You can consume dairy products with a minimum percentage of fat content. It is advisable to drink only natural juices, compotes and tea from liquids.

The following should be completely excluded:

all types of alcohol, sweet (grape juice) and carbonated drinks, cocoa, coffee
fried foods
meat, fish, mushroom broths
pork, lamb, goose, duck
smoked meats, canned food, sausages
pickles, marinades, spices, mushrooms
white cabbage, sorrel, spinach, lettuce, radishes, turnips, onions, rutabaga, legumes, raw ungrated vegetables and fruits, cranberries
pastries, black bread
confectionery, chocolate, ice cream, jam, creams
lard, cooking fats
cold food and drinks

A qualified nutritionist will help you think through the basics of nutrition for chronic pancreatitis, create a diet and take into account the wishes and habits of the patient.

Diet for pancreatitis

For any form of the disease, the patient is prescribed a strict diet “Table No. 5p”, according to which it is forbidden to eat spicy and fried foods. All dishes are steamed, boiled or baked. Alcohol and smoking are also prohibited.

It is also necessary to limit salt intake and eat small portions 6 times a day. Dishes should always be served warm. It is necessary to exclude all products with a high content of extractives or essential oils (fish, meat broths, cocoa, coffee, etc.), fresh berries, vegetables, herbs, fruits, sour juices, carbonated drinks, marinades.

FAQ

Does the pancreas die in chronic pancreatitis?

Chronic pancreatitis is a disease characterized by inflammation and dystrophy with subsequent development of connective tissue in the organ and disruption of digestive and endocrine function. The “death” of the gland is called pancreatic necrosis and occurs in acute pancreatitis, being a deadly condition

Why does pancreatitis develop if I don’t drink?

Indeed, in most cases, the development of pancreatitis is caused by the effect of alcohol, but there are other factors: cholelithiasis, liver diseases characterized by impaired formation and outflow of bile, diseases of the stomach and duodenum, heredity, a malfunction in the immune system, impaired blood supply to the organ, background diseases: viral hepatitis, hemochromatosis, cystic fibrosis, etc.

Can pancreatitis be cured?

Chronic pancreatitis is called chronic because it cannot be completely cured, but correct medical tactics can achieve long-term remission.

Can pancreatitis lead to the development of diabetes?

Yes, a long course of pancreatitis can lead to the development of not only a violation of the digestive function of the pancreas, but also a change in the endocrine function with the development of diabetes mellitus, especially in the presence of a hereditary predisposition to diabetes mellitus.

Is it important to follow a diet for pancreatitis?

Diet is a fundamental factor in achieving remission.

Pathogenesis of the disease

Inflammatory phenomena in the pancreas gradually lead to degenerative changes in its structure, tissue sclerosis and obliteration of the ductal system. This process usually occurs in waves. The exacerbation is replaced by remission, instead of the glandular tissue that produces enzymes, connective tissue appears. Gradually, enzymes become insufficient; first of all, the exocrine function of the pancreas (production of digestive enzymes) decreases, and then the endocrine function (decreased insulin production).

Symptoms of pancreatic enzymatic insufficiency appear when normal pancreatic tissue is damaged by 90%.

Triad of symptoms of chronic pancreatitis

pancreatic calcification;
diabetes;
steatorrhea is characteristic of an advanced stage of the disease. Steatorrhea occurs when lipase production by the pancreas falls below 16% of its normal level.

Impaired processing and absorption of nutrients in chronic pancreatitis leads to poor absorption of proteins, fats and vitamins. As a result, exhaustion, asthenia, and metabolic disorders of bone tissue and the blood coagulation system may develop.

Treatment stories

Story No. 1

Patient X., 52 years old, came to the EXPERT Clinic with complaints of girdling pain after eating fatty foods and a small amount of alcohol, nausea, and loose stools. From the anamnesis it is known that discomfort in the area above the navel with loose stools was observed for several years due to dietary errors, but after following a strict diet they disappeared without a trace. The woman was not examined for this reason. This is the first time that real complaints have arisen. In addition, 20 years ago, during pregnancy, the patient was told about the presence of thick bile on ultrasound. The patient was not examined further, as nothing bothered her. During a laboratory and instrumental examination, changes in blood tests were revealed: increased ESR, pancreatic amylase activity, and ultrasound revealed multiple stones in the gall bladder. After pain relief, the patient was referred for planned surgical treatment - removal of the gallbladder. After a successful operation, the patient continues to be monitored by a gastroenterologist, follows dietary recommendations, has no complaints, and her indicators have returned to normal.

Story No. 2

Patient B., 56 years old, applied to the EXPERT Clinic with complaints of periodic intense pain syndrome of a shingles nature for no apparent reason, accompanied by nausea and diarrhea. At the previous stage of the examination, diffuse changes in the structure of the pancreas were identified, which was regarded as chronic pancreatitis. The patient led a healthy lifestyle, did not drink alcohol or fatty foods. The prescribed treatment with enzyme preparations did not have a significant effect. When trying to find out the cause of the development of pancreatitis, the gastroenterologist at the EXPERT Clinic ruled out a number of diseases that could lead to the development of chronic pancreatitis (gastrointestinal tract disease, peptic ulcer, iron metabolism disorder, etc.) and drew attention to an immunological shift in laboratory tests. This served as the basis for an in-depth immunological examination, which made it possible to establish that the cause of damage to the pancreas was a malfunction of the immune system - autoimmune pancreatitis. A pathogenetic treatment was prescribed that influenced the mechanism of development of the disease - glucocorticosteroids according to a regimen, against the background of which, during a control examination, the signs of immune inflammation were eliminated. Currently, the patient is receiving long-term maintenance therapy under the supervision of a supervisor and has no complaints. During control ultrasound of the abdominal organs, no signs of pancreatic edema were detected.