Chronic Pancreatitis: Diagnosis and Management

Posted By SHL Librarian

Presented by: Walter G. Park, MD, MS
Instructor, Gastroenterology and Hepatology
Stanford University Medical Center
October 13, 2011

Unlike acute pancreatitis—a sudden inflammation of the pancreas—chronic pancreatitis is a long-term condition that alters the organ’s normal structure and function, and can cause persistent, debilitating pain.

The pancreas is a gland located directly behind the stomach, and close to the spine, that serves two primary functions: to produce insulin, a hormone needed to regulate glucose metabolism, and to make digestive enzymes that help absorb nutrients in the food you eat.

It is estimated that in Western Europe and North America, chronic pancreatitis is diagnosed in three to nine people in 100,000. While not common, chronic pancreatitis has a significant effect on quality of life and economic productivity, says Walter G. Park, MD, MS, an instructor of gastroenterology and hepatology, at a presentation sponsored by the Stanford Health Library.

One large-scale study showed that only 40 percent of patients with the condition could work, and 16 percent were disabled. The disease also affects social life, personal relationships, and daily activities. It is most prevalent in middle-aged men (70-90 percent are male).

Causes and Symptoms
The most common cause is long-term heavy alcohol abuse, which is believed to account for approximately 70 percent of all cases. But since only about 10 percent of alcoholics develop chronic pancreatitis, Dr. Park said drinking is probably only a trigger for people with an underlying vulnerability rather than a direct cause.

Other possible causes include nicotine; cancer or cysts that may create anatomical obstructions; high triglyceride levels; and certain medications, but about 20 percent of all cases are from unknown (idiopathic) origins. (New studies point to changes in these statistics: 44 percent from alcohol, 29 percent idiopathic, and 27 percent from other causes.)

Symptoms range from severe abdominal pain to nausea, weight loss, and eventual diarrhea and malnutrition. Many develop diabetes because the pancreas is no longer able to produce insulin properly. A doctor may suspect the disease because of the patient’s symptoms, history of repeated acute pancreatitis flare-ups, or alcohol abuse.

Under a microscope, a tissue sample will show cell atrophy, chronic inflammation, scar tissue, and/or ductal changes, but there currently is no safe and reliable way to get the tissue, said Dr. Park. “We do not have a way to acquire a tissue sample without the risk of surgery.” he said. “That means we need to rely on other means to make a diagnosis.”

Diagnosis and Management
Structural tests, such as a CT or MRI scan, can show physical damage to the pancreas, but not until the disease is relatively advanced. An endoscopic ultrasound or a magnetic resonance cholangiopancreatography (MRCP) test are now used as a noninvasive approach to looking for common features of the disease. Functional tests are used to stimulate hormones and measure the organ’s ability to respond. Blood tests may also be used to check the blood glucose levels, which may be elevated.

“In terms of managing the disease, the key problem is debilitating pain,” said Dr. Park. “But we also need to address malnutrition, diabetes, and other complications.”

The pain associated with chronic pancreatitis may be a result of a plumbing problem, an obstruction of pancreatic secreted fluid causing a buildup of pressure and reduced blood flow. Surgery can be used to open the duct, but 25 to 50 percent of patients still have pain after surgery, he said. The pain could also be a wiring problem, caused by the inflammation of nerves that alters the biology of the pancreas and eventually changes the perception of pain.

While pain is a key symptom of chronic pancreatitis, the use of opiate-type pain medications should be minimized because the condition is long term and there are many side effects with long-time usage of these drugs, he said. Instead, medications may include antioxidants, like selenium, vitamin E, vitamin C, or beta carotene; selective serotonin re-uptake inhibitors (SSRIs); anticonvulsants; or neuropathic medications that help to alter the perception of pain.

Other tools include enzyme replacement therapy and endoscopic treatment to drain fluid or remove stones. “For some select patients, surgery may be an option,” said Dr. Park, such as a procedure to remove a ductal obstruction or to remove the most damaged part of the gland.

Multidisciplinary Care
Dr. Park works closely with a variety of other specialists to help treat pain, minimize other complications, and maintain quality of life. He collaborates with experts from the Stanford Pain Center, as well as surgeons, radiologists, and advanced endoscopists.

He also works with nutritionists to help patients manage their diet and to track them for signs of nutrient deficiencies. “Malnutrition can show up 10 to 15 years into the disease,” he said. “Patients need to be reminded to stop drinking, smoking and to modify their diet.”

People with chronic pancreatitis should keep a diet log to track their food intake. They need to eat more calories using a low-fat diet and maintain their metabolism by eating four to six small meals a day. Supplements like Ensure and medium-chain triglycerides like coconut oil and palm kernel oil are also recommended.

About the Speaker
Walter Park, MD, MS, is an instructor of medicine (gastroenterology and hepatology), with a particular interest in the diagnosis and management of acute and chronic pancreatitis. He received his medical degree at Johns Hopkins School of Medicine and completed his residency in internal medicine and a fellowship at Stanford, where he also received an MS in health services research. He is Board Certified in internal medicine and in gastroenterology by the American Board of Internal Medicine.

For More Information:

Stanford Health Library can do the searching for you. Send us your medical questions.

About Dr. Park
http://med.stanford.edu/profiles/Walter_Park

Stanford Digestive Health Program
http://stanfordhospital.org/digestivehealth/pancreas/Stanford

Division of Gastroenterology and Hepatology
http://gastrohep.stanford.edu/

Stanford Pain Management Center
http://paincenter.stanford.edu/