Chronic Pancreatitis
Chronic pancreatitis can cause recurrent bouts of abdominal pain, slow gastric emptying (gastroparesis), diabetes, bile duct obstruction, and gastrointestinal issues related to low levels of pancreatic enzymes. The causes of chronic pancreatitis are numerous and include smoking and alcohol consumption, anatomic variants such as pancreas divisum, trauma to the pancreas, recurrent acute pancreatitis, familial genetic syndromes, and others. Patients who suffer from chronic pancreatitis can find it completely debilitating. It can interfere with their work, personal lives, and even simple daily tasks. Opioid dependence is often associated with chronic pancreatitis and contributes to the poor quality of life of patients suffering from the disease.
Chronic inflammation of the pancreas causes the gland to become fibrotic and its function becomes impaired. There are many anatomic variations of chronic pancreatitis and the pattern of disease dictates which treatments may be most beneficial. First and foremost lifestyle changes are necessary to prevent the progression of the disease. Cessation of alcohol consumption and smoking are necessary. Smoking is extremely toxic to the pancreas and is the major risk factor for recurrent acute pancreatitis transforming into chronic pancreatitis and also is a major risk factor for the development of pancreatic cancer.
Endoscopic retrograde cholagiopancre-atograph (ERCP)
This procedure is typically the first intervention for the treatment of chronic pancreatitis. Through ERCP obstructing stones in the pancreatic duct can be removed and narrowed areas in the pancreatic duct (strictures) can be stented. Some patients do not respond or only temporarily respond to ERCP, at which point they are considered for surgery.
Peustow procedure
When the main pancreatic duct is dilated more than 6mm, this procedure is performed. It involves opening the pancreatic duct over the length of the gland and suturing a piece of intestine to the duct so that it drains properly. This procedure can be very successful in select patients and can be performed robotically in a minimally invasive fashion.
Frey Procedure
This procedure is good for patients who have severe inflammation in the head of the pancreas with associated dilation of the main pancreatic duct. It involves coring out the tissue in the head of the pancreas and opening the main pancreatic duct along the length of the gland then sewing a piece of intestine over the cored-out region and the duct to improve drainage.
Whipple Procedure
This procedure is used for patients who have disease localized in the head of the pancreas without associated ductal dilation. It involves removal of the head of the pancreas, lower bile duct, and a portion of the stomach with the first portion of the intestine. It is especially helpful for patients who have associated slow emptying of the stomach (gastroparesis) and/or narrowing of the bile duct.
Distal Pancreatectomy with/without Splenectomy
This procedure is performed in cases where the disease is located in the body or tail of the pancreas. It involves the removal of that portion of the gland. The decision to remove the spleen is made based on whether or not the splenic vein has a clot in it. If the splenic vein is clotted due to the chronic inflammation in that region, the spleen will be removed to prevent gastrointestinal bleeding in the future. This procedure by the pancreatic surgeon can often be performed robotically, so the recovery is short
Before surgery
The steps followed before surgery are:
- An office visit for surgical consultation where a comprehensive history and physical exam is performed.
- Completion of clinical tests for workup and staging.
- Multidisciplinary tumor board review for an expert recommendation regarding treatment strategy.
After surgery
The type of surgical procedure done determines the kind of post-surgery care required. Post care after a surgical operation involves:
- A brief admission to the ICU is sometimes required for complex procedures such as a whipple procedure. Recovery then continues in the hospital ward for another three to five days. Procedures performed robotically typically have a faster recovery and can expect discharge from the hospital one or two days earlier than after open procedures.
- The goals of postoperative care include: monitoring for and intervening on any complications that can occur, awaiting the resumption of normal bowel function, maintaining adequate hydration and nutrition, physical and occupational rehabilitation, and providing adequate pain control. Once these measures are met, the patient will be discharged from the hospital. Post-operative follow-up will be scheduled one week from discharge with Dr. Tierney.
Frequently Asked Questions About Chronic Pancreatitis
What is chronic pancreatitis and what causes it?
Chronic pancreatitis is long-term inflammation of the pancreas that gradually replaces working tissue with scar tissue, so the gland becomes fibrotic and stops functioning properly. Unlike acute pancreatitis, which is a single episode that usually settles, the damage in chronic pancreatitis accumulates and does not reverse. Common causes include alcohol and smoking, repeated episodes of acute pancreatitis, and anatomical variants such as pancreas divisum. It can also follow injury to the pancreas or arise from inherited genetic conditions. In some people no cause is ever identified. Smoking deserves particular mention because it is strongly toxic to the pancreas and is a major driver of acute pancreatitis progressing to chronic disease.
What are the symptoms of chronic pancreatitis?
The dominant symptom is abdominal pain, often in the upper abdomen and radiating to the back, which may come in episodes or become constant. Many people find it genuinely disabling, affecting work, family life and ordinary daily tasks. As the gland loses function, other problems follow. Reduced enzyme production causes bloating, greasy or floating stools, weight loss and difficulty absorbing nutrients. Reduced insulin production causes diabetes. Some patients develop slow stomach emptying, called gastroparesis, or blockage of the bile duct causing jaundice. Symptoms vary considerably depending on which part of the gland is affected and how advanced the scarring is.
How is chronic pancreatitis diagnosed?
A CT scan is usually the first test, and it does more than confirm the diagnosis. It shows how severe the scarring is, whether the pancreatic duct is dilated, whether stones or narrowed segments are present, and where in the gland the disease sits. That anatomical picture is what determines which treatments are likely to help. Blood tests assess pancreatic function, blood sugar and nutritional status, and a formal nutritional assessment is part of the workup. Further imaging such as MRI or endoscopic ultrasound is sometimes needed, particularly where it is important to distinguish chronic inflammation from a tumour, which can look similar.
Can chronic pancreatitis be cured?
No, and it is important to be straightforward about that. The scarring already present in the gland is permanent, and no treatment reverses it. What treatment can do is slow the disease down, relieve pain, and manage the consequences of a pancreas that no longer works fully. Stopping alcohol and stopping smoking are the two changes that most affect how quickly the disease progresses, and they matter more than any procedure. Pancreatic enzyme supplements taken with meals restore digestion, and diabetes is treated as it develops. Pain management is approached deliberately, with the aim of controlling symptoms while limiting long-term reliance on opioids, which is a recognised problem in this condition. Endoscopic and surgical treatments are used when pain persists despite these measures.
What endoscopic and surgical treatments are available?
Where the scan shows stones or a narrowed segment in the pancreatic duct, the first step is usually ERCP, an endoscopic procedure that can remove stones or place a stent to relieve the obstruction without any incision. Some patients improve lastingly, some improve only temporarily, and some do not respond, at which point surgery is considered. Surgical options fall into two groups, chosen on the anatomy seen on imaging. Drainage procedures, such as the Puestow, open the pancreatic duct along the gland and connect it to a loop of intestine so it drains properly, and are used when the duct is dilated. Resection procedures remove the diseased part of the gland and are used when disease is concentrated in one area without duct dilation, including the Frey procedure, the Whipple procedure and distal pancreatectomy. Many of these can be performed robotically, which shortens recovery.
Does chronic pancreatitis increase the risk of pancreatic cancer?
Yes. Long-standing inflammation of the pancreas is a recognised risk factor for pancreatic cancer, and the risk is higher again in people who continue to smoke, since smoking independently raises pancreatic cancer risk. This is one of the reasons stopping smoking matters so much in this condition. It also means that new or changing symptoms in someone with established chronic pancreatitis are taken seriously and investigated rather than assumed to be the usual disease, and it is part of why imaging is sometimes repeated. The great majority of people with chronic pancreatitis do not develop pancreatic cancer, but the association is real enough to warrant ongoing follow-up.