Pancreatitis is inflammation of the pancreas. The main symptom of pancreatitis is abdominal pain, which can often be severe.
The pancreas is a small, leaf-shaped organ that is located behind the stomach and below the ribcage.
The pancreas has two important functions:
- it produces digestive juices that are used by the intestines to help digest food, and
- it produces powerful 'messenger chemicals', called hormones, that can have an important effect on all the cells in the body.
Insulin is the most important hormone produced by the pancreas, because it regulates the levels of sugar (glucose) in the blood.
Types of pancreatitis
There are two types of pancreatitis:
- Acute pancreatitis, in which the pancreas becomes inflamed over a short period of time. The inflammation passes after a few days.
- Chronic pancreatitis, in which the inflammation of the pancreas persists for many years causing it to become more and more damaged. Chronic pancreatitis can often develop after repeated previous episodes of acute pancreatitis.
The rest of this section will focus on chronic pancreatitis. See Useful links, right, for more information about acute pancreatitis.
How common is chronic pancreatitis?
Chronic pancreatitis is uncommon. It is estimated that 45 out of every 100,000 men and 12 out of every 100,000 women have chronic pancreatitis.
Chronic pancreatitis mainly affects men. It usually occurs people aged 40 to 50.
Prolonged alcohol misuse is the biggest risk factor for developing chronic pancreatitis. Long-term alcohol misuse (a period going across many years) is thought to account for 70% of all cases of chronic pancreatitis.
The outlook for chronic pancreatitis depends on a number of factors. The three most important factors are:
- the person's age when they're diagnosed,
- the person's history of alcohol use, and
- whether the pancreas is damaged enough to have stopped producing insulin (resulting in associated symptoms of diabetes).
For example, a 20-year-old man who is diagnosed with chronic pancreatitis and has no history of alcohol use should have a good outlook. His natural lifespan should not be adversely affected.
The lifespan of a 50-year-old man with chronic pancreatitis and a long history of alcohol misuse may be shortened by 10 to 20 years. This is because a pancreas that does not function properly can place additional strain on the body.
About 70% of people with chronic pancreatitis will survive for at least 10 years after receiving their diagnosis. About 45% of people with chronic pancreatitis will survive for at least 20 years after receiving their diagnosis.
Although there is no cure for chronic pancreatitis, medication can control the symptoms of pain. In very severe cases, surgery may be required.
The most effective way of preventing chronic pancreatitis is to avoid drinking alcohol or to at least drink it in moderation. See Prevention, above, for more information.
Most people with chronic pancreatitis will have irregular episodes of pain.
The pain of chronic pancreatitis is located in your upper abdomen and can feel like a dull ache that can often be severe. The pain may travel from your abdomen and along your back. It can often feel worse after eating.
Leaning forward or curling into a ball may help to relieve the pain to a certain extent.
You may also experience symptoms of nausea and vomiting (being sick) during the episodes of pain.
As chronic pancreatitis progresses, the episodes of pain may become more frequent and more severe. Some people may eventually experience a constant pain in their abdomen.
Advanced chronic pancreatitis
Additional symptoms can occur when the pancreas loses its ability to produce insulin and digestive juices (used to help break down food in the digestive system).
The pancreas usually only loses these functions many years after the original onset of symptoms.
A lack of insulin means you will then develop type 1 diabetes. Symptoms of type 1 diabetes include:
- increased thirst,
- frequently passing urine,
- feeling very hungry,
- weight loss,
- fatigue, and
- blurred vision.
Type 1 diabetes is controlled with regular insulin injections. See Useful links for more information about type 1 diabetes.
The lack of the digestive juices produced by your pancreas will mean that your digestive system will have difficulty breaking down fats and certain proteins. This can cause your faeces (stools) to become particularly smelly and greasy. The stools are often difficult to flush down the toilet.
You may also have:
- abdominal cramps, and
- excessive flatulence (breaking wind).
Chronic pancreatitis usually develops when repeated episodes of acute pancreatitis lead to your pancreas becoming permanently damaged.
To understand the causes of chronic pancreatitis, it is first necessary to understand the causes of acute pancreatitis.
Acute pancreatitis is caused when something goes wrong with a chemical called trypsin. Trypsin is an enzyme that is produced by the pancreas. It is used to help break down the proteins in food in order to aid digestion.
When trypsin is produced by the pancreas, it remains in an inactive state and has no digestive properties. It is not until trypsin moves out of the pancreas and into the intestines that it becomes active and is able to start breaking down proteins.
In cases of acute pancreatitis, trypsin is activated while it is still in the pancreas. The trypsin starts to break down the cells of the pancreas. In other words, the pancreas starts to digest itself, causing it to become irritated and inflamed.
Alcohol is a main risk factor for the development of acute pancreatitis because it can cause trypsin to become activated while it is still in the pancreas. It is unclear why this happens.
One theory is that the ethanol molecules contained in alcohol interfere with the normal workings of the cells of the pancreas, causing them to activate trypsin prematurely.
Alcoholic chronic pancreatitis
As with acute pancreatitis, alcohol misuse is the biggest risk factor associated with chronic pancreatitis, accounting for 70% of all cases. People who consume large amounts of alcohol have an increased risk of repeated episodes of acute pancreatitis.
Over time, repeated episodes of acute pancreatitis will eventually cause the pancreas to become permanently damaged, resulting in chronic pancreatitis. Chronic pancreatitis that has been caused by alcohol misuse is known as alcoholic chronic pancreatitis.
Alcoholic chronic pancreatitis usually only develops in people who have been drinking more than 10 standard drinks of alcohol a day for more than 10 to 15 years.A standard drink of alcohol is roughly equivqlent to a pint of beer, a small glass of wine or a pub measure of spirits
Despite the risks of drinking large amounts of alcohol, alcoholic chronic pancreatitis is relatively uncommon among people with a long-term history of alcohol misuse. The condition affects 5-10% of people with a long-term history of alcohol misuse.
It is thought that people who are affected by alcoholic chronic pancreatitis may have certain 'altered genes' (genetic mutations) that make them more vulnerable to the effects of alcohol.
Idiopathic chronic pancreatitis
In most of the remaining 30% of cases of chronic pancreatitis there is usually no known cause or reason to explain why the condition developed. Chronic pancreatitis that develops with no known cause is known as idiopathic chronic pancreatitis.
Idiopathic chronic pancreatitis usually first develops either in:
- children and young adults who are aged between 10 and 20, or
- older adults who are over 50.
For reasons that are not fully understood, idiopathic chronic pancreatitis rarely affects other age groups.
It has been speculated that genetic mutations may be responsible for many cases of idiopathic chronic pancreatitis.
Two particular mutated genes - the SPINK-1 gene and the CFTR gene - have been detected in about half of those with idiopathic chronic pancreatitis. It is thought that these two mutated genes may interfere with the normal workings of the pancreas.
Less common causes
There are a number of medical conditions that account for about 1% of all cases of chronic pancreatitis. These are listed below.
- Autoimmune chronic pancreatitis, a rare condition in which the immune system begins to attack the pancreas.
- Heredity pancreatitis, a rare genetic condition in which people are born with a malfunctioning pancreas.
- Cystic fibrosis, a genetic condition in which certain organs, including the pancreas, can become damaged. See Useful links for more information about cystic fibrosis.
Unlike acute pancreatitis, there are no reliable blood tests that can be used to diagnose chronic pancreatitis. The condition can usually only be diagnosed by carrying out tests that are designed to look at the pancreas.
Therefore, if, as a result of your symptoms and medical history, your GP suspects that you have chronic pancreatitis, you will be referred for further testing. The tests will usually be carried out at your local hospital. The tests may include:
- computerised tomography (CT) scans,
- magnetic resonance imaging (MRI) scans,
- ultrasound scans, and
- endoscopic retrograde cholangio-pancreatography (ERCP).
An ERCP uses a narrow, flexible tube that has a camera on the end that is used to study the tissue of the pancreas. The tube, known as an endoscope, is guided into your digestive system using an ultrasound scanner.
If you are diagnosed with chronic pancreatitis, it may be necessary for you to make some lifestyle changes.
Give up alcohol
The most important thing is to stop drinking alcohol. This will help prevent your pancreas from being damaged further and may also help to reduce the symptoms of pain.
You should tell your GP if you think that you may have problems quitting alcohol. They can refer you to specialist services that are designed to help people stop drinking alcohol.
Give up smoking
If you smoke cigarettes, you should also try to quit. While smoking does not cause chronic pancreatitis, it can speed up its progress, making it more likely that you will lose pancreatic function. Your GP will be able to refer you to a quit-smoking service.
You may also need to change your diet because your digestive system may be having problems digesting certain foods.
For most people with chronic pancreatitis, it is recommended that they eat a low-fat diet and eat six small meals a day rather than three large ones. Your GP will be able to provide you with appropriate dietary advice. Alternatively, they may refer you to a dietitian who will draw up a suitable diet plan.
You may also be given tablets that contain an artificial version of the enzymes that are produced by your pancreas in order to help improve the effectiveness of your digestive system.
The enzyme tablets should help to improve the symptoms of bloating and abdominal cramps, as well as making your stools less greasy and foul-smelling.
Pain relief is an important part of the treatment of chronic pancreatitis. Not only is chronic pain physically unpleasant, it can have adverse psychological effects, such as depression.
A step-by-step approach to pain relief is usually recommended, which means that your GP will first try painkillers that are less strong. If these don't work, they will 'step up' to more powerful painkillers.
Over-the-counter (OTC) painkillers may be effective in treating mild to moderate pain. More severe pain may require stronger, opiate-based painkillers.
There is a risk that you may become addicted to the more powerful opiate-based painkillers. To minimise this risk, only use the painkillers as instructed.
If your pancreas is damaged to such an extent that it is not producing enough insulin, you will develop type 1 diabetes. This means that you will need to have regular insulin treatment for the rest of your life in order to keep your blood sugar levels normal.
Insulin is usually administered using injections. Insulin tablets are not usually recommended because your digestive system may be unable to break the tablets down to release the insulin.
See Useful links for more information about the treatment of type 1 diabetes.
If you have severe, chronic pain that fails to respond to painkillers, surgery may be required. It is thought that severe chronic pain can develop for two reasons:
- Openings (ducts) in the pancreas can become blocked as a result of a build-up of calcium in the damaged tissue. The blocked ducts cause a build-up of digestive juices and this puts the ducts under an increased pressure, leading to pain.
- The top section of the pancreas, known as the head of the pancreas, can become inflamed. The inflammation can irritate the main nerve ending that runs out of the head of the pancreas.
In cases of chronic pancreatitis where the ducts are blocked, it may be possible to relieve the pressure on the ducts by widening them.
This can be done using an endoscope (a narrow, flexible tube) that is guided into your digestive system using an ultrasound scanner. A tiny balloon is passed down through the endoscope before being inflated in order to widen the duct. A tiny metal clasp, known as a stent, may then be used to keep the duct widened.
In cases where the head of the pancreas has become inflamed, and it is thought that the inflammation is irritating the nerve, the head of the pancreas can be surgically removed. This type of surgery is known as a pancreas resection.
Removing the head of the pancreas can also reduce pressure on the ducts. A pancreas resection can therefore be used if the results of the endoscopic treatment was ineffective.
The advantage of only removing the head of the pancreas is that the rest of the pancreas can often maintain its functions of producing insulin and digestive juices.
There are a number of different techniques that can be used to carry out a pancreas resection. Three widely used techniques are:
- the Beger procedure,
- the Frey procedure, and
- a pylorus-sparing pancreaticoduodenectomy (PPPD).
The Beger procedure
This procedure is used to treat inflammation of the pancreas head. The inflamed tissue is removed and the rest of the pancreas is reconnected to the intestines.
The Frey procedure
The Frey procedure can be used to treat cases where there is evidence that the ducts of the pancreas have become blocked and the head of the pancreas has become inflamed.
The inflamed part of the head is removed and then ducts are directly connected to the intestines, allowing the digestive juices to flow into the intensities.
Pylorus-sparing pancreaticoduodenectomy (PPPD)
A pylorus-sparing pancreaticoduodenectomy (PPPD) is usually recommended to treat the most severe cases of chronic pain, where there are both blocked ducts and inflammation of the head of the pancreas.
During a PPPD, the head of the pancreas is removed along with the gall bladder and bile ducts. The rest of the pancreas is then reconnected to the stomach.
Results of pancreas resections
Each type of surgery has its own advantages and disadvantages. PPPD seems to be the most effective technique in terms of reducing pain and preserving the function of the pancreas.
Possibly because it is the most complex of the three techniques, PPPD carries an increased risk of complications, such as infection and internal bleeding.
The Beger and Frey procedures carry a lower risk of complications, and have faster recovery times and less post-operative pain compared with PPPDs. However, they may not be as effective in providing long-term pain relief and preserving the function of the pancreas.
Before deciding on a surgical procedure, you should discuss the pros and cons of each technique with your surgical team.
In the most serious cases of chronic pancreatitis, where the pancreas has been extensively damaged, it may be necessary to remove the entire pancreas. This type of surgery is known as a total pancreatectomy.
A total pancreatectomy can be very effective in treating the symptoms of pain. It carries the obvious disadvantage that your pancreas will no longer be able to produce the insulin that is needed by your body.
Autologous pancreatic islet cell transplantation (APICT) is a relatively new technique that attempts to overcome this disadvantage.
Autologous pancreatic islet cell transplantation (APICT)
During APICT, special cells, known as islet cells, are removed from the pancreas. Islet cells are responsible for producing insulin.
The pancreas is then surgically removed from the body. At the same time, the islet cells are mixed with a special solution, which is then injected into the liver. If the APICT procedure is successful, the islet cells will remain in the liver and will begin to produce insulin.
In the short-term, APICT appears to be effective, but you may require additional insulin treatment in the long term.
See Useful links for more information about APICT.
Psychological effects of chronic pancreatitis
Any chronic health condition, particularly one that causes recurring or constant pain, such as a chronic pancreatitis, can have an adverse effect on your emotional and psychological health.
One study that looked at people living with chronic pancreatitis found that 15% of people had some sort of psychological or emotional problem, such as stress, anxiety or depression.
Contact your GP if you are experiencing psychological and emotional difficulties. Effective treatments are available that can help to improve symptoms of stress, anxiety and depression.
Joining a support group for people with chronic pancreatitis may also help, because talking to other people with the same condition can often help to reduce feelings of isolation and stress. See Useful links, right, for more information.
A pseudocyst is a collection of fluid that can form around your pancreas. It usually develops when digestive juices leak out of a damaged pancreatic duct.
In 70% of cases, pseudocysts do not cause symptoms and do not require treatment.
In the other 30% of cases, a pseudocyst can:
- become infected,
- rupture (split) leading to internal bleeding, or
- block part of the intestine.
If a complication does develop, surgery may be required to drain the cyst.
Chronic pancreatitis increases your risk of developing pancreatic cancer. However, the increased risk is relatively low. For example, it is estimated that for every 500 people with chronic pancreatitis, only one will develop pancreatic cancer.
See Useful links for more information about pancreatic cancer.