Chronic pancreatitis

Chronic pancreatitis: description

Chronic pancreatitis is a recurring inflammation of the pancreas. As a result, the diseased organ is less and less able to perform its tasks – producing digestive enzymes and important hormones (such as insulin). This increasingly limits the quality of life of those affected. In addition, chronic pancreatitis significantly reduces life expectancy.

Every year, between 1,500 and 8,000 people in Germany contract chronic pancreatitis. Often, the disease occurs in the 3rd and 4th decade of life. Mostly long-term alcohol consumption is the cause. Rarely does chronic pancreatitis develop during childhood. Then often a genetic component plays a role.

Chronic pancreatitis: symptoms

Chronic pancreatitis often begins insidiously and progresses slowly. Initially, only mild to moderate symptoms often show up. As in the case of acute pancreatitis, the chronic form also has an effect belt-shaped upper abdominal pain radiating to the back or shoulders a typical symptom. They often occur during or after meals and can last for days. At a late stage of the disease, however, patients often no longer experience epigastric pain.

In addition to pain, chronic pancreatitis can be symptoms like anorexia, nausea such as Vomit trigger. The patients lose weight, In addition, occurs greasy, foul-smelling bowel movement on.

The more chronic pancreatitis progresses, the stronger it becomes Production of digestive enzymes impaired for fat digestion, The increasing lack of pancreatic enzymes has the consequence that fat-soluble vitamins (A, D, E, K) from the diet can no longer be adequately absorbed. That solves Vitamin deficiency symptoms from: night blindness (lack of vitamin A), fatigue and gait disturbances (lack of vitamin E), a tendency to bleeding (lack of vitamin K) as well as soft bones (osteomalacia due to lack of vitamin D).

In the advanced stage of chronic pancreatitis is also the Formation of hormones throttled to regulate blood sugar: Insulin (lowers blood sugar levels) and glucagon (raises blood sugar levels). As a result, the patient develops the diabetes (Diabetes mellitus).

Chronic pancreatitis: causes & risk factors

Chronic pancreatitis is caused in 80 percent of cases by excessive alcohol consumption (alcohol abuse). The alcohol directly damages the pancreatic tissue and weakens the immune system. Alcohol inhibits the release of the messenger substance interferon, which normally stimulates the immune system. Chronic pancreatitis can also be triggered by the following factors:

Genetic condition (Hereditary pancreatitis)

In hereditary pancreatitis, the pancreas inflames already in childhood. A genetic defect leads to an altered structure and function of an endogenous substance that activates the digestive enzymes: trypsinogen. The digestive enzymes are thus already activated in the pancreas and not only in the small intestine. They “digest” the pancreatic tissue, resulting in an inflammatory response.

Patients with cystic fibrosis are also more likely to suffer from chronic pancreatitis because the viscous mucus prevents normal pancreatic fluid leakage.

drugs

Medications can also trigger chronic pancreatitis. These include beta-blockers, diuretics, ACE inhibitors, estrogens or anti-epileptics. Similar to alcohol, the drugs damage the tissue of the pancreas, causing it to become inflamed.

Excess of calcium in hyperparathyroidism

The parathyroid gland produces the parathyroid hormone, which regulates the level of calcium in the blood. It mobilizes calcium out of the bones to raise the level of calcium in the blood. With excess parathyroid hormone, the excess calcium reacts with the digestive enzymes in the pancreas. It forms stones that can cause chronic pancreatitis.

Excess of triglycerides (hypertriglyceridemia)

Also, an excess of certain blood lipids (triglycerides) with values> 1000 mg / dl causes in rare cases chronic pancreatitis. The exact mechanism behind it is not yet clearly known. Cleavage of the triglycerides (lipase) is thought to produce free fatty acids that cause inflammation of the pancreatic cells.

autoimmune pancreatitis

Autoimmune pancreatitis is a rare form of chronic pancreatitis. The body increasingly forms antibodies which attack the own pancreatic tissue. A single cortisone therapy is sometimes sufficient to cure, without further therapeutic measures must be taken.

Chronic pancreatitis: examinations & diagnosis

If you suspect chronic pancreatitis, consult your family doctor or a specialist in internal medicine and gastroenterology. The detailed description of your complaints and possible pre-existing conditions already provides the doctor with valuable information about your state of health (anamnesis). The doctor could ask the following questions:

• Where exactly does it hurt you? Does the pain radiate?
• Does the pain occur after eating?
• How much alcohol do you drink? Do you suffer from alcohol addiction?
• Have you noticed shiny, greasy diarrhea?
• Have you ever had pancreatitis?
• Have you ever had elevated blood lipid levels or elevated levels of calcium in an investigation?
• Do you take any medicine?

Physical examination

The doctor will ask you to lie down and clear your upper body so he can examine you. Chronic pancreatitis causes belt-shaped upper abdominal pain in most sufferers, which can radiate into the back and possibly into the chest. The doctor will first listen to the stomach with the stethoscope. Then he will gently scan the belly, paying attention to possible pain.

blood test

In an acute inflammatory thrust, the pancreatic enzymes in the blood may be elevated. The fat-splitting pancreatic enzyme lipase is increasingly released into the blood. The carbohydrate-splitting enzyme amylase and the protein-splitting enzyme elastase may also be increased. However, levels of digestive enzymes in the blood are not elevated in all patients with chronic pancreatitis.

stool examination

The enzyme elastase, which is formed by the pancreas, is released into the intestine and excreted undigested. If the pancreas does not work properly, correspondingly lower amounts of elastase enter the intestine – accordingly the elastase value also decreases in the stool. If chronic pancreatitis is suspected, the doctor will measure the elastase concentration in the stool as part of a stool examination. This study is considered the first choice method for the diagnosis of chronic pancreatitis.

At a concentration of less than 200 micrograms per gram of stool, there is damage to exocrine pancreatic function. From an elastase 1 concentration of less than 100 micrograms per gram of stool, the dysfunction is classified as severe.

In addition, the amount of fat and the digestive enzyme chymotrypsin in the stool can be determined. Increased excretion of fats and reduced stool chymotrypsin levels in the stool also indicate pancreatic dysfunction, suggesting chronic pancreatitis.

Imaging procedures

To diagnose chronic pancreatitis, an abdominal ultrasound scan (abdominal ultrasound scan), magnetic resonance imaging (MRI) or computed tomography (CT) should be performed. The extent of tissue damage can be assessed with the aid of the imaging measures. With the help of endoscopic retrograde cholangiopancreatography (ERCP) it can be clarified whether a tumor in the region of the pancreatic or bile duct is the cause of the complaints.

ultrasound

Due to the recurrent bursts of inflammation, the pancreatic tissue scar with time and calcifications form. An ultrasound examination of the abdomen (abdominal ultrasonography) can provide initial indications. If such calcifications are present, this is considered as evidence of chronic pancreatitis. Since the pancreas in the abdomen is behind other organs, however, it can often not be optimally represented by an ultrasound examination. In that case, the doctor uses other imaging techniques such as computed tomography, magnetic resonance imaging or ERCP.

Computed Tomography and Magnetic Resonance Imaging

When there is a suspicion of chronic pancreatitis, computed tomography (CT) provides a detailed picture of the pancreas. Magnetic resonance imaging (MRI) also allows an even more accurate visual representation. Chronic pancreatitis typically presents on the images through calcification of the pancreatic tissue as well as through pancreatic duct alteration or through so-called pancreatic pseudocysts. Also tumors of the pancreas can be discovered with these two procedures.

Endoscopic cholangiopancreatography (ERCP)

Since chronic pancreatitis can cause a tumor (pancreatic carcinoma) in the course of the disease, endoscopic retrograde cholangiopancreatography (ERCP) is often performed. In an ERCP, the doctor sheds a small tube through the esophagus into the stomach and into the duodenum. Thus, he can closely inspect the common duct of pancreas and bile and may already recognize the cause of chronic pancreatitis. He then injects an X-ray contrast medium into the exhalation duct. This makes it possible to visualize the ducts of the pancreas and gallbladder as well as any obstacles to escape (for example, a tumor) in an X-ray image.

Chronic pancreatitis: treatment

The most important measure of chronic pancreatitis is the absolute and permanent renunciation of alcohol. Only abstinence prevents further inflammation and thus a permanent destruction of the pancreatic tissue. For the withdrawal of alcohol, you should definitely seek professional help, since only very few people alone manage to stay permanently abstinent. At least for people who are physically dependent on alcohol, the first thing they do is start detoxification in a clinic in which the physical withdrawal symptoms are overcome under medical supervision and if necessary with medication. This is followed by further appropriate measures. These include outpatient or inpatient addiction therapy to help cope with the psychological dependence on alcohol, and the visit of self-help groups that support the process.

People with chronic pancreatitis need to pay special attention to their diet. Some have lost a lot of weight due to the disease and need to rebuild their physical reserves. However, it is important how and what the patients eat: Ideally, the portions should be small and contain little carbohydrates and fat. For the breakdown of carbohydrates, the body needs amylase from the pancreas – which should be spared. Oily foods, on the other hand, are often very poorly tolerated due to the lack of secretion production in chronic pancreatitis and cause flatulence and fatty stools. Better tolerated are fats with medium-chain fatty acids (MKT) as they are found in coconut oil and palm kernel oil or in special dietary foods. They do not have to be broken down by enzymes for their uptake into the gut.

In addition, the symptoms of chronic pancreatitis can be relieved with the help of medication and surgical procedures.

Chronic pancreatitis – medication

In an acute inflammatory thrust, the pain therapy of an acute form of pancreatitis. Patients receive opioids for pain relief in the form of buprenorphine or pethidine. In addition, patients can take the fat-splitting enzyme lipase at mealtimes in the form of tablet. This relieves the digestive discomfort.

Some patients suffer from deficiency of fat-soluble vitamins (vitamins A, D, E, K) due to the fat digestive disorder. They are administered directly into the blood via the muscle. This is how the intestine can be bypassed.

In patients with severe chronic pancreatitis, the pancreas is often so severely damaged that it can no longer regulate the blood sugar balance – they develop diabetes. In that case, patients also need insulin therapy.

Chronic pancreatitis – surgical procedure

Chronic pancreatitis often causes calcification that can cause or narrow stones in the pancreatic duct. With the help of a special endoscopic method, endoscopic cholangiopancreatography (ERCP), the common effusion of bile and pancreas can be increased again. The doctor leads to a small tube in the Pankreadgang before. Then a small balloon is inflated over it, which stretches the gait again. In some cases, a small tube (stent) is additionally used to prevent a renewed narrowing. Stones in the pancreatic duct can be smashed by the surgeon with the help of electrical shock waves to improve the drainage.

Chronic Pancreatitis: Course & Prognosis

The prognosis of chronic pancreatitis depends on how pronounced comorbidities such as alcohol dependence are and how consistently the recommended therapeutic measures are followed. In the long term, chronic pancreatitis causes tissue alterations that can cause various complications such as pancreatic pseudocysts, splenic vein or portal vein clots. In the advanced stage, chronic pancreatitis also increases the risk of developing pancreatic cancer (pancreatic carcinoma).

Chronic pancreatitis – prognosis

Chronic pancreatitis usually runs for several years and is usually associated with other diseases. Although it is rarely fatal, the life expectancy of patients is significantly reduced due to the often severe accompanying and sequelae. Chronic alcohol consumption, which affects 80 percent of those affected, drastically reduces life expectancy. If chronic pancreatitis has led to a functional impairment of the pancreas, sufferers often suffer from chronic diarrhea and a concomitant weight loss. The underweight weakens the entire organism, making those affected more susceptible to infections. In addition, complications occur more easily. Within ten to fifteen years, about 50 percent of patients die from chronic pancreatitis.

Chronic pancreatitis – complications

Chronic pancreatitis is associated with permanent tissue damage. The risk of subsequent complications is thereby increased. This includes:

Pancreatic pseudocysts

Due to the inflammatory tissue changes so-called pancreatic pseudocysts can form. These are encapsulated fluid collections surrounded by wound healing tissue and collagen fibers. Compared to real cysts, however, the fluid retention is not surrounded by a proper wall. Pancreatic pseudocysts can recede on their own within six weeks. In some cases, they infect themselves or break down. If the patients suffer from discomfort, a small tube is usually surgically applied so that the contents of the pseudocyst can be continuously diverted.

Splenic vein and portal vein thrombosis

Severe, chronic pancreatitis can squeeze the splenic vein or portal vein and lead to blood clots (thrombosis) in these vessels due to calcifications and structural changes. Depending on the size of the blood clot, the blood may back up in the portal vein leading to the liver. This is especially true if the patient has liver cirrhosis due to long-term alcohol consumption. In the portal vein develops an elevated blood pressure, which can cause accumulation of water in the abdomen (ascites). In addition, the congestion in front of the liver can cause so-called Kollateralkreisläufen form, via which the blood flows from the portal vein directly back to the right heart.

Pancreatic cancer (pancreatic carcinoma)

As a late complication of chronic pancreatitis, pancreatic carcinoma may develop in the advanced stage. Due to the permanent inflammation, the dying cells in the pancreatic tissue must be constantly replaced. In addition, the healthy cells divide much more often than usual. With each division errors can occur – in the worst case the cell can degenerate. Such cells no longer have adequate repair mechanisms and then divide exponentially – a tumor is formed. A chronic pancreatitis should therefore be recognized early and treated.