Chronic Pancreatitis

For various reasons, which are still not fully understood, chronic pancreatitis causes increasingly severe pain in the upper abdomen, which often radiates round the back like a belt. This pain is probably caused by changes in the nerve tissue in the pancreas, and/or the blockage of the pancreatic ducts, which cause increasing pressure on the organ. Often the pain is so severe that it cannot be eliminated or relieved, even by taking the strongest painkillers (opiates).

What are the causes of chronic pancreatitis?
In the western world, excessive alcohol consumption is the commonest cause (80%) of chronic pancreatitis. However, not all alcohol-related cases are due to chronic over-consumption of alcohol. As everyone has a different tolerance level for alcohol, there are some cases where the disease is triggered by drinking only a relatively small amount of alcohol. In addition to alcohol consumption, there are other important causes of chronic pancreatitis. These include genetic defects, defects in the pancreatic ducts (pancreas divisum), medication and metabolic disorders. Sometimes, no particular cause can be found.

What are the symptoms of chronic pancreatitis?
- Pain
- Digestive disorders
- Diarrhoea
- Weight loss
- Diabetes mellitus

What tests and preliminary examinations must be carried out in the case of chronic pancreatitis?
A description of the examination procedure can be found under Methods of Examination.
If chronic pancreatitis is suspected, a computerised tomography is normally carried out to obtain information on any changes in the form of the pancreas and any distinctive distension of the ducts. In addition, characteristic calcification in the pancreas will be shown. Early changes in the pancreatic ducts will however be shown best by means of ERCP. This investigation method, together with a high-quality MRI, should be carried out at a specialist center (such as the Inselspital). The extent of the limitation of the digestive function of the organ and blood sugar regulation is indicated by specific tests.

The blood sugar reading is done by taking a blood sample and the amount of digestion ferments being produced is tested by a stool examination.

The Treatment of Chronic Pancreatitis
Treatment is primarily determined by the patient's symptoms. In most cases the main problem for the patient is almost unbearable pain in the upper abdomen. First and foremost, the consumption of alcohol should immediately be reduced, or better still, stopped. Secondly, oral pancreatic enzyme supplements can be taken, which alleviate the condition by suppressing pancreatic secretions and bring about a satisfactory restoration of the digestive process. If these two measures do not bring the pain relief hoped for, different drugs of varying strengths can be used to relieve the pain. If this still fails to result in satisfactory relief, an operation will have to be considered.

If there are indications, such as fatty deposits in the stools and/or foul-smelling diarrhoea, that the pancreas is not producing sufficient digestive enzymes, the enzymes must be supplemented by a regular intake of the appropriate medication (e.g. Creon). Dependent on the fat content of the food, a certain number of capsules containing the required enzymes are taken with each meal. In many cases, to allow the artificial enzymes to have an effect, the acid production in the stomach has to be suppressed by taking acid blockers (e.g. Antra). Finally, patients must be careful to take an adequate supply of fat-soluble vitamins /A, D, E, K). In serious cases, these may have to be administered by injection.

If the blood sugar level rises, this is a sign that the pancreas is not producing enough insulin. As a first step, an attempt can be made to stabilise the blood sugar level by following an appropriate diet. Often though, the sugar level can only be regulated by the administration of regular injections of insulin.

When is an operation required?
For every second patient with chronic pancreatitis, an operation is necessary at some point in the course of the disease. This operation must be planned and performed with the greatest of care, and therefore should only be carried out in specialist hospitals (e.g. the Inselspital). There are two main reasons why an operation may be required:
1. The pain cannot be brought properly under control, even by using the strongest painkillers (opiates).
2. The changes in the pancreas caused by chronic inflammation are having an effect on neighbouring organs, such as the constriction or blockage of the duodenum, the bile duct, the main pancreatic duct and the blood vessels behind the pancreas.

Sometimes, so-called "pseudo-cysts" (fluid-filled sacs) can form. These growths, which are filled with pancreatic juices, form on or just under the surface of the pancreas. Often pancreatic pseudo-cysts disappear by themselves, without any treatment being needed. However, they can become increasingly large and cause nausea, vomiting, pain and weight loss. The best approach is to have them surgically removed.
When best to have the operation has to be discussed with a surgeon who is experienced in the treatment of pancreatic disorders. The early removal of the focus of the inflammation provides a better chance of restoring the functions of the pancreas (digestion, blood sugar control).

What does the operation involve?
The operation is usually begun with a horizontal or vertical incision through the abdominal wall. The abdominal wall is pulled apart and tied back in order that the surgeon and his team have a good view of the internal organs. Operations on the pancreas in cases of chronic pancreatitis can be divided into "draining" and "resectioning" procedures. The type of procedure used depends on the changes in the pancreas. In a draining operation, the main pancreatic duct is opened along its entire length and is attached to the small intestine, so that the pancreatic juices can drain directly into the small intestine. If there is a pseudocyst, this can be opened and it can be sewn on to a section of the small intestine so that fluid which has accumulated can flow away.

In most cases, the pancreas has undergone such changes as a result of the inflammation that this procedure can only provide a short-term improvement. Often, the drainage stops after a few months as the ducts become blocked again, and the patient once again experiences pain. In such cases, the removal (resection) of the damaged part of the pancreas is the normal treatment chosen. As inflammation is almost always most severe in the head of the pancreas, this is the part which is normally removed.
Nowadays, every effort is made to perform this operation with the greatest of care. This means that only the most severely damaged pancreatic tissue is removed. The surrounding organs, such as the duodenum, the bile ducts and the stomach are saved (pancreatic head resection preserving duodenum). In rare cases, it may also be necessary to remove these organs (Whipple Operation.
If the focus of the inflammation is mainly to be found in the tail of the pancreas (this is rare), the tail will be removed, and, where possible, the spleen will be saved. For technical reasons, however, the spleen must also be removed in some cases.
After the removal of the pancreatic tissue, a section of small intestine will be sewn on to the remaining part of the pancreas, in order that the digestive juices can again drain away unhindered.

These operations on the pancreas are extremely demanding and should only be performed in major specialist centers by suitably qualified surgeons.

Part of my pancreas has been removed - what happens now?
Patients who have had a part or the whole of their pancreas removed may experience a reduction in the functioning of their pancreas, dependent on how much of the organ has been lost. This leads to two problems, above all: · Too few pancreatic enzymes (leading to digestion problems) · Too little insulin (leading to high blood-sugar levels) These deficiencies can be treated by taking suitable medication.

Pancreatic Enzyme Substitution
Nowadays there are excellent, modern preparations on the market which contain substances that replace the pancreatic enzymes (e.g. Creon). These preparations must be taken with all meals, including fat- or protein-rich snacks. The required dosage varies from patient to patient and is determined by the nature of the food and the symptoms of the patient. It is essential that the therapy eliminates the patient's bloated feeling and the foul-smelling diarrhoea with the fatty deposits. Typically, 2-3 capsules have to be taken with main meals and 1-2 capsules with snacks. It is important that the pancreatic enzymes reach the food so that they can fulfil their function. For this to happen, 6-12 capsules need to be taken every day. These numbers may be significantly higher or lower, dependent on how well the remaining part of the pancreas functions.

These enzyme preparations are normally easily digestible and have virtually no side-effects. In very rare cases, they can cause an allergic reaction.

Insulin Substitution
If the pancreatic disorder or operation lead to high blood sugar levels being recorded, the patient will require an appropriate form of blood sugar therapy. To start with, and where the blood sugar levels are not particularly high, the situation can be controlled by following a suitable diet and taking tablets which influence the sugar level. However, where extensive resectioning of the pancreas has been carried out, direct insulin replacement treatment is sometimes required. Various forms of insulin are now available for this treatment. These either come from animals or are manufactured using gene technology. For the most part, these are identical to human insulin and are therefore described as human insulin. All forms of insulin must be injected. The large variety of insulin types allows the therapy to be tailored to the needs of the patient, and special attention can be paid to eating habits.

My spleen has been removed - what happens now?
Sometimes the spleen is also removed as part of an operation on the pancreas.
It is quite possible to live without a spleen. The spleen plays a certain role in the human immune system. If it is removed, a person is more susceptible to certain bacterial infections. To provide protection against infection after removal of the spleen, the patient should be given certain inoculations after the operation. According to current guidelines, these inoculations should be repeated every 3 to 5 years. In addition, the patient should always seek medical help if he contracts a serious infection, and tell the doctor that he or she no longer has a spleen. The doctor can then decide whether treatment with antibiotics is required.

The removal of the spleen can also lead to a build-up of blood platelets (thrombocytes). It is important to have this situation regularly monitored. If the number of platelets is too high, this can lead to the thickening of the blood and a possible thrombosis. If the level is too high, your doctor will prescribe a temporary course of medication to thin the blood, in order to reduce the risk of thrombosis.

After Care
Following a pancreas operation in the case of chronic inflammation, regular checks on the digestion and level of blood sugar must be carried out. These can normally be done perfectly satisfactorily by the patient's family doctor. A regular examination using radiological procedures (e.g. a CAT scan) is not required. However, the specialist clinic which carried out the surgery should play a role in after care, as problems related to the operation can arise.