Chronic pancreatitis is a chronic inflammatory disease of the pancreas, with progressive evolution, characterized by the destruction of exocrine and endocrine pancreatic tissue evolving finally to pancreatic failure. Chronic pancreatitis is a disease that occurs slowly, as a different condition from acute pancreatitis and not as a consequence of it.
Symptoms that may suggest a chronic pancreatitis are generally dominated by abdominal pain, localized in the epigastric region or around the navel, it can sometimes be triggered by heavy meals and can last for a few days, nausea, fever, swollen abdomen which is very sensitive to the touch, fatigue, headaches. The presence of steatorrhea (bulky, paste and rancid odor stools) is a very late sign, when the disease is already accompanied by malabsorption and weight loss. The presence of a case history of chronic alcoholism is an important element for diagnosis.
- Chronic alcoholism is the most important cause of chronic pancreatitis, generating over 90% of cases of chronic pancreatitis. Toxic dose of pure alcohol is 60 -70 ml / day in men and 40 ml / day in women. At autopsy 45% of chronic alcoholics show morphological changes of chronic pancreatitis, even if they had no clinical signs of disease. Clinical symptoms of chronic pancreatitis usually are installed later, after 10-20 years of important use of alcohol. At some patients may occur an ethanol liver damage (steatosis, alcoholic hepatitis or ethanolic cirrhosis).
- Gallstones, although it is certainly a factor for acute pancreatitis, is not a generator factor for chronic pancreatitis. Thus, a cholecystectomy in asymptomatic patients to prevent chronic pancreatitis is unjustified, as well as a correlation between chronic pancreatitis and gallstones.
- Hypercalcemia of hyperparathyroidism, is another possible etiologic factor of acute pancreatitis, but certainly not one for chronic pancreatitis.
- Ductal obstructions given by pancreatic trauma, pancreatic tumors, stenosis of Oddi’s sphincter, presence of stones in Wirsung duct.
- Hereditary pancreatitis involves the presence of a gene that is transmitted autosomal reigned. In this case the family history is important.
- Various conditions such as malnutrition (tropical chronic pancreatitis in India, Africa and Southeast Asia), hemochromatosis (tanned diabetes – cause is iron deposition in the liver, pancreas and myocardium).
In conclusion, the cause of chronic pancreatitis is almost exclusively represented by chronic alcoholism.
In conditions of chronic alcoholism, the pancreas secretes a pancreatic juice with higher protein content than normal. These proteins will precipitate in the form of protein plugs, which will cause obstruction of small ducts of the pancreas and will activate the pancreatic enzymes. Some of the protein plugs will calcify by impregnation with calcium carbonate. Stone formation is favored by the alteration done by the alcohol over the synthesis of litostatin, a pancreatic enzyme known in the past as pancreatic stone protein. This enzyme prevents the precipitation of calcium carbonate in the pancreatic juice. Following obstruction some ducts will broke, others will suffer o process of fibrosi, leading in the final to the appearance of stenosis. Finally, will appear pancreatic tissue destruction and deposition of calcium in the pancreatic cells.
Chronic pancreatitis have most often inisidios onset, sometimes difficult to differentiate from repetitive acute pancreatitis alcoholic relapse. Chronic pancreatitis is 3-4 times more common in men than in women. Diagnosis is usually after age 40 years, but sometimes can occur in cases diagnosed around the age of 30 years, in these cases is possible the existence of a genetic factor.
Symptomatology is dominated by epigastric pain or around the navel, often with radiation to back. Pain can be dragged, annoying, less occasionally, sometimes may be intense, permanent, disabling. Often the pain is caused by diet and therefore, patients with chronic pancreatitis prefer not to eat, but only to consume alcohol, which can have an analgesic effect for them. At 10% – 20% of chronic pancreatitis, painful symptoms may be absent, the diagnosis being made at the laboratory of exploration.
Other symptoms may include obstructive jaundice made by the compression of the pancreatic head over the coledoc, malabsorption with steatorrhea or diabetes mellitus (occurs in 50% – 70% of chronic pancreatitis calcified).
- Laboratory tests may show a slight increase in amylase, lipase or amylase of the urine. Values of this enzymes are not so high as in acute pancreatitis, but there are severe forms of chronic pancreatitis which have normal levels of these parameters.
- Determination of fat in the stool may show steatorrhea (more 7g/ day lipid) and protein determination in the stool can show creatorrhea (less than 2.5 g / day protein), a sign of protein malabsorption.
- Blood glucose levels may be increased because of secondary diabetes, is useful a oral glucose tolerance test.
- Imaging currently is the most useful diagnostic methods for chronic pancreatitis:
- Abdominal radiography may reveal the presence of calcifications in 30% of cases of chronic pancreatitis;
- Abdominal ultrasound, can identify calcification of the pancreas, dilation of Wirsung duct, stones in Wirsung duct, pancreatic cysts. Not all cases of chronic pancreatitis have these signs, but they often are linked;
- Computer tomography is the most accurate method of diagnosing chronic pancreatitis. At the same time is useful for monitoring the disease;
- Endoscopic retrograde pancreatography, highlights aspects of morphological pancreatic duct, stenosis and dilatation, as occurs in chronic pancreatitis.
5. Pancreatic secretory tests, evaluates the functional reserve of the pancreas, they are:
- Lundh test, which consists of dose pancreatic enzymes in pancreatic juice which is obtained through duodenal tubing after food stimulation;
- Secretin test, pancreatic secretion is stimulated after the administration of secretin. In case of chronic pancreatitis decrease both secretory volume and bicarbonate flow;
- Fecal elastase 1 test, a functional test, which highlights the early pancreatic failure, it is the gold test for the diagnosis of chronic pancreatits used nowadays.
Classification of chronic pancreatitis:
Classification of chronic pancreatitis is made by clinical and pathological forms.
Clinical forms of chronic pancreatitis:
- Chronic pancreatitis with pain;
- Asymptomatic chronic pancreatitis;
Pathological forms of chronic pancreatitis:
- Chronic obstructive pancreatitis, Wirsung duct dilatation is dominant;
- Calcified chronic pancreatitis, dominated by calcifications of the pancreatic tissue;
- Mixed chronic pancreatitis with pancreatic tissue calcification and dilatation of the duct.
Chronic pancreatitis is a disease of long evolution and relapse of exacerbation. At first it may be asymptomatic, but in time the symptoms will appear of which the most important is pain. Stopping alcohol consumption may have a beneficial effect on pain. In time will come malabsorption.
Complications of chronic pancreatitis are:
- pancreatic pseudocyst sometimes can cause compression;
- pancreatic abscess, which is produced by infecting a pancreatic pseudocyst;
- obstructive jaundice;
- splenic vein or portal vein thrombosis caused by inflammation.
Treatment should begin with some dietary measures, the most important is the final and complete suppression of alcohol consumption. Should be avoided heavy meals, rich in fat and protein because it stimulates pancreatic secretion and may cause exacerbation of pain.
Drug treatment of chronic pancreatitis is to:
- Analgesics for painful episodes (Metamizol, Fortral);
- Pancreatic enzyme replacements, which can relieve symptoms of chronic pancreatitis. Doses of these drugs have to be large, even in the absence of malabsorption. Drugs with a high lipase concentration will be used (Creon, Mezym Forces, Nutryzym, etc.). Enterosoluble drugs are preferred due toneutralization of the lipase by gastric juice.
Endoscopic treatment consists of:
- Prosthesis of the Wirsung duct or gallbladder;
- Stone extraction from the Wirsung duct.
Surgery is recommended in forms with intense pain