Surgery

Chronic pancreatitis

Chronic pancreatitis

Chronic pancreatitis is a long-standing inflammation of the pancreas that results in destruction, fibrosis and alteration of the organ's normal structure and functions. This leads to irreversible changes. It can occur as repeated episodes of acute inflammation in a previously injured pancreas or as chronic damage with persistent pain or malabsorption. This is different from acute pancreatitis where the changes are reversible.

Signs and symptoms

  • Upper abdominal pain which increases after drinking or eating and lessens when fasting or sitting and leaning forward. Some people may not suffer from pain.
  • Nausea and vomiting.
  • Frequent, oily, foul-smelling bowel movements as a result of damage to enzyme secreting cells of the pancreas. Fats and nutrients are not absorbed properly, leading to a lose, greasy stool known as steatorrhea. This can also lead to malnutrition.
  • Weight loss
  • Type 1 diabetes

Causes

Among the causes of chronic pancreatitis, some are:

  • Alcohol
  • Autoimmune disorders
  • Intraductal obstruction
  • Idiopathic pancreatitis
  • Tumors
  • Ischemia
  • Calcific stones

The relationship between etiologic factors, genetic predisposition, and the pace of disease progression requires further clarification, though recent research indicates smoking may be a high-risk factor to develop chronic pancreatitis. In a small group of patients, chronic pancreatitis is hereditary. Almost all patients with cystic fibrosis have established chronic pancreatitis, usually from birth. Cystic fibrosis gene mutations have also been identified in patients with chronic pancreatitis but in whom there were no other manifestations of cystic fibrosis. Obstruction of the pancreatic duct because of either a benign or malignant process may result in chronic pancreatitis.

Pathophysiology

The mechanism of chronic pancreatitis viewed from a genetic standpoint indicates early onset of severe epigastric pain beginning in childhood. It is an autosomal dominant disease. Chronic pancreatitis disease is identified in the cationic trypsinogen gene PRSS1, and mutation, R122H. R122H is the most common mutation for hereditary chronic pancreatitis with the replacement of arginine with histidine at amino acid position 122 of the trypsinogen protein. There are, of course, other mechanisms such as alcohol, malnutrition and smoking, each exhibiting its effect on the pancreas.

Treatment

The different treatment options for management of chronic pancreatitis are medical measures, therapeutic endoscopy and surgery by top gastro surgeons in Kolkata. Treatment is directed, when possible, to the underlying cause, and to relieve pain and malabsorption. Insulin-dependent diabetes mellitus may occur and need long term insulin therapy. The abdominal pain can be very severe and require high doses of analgesics, sometimes including opiates. Alcohol cessation and dietary modifications (low-fat diet) are important to manage pain and slow the calcific process. Antioxidants may help but it is unclear if the benefits are meaningful.

Pancreatic enzymes

Pancreatic enzyme replacement is often effective in treating the malabsorption and steatorrhea associated with chronic pancreatitis. Treatment of CP consists of administration of a solution of pancreatic enzymes with meals. Some patients do have pain reduction with enzyme replacement. As they are relatively safe, giving enzyme replacement to a chronic pancreatitis patient is an acceptable step in treatment for most patients. Treatment may be more likely to be successful in those without the involvement of large ducts and those with idiopathic pancreatitis.

Surgery

Surgery by a gastroenterologist surgeon in Kolkata to treat chronic pancreatitis tends to be divided into two areas, resectional and drainage procedures. Among the reasons to opt for surgery is the presence of a pseudocyst, fistula, ascites, or a fixed obstruction.