Chronic Pancreatitis Treatment

The symptoms of chronic pancreatitis include:

• Diabetes: Chronic pancreatitis can affect the pancreas' ability to produce insulin to regulate glucose levels, leading to diabetes. Symptoms of diabetes include increased hunger and thirst, frequent urination, weight loss and fatigue.
• Frequent, oily, foul-smelling bowel movements: Damage to the pancreas reduces the production of pancreatic enzymes that aid digestion, which can result in malnutrition. Fats and nutrients are not absorbed properly, leading to loose, greasy stool.
• Nausea
• Upper abdominal pain: Frequently chronic and debilitating pain is the most common symptom of chronic pancreatitis. The pain may increase after drinking or eating and lessens when fasting or sitting and leaning forward. However, some people with chronic pancreatitis report little to no pain.
• Vomiting
• Weight loss

While the exact cause of chronic pancreatitis remains somewhat of a mystery, we do know that the risk of developing chronic pancreatitis is increased by a number of factors, including:

• Alcohol consumption, which is the most frequent risk factor to trigger pancreatitis
• Autoimmune destruction of the pancreas (autoimmune pancreatitis)
• Excess triglycerides or calcium in the blood
• Tobacco use, which may trigger pancreatitis, depending on amount

Genetic mutations are being recognized more frequently as a cause of chronic pancreatitis. These include hereditary pancreatitis (mutation in the cationic trypsinogen gene, PRSS1); mutations in the gene that causes cystic fibrosis (cystic fibrosis transmembrane conductance regulator gene, CFTR); mutations in the pancreatic secretory trypsin inhibitor gene (SPINK1) and mutations in the chymotrypsinogen gene (CTRC).

A variety of tests are available to assess patients for chronic pancreatitis. These tests include:

• Pancreas exocrine function tests:  Measurement of the pancreatic enzyme elastase in the stool (fecal elastase)
• Pancreatic function tests: These measure bicarbonate levels (in select patients)
• Abdominal ultrasound exams: Sound waves create images of abdominal organs
• Computed tomography (CT) scans: Our radiologists offer 64-slice CT exams, which can produce superior three-dimensional images.
• Endoscopic ultrasound (EUS): A thin tube, called an endoscope, which is specially equipped with a device that emits and detects sound waves as they bounce off tissue. The device sends this data to a computer, which then creates an image of the tissue for evaluation. This test can also be combined with administration of the hormone secretin to get information about how well the pancreas is able to produce digestive fluid and empty this fluid into the intestine.
• Magnetic resonance cholangiopancreatography (MRCP): Magnetic resonance imaging uses a powerful magnetic field and radiofrequencies to create images of the pancreas, its ducts, and the surrounding organs. This test is frequently combined with administration of the hormone secretin to improve visualization of the pancreatic anatomy and (indirectly) the function.
• Genetic testing: Performed if it is suspected that you may have a genetic reason for pancreatitis. Our team includes genetic counselors who will explain the implications of having a mutation and the risk for you and family members.
• Biopsy: In select patients, physicians will remove a small piece of pancreatic tissue for examination.
• Endoscopic retrograde cholangiopancreatography (ERCP): An exam performed by our interventional endoscopy experts. Like EUS, the physician inserts an endoscope down the throat and into the gastrointestinal tract. This instrument has a light and camera at the end of it to view inside the tract.

Not all tests are performed on every patient.

Each case is different, so treatment is tailored according to symptoms and the cause of the chronic pancreatitis.

Treatments for chronic pancreatitis include the following:

• Alcohol avoidance: Avoiding alcohol will help reduce pain and significantly decrease progression of the disease.
• Modified diet: Many patients with chronic pancreatitis feel better if they switch to a diet low in fat and eat smaller, more frequent meals.
• Pancreatic enzyme supplements: If the pancreas is not working properly, physicians prescribe pancreatic enzyme supplements to aid in digestion and to assure absorption of food. These pancreatic enzyme supplements help the digestion of food and improve symptoms of fatty diarrhea (steatorrhea), bloating, and abdominal distention and frequently help lessen abdominal pain.
• Pain-relieving medicines: Non-narcotic pain-relieving drugs can help relieve pain. When these medicines are not enough, narcotic analgesics are used. These drugs are highly effective at relieving pain, but they also pose risks for drug dependency, so physicians prescribe them cautiously. Our team works closely with UChicago Medicine's pain management specialists to optimize care and assure pain control.
• Stenting of the pancreatic duct: Many patients with chronic pancreatitis have narrowed pancreatic ducts. Our gastrointestinal interventional endoscopy physicians can perform a procedure to insert a flexible plastic tube into the duct to prop it open. This procedure can relieve pain in some people.
• Removal of pancreatic duct stones: These stones can be removed via a variety of minimally invasive techniques performed in the interventional endoscopy lab.
• Extra corporeal shock wave lithotripsy: In some cases, pancreatic duct stones may be too big or are embedded in pancreatic tissue, making it impossible to remove the stones with an endoscope. When the patient is not a surgical candidate or is not interested in surgery, the stone may be crushed with shock waves that travel through the skin directly to the stone. On occasion, after this fragmentation, our endoscopists may then be able to remove the stones.
• Nerve blocks: Patients who do not respond to traditional pain-relieving measures may be candidates for a nerve block treatment. This therapy involves the injection of a powerful nerve-blocking substance directly into the nerves that carry pain signals from the pancreas. Although a nerve block usually provides only temporary relief of symptoms, there are a number of situations where it is useful to consider this alternative.

There are a variety of surgical procedures used to treat chronic pancreatitis. At UChicago Medicine, our pancreas care team holds regular meetings where each patient's case is presented and discussed to determine the best approach that will relieve abdominal pain, improve drainage of pancreatic secretions and reduce the chance for future attacks of pancreatitis.

Some patients may benefit from a pancreatic resection (surgical removal of part or all of the pancreas). Others may benefit from a drainage procedure that relieves pressure within the pancreatic ducts. A combined approach that involves both drainage treatments and resection may also be considered. A number of advanced procedures are performed at UChicago Medicine, including:

• Whipple procedure (removal of the head of the pancreas and duodenum)
• Duodenum-sparing pancreatic head resection, including the Beger procedure, the Frey procedure and the Bern modification.
• Spleen-preserving pancreatic tail resection (distal pancreatectomy)
• Minimally invasive (laparoscopic) pancreatic operations, such as pseudocyst drainage and distal pancreatectomy. Benefits of minimally invasive surgery include small incisions, less scarring and a faster recovery.

If resection (removal) of the entire pancreas (total pancreatectomy) is advised, some patients may be eligible for autologous islet cell transplantation, a highly specialized procedure offered in only a few centers worldwide. Islet transplant prevents or reduces the effects of diabetes after pancreas removal. In the past, surgeons were hesitant to remove the pancreas because patients normally developed "brittle diabetes" that was difficult-to-control after surgery. The risk of diabetes posed problems that sometimes outweighed the benefits of pancreas resection. Today, a handful of other U.S. hospitals, including UChicago Medicine, can offer islet transplantation. That allows patients with pancreatitis can undergo pancreas resection to alleviate severe pain without the fear of developing brittle diabetes. 

Experience Matters 

Studies show that patients who have had pancreatic resections at experienced hospitals fare better than people who have the same procedure at smaller hospitals with a lower volume of cases. At UChicago Medicine, our physicians are among the nation’s most experienced pancreatic surgeons, clinical pancreas specialists and islet isolation experts with respect to both the range of alternatives offered and the number of procedures performed.