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Gastrointestinal & Hepatic System

Chronic Pancreatitis

Progressive inflammatory disease of the pancreas resulting in irreversible damage, fibrosis, calcification, and loss of exocrine (digestive enzymes) and endocrine (insulin) function.

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Referral and warning signs

When to refer

Referral to specialist (Gastroenterology/Pancreatobiliary Surgery) for: Diagnosis confirmation. Management of moderate/severe pain. Management of exocrine/endocrine insufficiency. Evaluation and management of complications (pseudocysts, obstruction). Consideration for endoscopic or surgical interventions.

Red flags

  • Intractable pain unresponsive to standard analgesia
  • Significant unintentional weight loss
  • New onset jaundice
  • Symptoms of gastric outlet or biliary obstruction
  • Suspicion of pancreatic malignancy (e.g., new mass on imaging)

Signs and symptoms

  • Chronic Abdominal Pain: Often epigastric, radiating to the back, may be constant or episodic, often severe, can be worsened by eating (especially fatty foods) or alcohol.
  • Exocrine Insufficiency (Malabsorption): Steatorrhoea (bulky, greasy, foul-smelling stools), diarrhoea, weight loss, deficiencies of fat-soluble vitamins (A, D, E, K).
  • Endocrine Insufficiency (Diabetes Mellitus): Symptoms of diabetes (polyuria, polydipsia, weight loss) develop later in the disease course.
  • Nausea, vomiting.
  • Jaundice (if common bile duct obstructed by fibrosis/inflammation/pseudocyst).

Risk factors

  • Chronic alcohol abuse (most common cause in Western countries)
  • Tobacco smoking (accelerates progression)
  • Recurrent acute pancreatitis episodes
  • Idiopathic (including Tropical pancreatitis - common in some regions)
  • Genetic mutations (e.g., PRSS1, SPINK1, CFTR)
  • Autoimmune pancreatitis
  • Ductal obstruction (strictures, stones, tumours, pancreas divisum)
  • Hypercalcemia, Hyperlipidemia (less common causes of chronic)

Diagnosis

Clinical assessment

Suspect in patients with chronic epigastric pain (esp. alcoholics), steatorrhoea, weight loss, or diabetes. Diagnosis often delayed as early stages can be subtle. Differentiate pain from PUD, biliary colic, chronic mesenteric ischemia.

Investigations

  • Pancreatic Function Tests:
  • - Faecal Elastase-1: Non-invasive test for exocrine insufficiency (low levels indicate insufficiency).
  • - 72-hour Faecal Fat quantification (gold standard for steatorrhoea, cumbersome).
  • - Direct tests (Secretin stimulation test - specialist centres).
  • Imaging:
  • - Abdominal X-ray: May show pancreatic calcifications (pathognomonic but insensitive).
  • - Abdominal Ultrasound: May show ductal dilatation, calcifications, pseudocysts (often limited by bowel gas).
  • - CT Scan (Abdomen): Good for detecting calcifications, ductal changes, atrophy, pseudocysts, masses.
  • - MRI/MRCP (Magnetic Resonance Cholangiopancreatography): Excellent for visualizing pancreatic duct anatomy, strictures, side branches.
  • - Endoscopic Ultrasound (EUS): Highly sensitive for detecting subtle parenchymal and ductal changes of chronic pancreatitis.
  • - ERCP (Endoscopic Retrograde Cholangiopancreatography): Primarily therapeutic (stenting strictures, stone removal), less used for diagnosis now due to risk.
  • Blood tests: Glucose/HbA1c (diabetes), Amylase/Lipase (often normal or only mildly elevated unless acute flare), Calcium, Lipids.

Diagnostic criteria

Diagnosis based on combination of characteristic clinical features (chronic pain, malabsorption, diabetes) AND supportive imaging findings (calcifications, ductal changes, atrophy) +/- evidence of exocrine/endocrine insufficiency.

Management

Non-pharmacological management

  • Alcohol Abstinence: Absolutely essential.
  • Smoking Cessation: Crucial.
  • Dietary Modification: Low-fat diet, small frequent meals. Avoid large fatty meals that trigger pain.
  • Nutritional support: Address malnutrition, supplement fat-soluble vitamins (A, D, E, K) if deficient.
  • Pain Management: Often challenging. May involve multidisciplinary approach (pain specialists). Endoscopic therapy (stenting, stone removal) or surgery (pancreatic duct drainage procedures, resection) may be needed for intractable pain related to obstruction.
  • Management of complications (pseudocysts, diabetes, etc.).

Pharmacological treatment

  • Pain Management:
  • - Analgesics (Stepwise approach - WHO ladder): Start with Paracetamol, NSAIDs (use cautiously). Progress to weak opioids (Tramadol). Strong opioids (Morphine, Pethidine) often required for severe pain (risk of dependence).
  • - Adjuvant agents: TCAs (Amitriptyline), Gabapentin/Pregabalin may help neuropathic component.
  • - Pancreatic Enzyme Replacement Therapy (PERT): Can sometimes reduce pain by reducing pancreatic stimulation (mechanism debated).
  • Exocrine Insufficiency (Malabsorption/Steatorrhoea):
  • - Pancreatic Enzyme Replacement Therapy (PERT): High-dose, enteric-coated preparations (e.g., Creon, Pancreaze) containing lipase, protease, amylase. Dose based on meal fat content and symptom response (e.g., 25,000-75,000 units lipase per meal). Must be taken WITH meals/snacks.
  • - PPIs or H2RAs: May be added to improve efficacy of PERT by reducing acid degradation.
  • - Fat-soluble vitamin supplementation.
  • Endocrine Insufficiency (Diabetes):
  • - Management similar to other types of diabetes, but often brittle.
  • - Insulin therapy is usually required eventually.
  • - Monitor closely for hypoglycemia.
  • - Oral agents less effective.
  • Autoimmune Pancreatitis: Corticosteroids (specialist management).

Monitoring

  • Monitor pain control and analgesic requirements.
  • Monitor symptoms of malabsorption (stool character, weight).
  • Monitor glycaemic control (blood glucose/HbA1c).
  • Monitor nutritional status, vitamin levels.
  • Periodic imaging to assess for complications (pseudocysts, malignancy).

Complications

  • Chronic debilitating pain
  • Malabsorption, malnutrition, vitamin deficiencies
  • Diabetes mellitus ('pancreatogenic diabetes')
  • Pancreatic pseudocysts
  • Bile duct or duodenal obstruction
  • Pancreatic duct strictures/stones
  • Splenic vein thrombosis -> Gastric varices
  • Pseudoaneurysm formation
  • Increased risk of pancreatic cancer (long-standing chronic pancreatitis)

Prevention

  • Avoid excessive alcohol consumption.
  • Smoking cessation.
  • Treat underlying causes where possible (e.g., hyperlipidemia, hypercalcemia).

Patient education

  • Explain chronic nature of the disease and irreversible damage.
  • Absolute need for alcohol and smoking cessation.
  • Dietary advice (low fat, small meals).
  • How to take pancreatic enzymes correctly (with food).
  • Pain management plan and risks of opioid dependence.
  • Diabetes management if present.
  • Recognizing complications.
  • Importance of long-term follow-up.

Uganda-specific notes

Alcohol is a major cause, but idiopathic/tropical pancreatitis also relevant. Diagnosis relies heavily on clinical picture and basic imaging (ultrasound, X-ray for calcification). Access to advanced imaging (CT/MRCP/EUS), ERCP, PERT, and specialist care/surgery is very limited. Management focuses on pain control, alcohol cessation, and managing malabsorption/diabetes when possible.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 6, Section 6.3.6

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