Chronic pancreatitis
The pancreas is a small organ sitting behind the stomach, and it holds down two jobs that look incompatible at first glance: it makes a juice full of enzymes…
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Medicines commonly prescribed for Chronic pancreatitis
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: ORAL SOLUTION/SUSPENSION DROPS, 100 mg/mlActive substance: tramadolManufacturer: Farmalider S.A.Prescription requiredDosage form: MODIFIED-RELEASE TABLET, 100 mgActive substance: tramadolManufacturer: Viatris LimitedPrescription requiredDosage form: TABLET, 20 mg pantoprazoleActive substance: pantoprazoleManufacturer: Farmalider S.A.Prescription required
The pancreas is a small organ sitting behind the stomach, and it holds down two jobs that look incompatible at first glance: it makes a juice full of enzymes for digesting food, and it releases insulin into the blood. In chronic pancreatitis its tissue is replaced by scar over the years. The difference from acute pancreatitis is fundamental: an acute attack is one severe flare after which the gland usually recovers, while the chronic form is accumulated damage that does not wind back. That sounds bleak, but there is good news hiding inside it: how fast the destruction goes depends almost entirely on what happens next, and the two most powerful decisions belong to the person, not to the doctor.
The pain that keeps coming back
The main complaint is bouts of pain in the upper abdomen, usually in the middle or on the left, often spreading through to the back. People describe it differently: burning, boring, like a band being tightened. It can last hours, or hold on for several days in a row. Many find relief by sitting up and leaning forward, or by drawing the knees to the chest; lying flat on the back is almost always worse.
Sometimes an attack clearly follows a large or fatty meal or a drink, but just as often no trigger can be found, and that is what confuses people: they work through foods, look for a pattern and never find one. Nausea often joins in, with vomiting that brings no relief.
Over time the attacks come closer together, and a dull ache settles in between them. There is a detail here that people are rarely warned about: the pain stops being a simple readout of what the gland is doing. Nerve pathways that have carried the signal for years become the source of it themselves, so it can persist after the inflammation has quietened down. This is not psychosomatic but a well-described mechanism, and it is treated differently from ordinary pain.
When food stops being absorbed
The gland makes enzymes with a huge margin to spare, so digestive trouble shows up late, often a decade after the first attacks. It is hard to mistake for anything else, though:
- stools become bulky and pale with an oily sheen, they are hard to flush away and they smell sharply unpleasant;
- the abdomen bloats and rumbles, and eating sends you to the toilet;
- weight falls away even though the person is eating as before;
- weakness, brittle bones, night blindness, dry skin and bleeding gums appear: that is how a shortage of fat-soluble vitamins and protein shows itself.
Later the gland's second job suffers too, and diabetes develops, the kind called pancreatogenic, or type 3. It has one feature worth knowing about: along with insulin the gland stops producing the hormone that raises blood sugar, so this diabetes is prone to sudden, deep drops in glucose. In chronic pancreatitis blood sugar is checked regularly, even when there are no complaints at all.
Signs that cannot wait
Seek emergency care if any one of these appears:
- severe abdominal pain that does not let go for hours, especially with repeated vomiting, bloating and an inability to drink: this may be a flare with tissue death;
- yellowing of the skin and of the whites of the eyes, dark urine and pale stools: something is pressing on the bile duct, and it needs sorting out quickly;
- fever with shivering alongside abdominal pain, which points to an abscess or to inflammation of the bile ducts;
- vomiting blood, or black tarry stools;
- sudden weakness, shaking, sweating and confusion in someone with diabetes: a drop in blood sugar, which in this form of diabetes can be severe.
One combination deserves separate mention, because it must not be written off as the usual illness: rapid weight loss, jaundice and new diabetes in someone over fifty. Chronic pancreatitis itself raises the risk of pancreatic cancer, and the early signs of the two look alike. This is no reason to live in fear, since the odds stay low, but it is a reason not to put the tests off until later.
What destroys the gland
Behind a course lasting many years there is usually alcohol, and it need not be drinking to excess: regular drinking is enough. The second most important factor is smoking, and that is a finding of recent years. It used to be seen as merely alcohol's companion, and it turned out to damage the gland in its own right and to speed up the scarring regardless of what is drunk. Then come causes that are rarer but change the treatment completely:
- inherited changes in the genes that govern how the enzymes work, suspected when the illness starts young or runs in the family;
- cystic fibrosis, the commonest cause in children;
- autoimmune inflammation, in which the immune system attacks the gland itself; it responds well to hormonal drugs, so it is important not to miss;
- stones and narrowings that block the juice from leaving the gland;
- an earlier abdominal injury or radiation;
- persistently high triglycerides or calcium in the blood.
In roughly one person in five the cause is never found. The diagnosis stands all the same, and that form is treated in exactly the same way.
How the diagnosis is confirmed
Early on, ordinary ultrasound and blood tests often show nothing, and amylase and lipase, contrary to popular belief, can be normal in the chronic form. One test is therefore not enough, and the work-up is built differently:
- a CT scan with contrast, which picks up calcification, a widened duct and cysts;
- MR cholangiopancreatography, which shows the ducts with no radiation and no procedure;
- endoscopic ultrasound, the most sensitive method in the early stages, with the probe brought up to the gland through the stomach;
- faecal pancreatic elastase, a simple way of telling whether there are enough enzymes;
- blood sugar and glycated haemoglobin, vitamin D and bone density.
Sometimes the picture resembles a tumour so closely that a piece of tissue is taken with a needle under endoscopic ultrasound guidance. That does not mean the doctor suspects the worst; it means the doctor does not want to rely on a guess.
What stops the destruction
Scar does not melt away, but the speed of further damage is something that can be steered. Two decisions do more than all the medicines put together: giving up alcohol and tobacco completely. Completely, because for a damaged gland there is no safe dose, and that holds even for people whose disease began from something else entirely. If stopping on your own does not work, that is not weakness of character but a reason to ask for help: there are talking approaches and there are drugs that reduce craving, and the same applies to nicotine.
Next come the enzyme capsules. They are not taken in courses but with every meal, snacks included, spread through the meal rather than swallowed all at once before it or after. When they seem not to work, the reason is usually too small a dose, or stomach acid destroying the preparation, in which case a drug that lowers acidity is added. Fat-soluble vitamins are prescribed separately, and vitamin D and calcium are kept under review.
Food deserves plain speaking, because the old advice is out of date. A strict fat-free diet is no longer recommended: it strips away calories and vitamins and deepens the wasting, whereas fat is absorbed perfectly well once the enzymes are properly matched. The sensible pattern is ordinary full meals in small portions five or six times a day, enough protein, no alcohol. Cutting fat back is worth doing only if stools stay greasy despite the enzymes, and that is best worked out with a dietitian. The autoimmune form stands apart: it responds quickly to hormonal drugs but is inclined to return, so it needs ongoing follow-up.
How the pain is handled
Treatment starts with simple painkillers. Anti-inflammatory drugs taken long term raise the risk of ulcers and kidney damage, so no long-term plan is built on them, and when they are prescribed a stomach-protecting drug goes with them.
Once the pain is constant and the nerve pathways themselves are part of it, ordinary painkillers do poorly. Drugs originally developed against depression and epilepsy help here: in this situation they are prescribed precisely as painkillers, and the dose is built up gradually. Opioids are used, but cautiously and for as short a time as possible, because in an illness measured in decades they accumulate problems of their own: dependence, constipation and a paradoxical increase in pain. Many people are helped substantially by chronic pain management approaches, and those are not a substitute for treatment but part of it.
When medicines are not enough, procedures come up for discussion. If the duct is blocked by a stone or narrowed, a stent is placed endoscopically and the stones are broken up. If the pain comes from a limited part of the gland, that part is removed. In the most severe cases the whole gland is removed, and so that the person is not left without insulin, islet cells are isolated from the removed organ beforehand and put into the liver, where they take and carry on working. Such operations are done in specialist centres, and the decision is made together with the surgeon after a conversation about the risks.
The checks people forget
Chronic pancreatitis calls not only for treating the attacks but for planned monitoring, which is exactly what heads off the things that creep up unnoticed:
- blood sugar and glycated haemoglobin roughly every six months;
- a review of nutrition and weight and of vitamin levels once a year, more often in children;
- bone density every two years: when fat is absorbed poorly, bones weaken early;
- vaccinations, especially against influenza and pneumococcus;
- if the pancreatitis is inherited, yearly surveillance is discussed because of the raised risk of a tumour.
It is worth remembering wellbeing in the broad sense too. Constant pain wears people down and often brings anxiety and low mood with it, and those in turn sharpen how the pain is felt. People get out of that circle with help rather than willpower, and raising it with your doctor is every bit as appropriate as talking about stools or weight.
Online consultation
Remotely it is convenient to go through everything that falls between appointments. If there is no diagnosis yet, your doctor can work through the character of the pain and of the stools and say which tests are needed and in what order, so that you do not go round in circles. If the diagnosis is already made, you can check whether you are taking the enzymes correctly and whether the dose is enough, discuss food without extremes, work out why the painkillers have stopped helping, and prepare for the conversation about a procedure. Online works for routine monitoring as well: going over the test schedule, looking through recent results, adjusting the regimen. The signs from the emergency section are not dealt with through a screen; with those you need to get to hospital.
This material is for information only and does not replace medical advice.
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Discuss your symptoms and possible next steps for Chronic pancreatitis with a doctor online.
