chronic pancreatitis

Last edited 03/2022 and last reviewed 03/2023

Chronic pancreatitis is characterised by irreversible glandular destruction and permanent loss of endocrine and exocrine function. It may follow episodes of acute pancreatitis or may occur without an identifiable attack.

The incidence is increasing. In the UK, about 5 new cases are reported annually per 100,000 of the population. The most common aetiological agent is alcohol but in some patients, no satisfactory explanation is available.

• is a continuous prolonged inflammatory process of the pancreas that results in fibrosis, cyst formation and stricturing of the pancreatic duct
  
  
• usually presents with chronic abdominal pain but it can sometimes be painless
  • classic chronic pancreatitis, usually associated with alcohol use, smoking, or certain gene mutations, typically begins with recurrent painful bouts of pancreatitis, followed by the insidious development of chronic, debilitating pain during the next 3 to 5 years after an initial episode (2)
    
    
• clinical course is variable but most people with chronic pancreatitis have had 1 or more attacks of acute pancreatitis that has resulted in inflammatory change and fibrosis
  • some people, however, chronic pancreatitis has a more insidious onset
    
    
• intensity of pain can range from mild to severe, even in people with little evidence of pancreatic disease on imaging
  • classic imaging findings of one or more of the triad of pancreatic ductal calcifications, ductal dilatation, and parenchymal atrophy indicate progression to chronic pancreatitis (2)
    
    
• annual incidence of chronic pancreatitis in western Europe is about 5 new cases per 100,000 people, although this is probably an underestimate
  • male to female ratio is 7:1 and the average age of onset is between 36 and 55 years
  • alcohol is responsible for 70-80% of cases of chronic pancreatitis
  • cigarette smoking is not thought to be a primary cause in itself, it is strongly associated with chronic pancreatitis and is thought to exacerbate the condition (1)
    • alcohol use (>80 g per day for 6 to 12 years) and smoking (a smoking history of >35 pack-years increases the risk of chronic pancreatitis by a factor of 5) have synergistic effects (2)
  • genetic mutations (in 10%) (2)
    • genetic mutations
      • most commonly involve cystic fibrosis transmembrane conductance regulator (CFTR), serine protease inhibitor Kazal type1 (SPINK1), or chymotrypsin C (CTRC)
      • hereditary pancreatitis is a rare autosomal dominant disease caused by cationic trypsinogen (PRSS1) gene mutation, accounts for approximately 1% of all cases
  • the disease is considered to be idiopathic in 28% of patients (2)
  • two thirds of patients with chronic pancreatitis are men, and risk is higher among black persons than among white persons

• chronic pancreatitis may be idiopathic or, in about 5% of cases, caused by hereditary factors (in these cases there is usually a positive family history)

• other causes include hypercalcaemia, hyperlipidaemia or autoimmune disease
  
  
• chronic pancreatitis causes a significant reduction in pancreatic function and the majority of people have reduced exocrine (digestive) function and reduced endocrine function (diabetes)
  • can also give rise to specific complications including painful inflammatory mass and obstructed pancreatic duct, biliary or duodenal obstruction, haemorrhage, or accumulation of fluid in the abdomen (ascites) or chest (pleural effusion)
  • significantly increases the risk of pancreatic cancer
    • risk is much higher in people with hereditary pancreatitis
  • regardless of the cause, chronic pancreatitis confers a predisposition to pancreatic cancer (2)
    • cumulative risk is 1.8% at 10 years and 4% at 20 years of follow-up among patients with sporadic chronic pancreatitis and 7.2% by 70 years of age among those with hereditary pancreatitis

Reference:

• NICE (September 2018). Pancreatitis
• Vege SS, Chari ST. Chronic Pancreatitis.N Engl J Med 2022; 386:869-878 DOI: 10.1056/NEJMcp1809396