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Conlon: Current management of chronic pancreatitis

Chronic pancreatitis, a progressive malabsorptive condition, is a major health problem with significant morbidity, mortality and associated economic health care costs. Epidemiological data are sparse. The overall prevalence of chronic pancreatitis in Europe is thought to be about 6–7 per 100 000 population, and the incidence is increasing, particularly among women. Recent data from our unit show that in Ireland patients with chronic pancreatitis present at an earlier age than reported elsewhere,1,2 have considerable endocrine/exocrine problems, often require hospitalization and are more likely to have osteoporosis than previously reported.1,2 Anecdotal evidence would also suggest that the incidence of chronic pancreatitis in Ireland is increasing in parallel with the known increased incidence of acute pancreatitis in the country.3

Data related the societal burden of the disease are scarce. Previous work by our group has suggested that chronic pancreatitis is associated significant adverse effects, including high levels of social deprivation, unemployment, substance abuse and divorce.1 Access to specialized care is limited and management is often ad hoc and haphazard, with a lack of standardized protocols.1 Hospitalization is frequent, with malnutrition common and outcomes poor. For society in general, patients with chronic pancreatitis represent a significant but underappreciated resource burden. Patients tend to be relatively young and, as a result of the nature of the condition, fail to maintain an active presence in the workforce with increased unemployment. Additionally, inpatient and outpatient costs tend to be significant because of ongoing pain and the considerable cost of treating exocrine and endocrine deficiencies.

A disease continuum has been suggested between acute pancreatitis, recurrent acute pancreatitis and chronic pancreatitis. Approximately 20–30% of patients with acute pancreatitis will experience recurrence, and in 10% of cases this will progress to chronic pancreatitis.4 We previously reported that hospital admissions for acute pancreatitis in Ireland had increased by 34% between 1997 and 2004.5 The greatest increases were seen among females and in young patients (aged < 30 years). The causes are multifactorial, although patterns of alcohol consumption and abuse appear to be significant. The precise mechanism by which alcohol causes acute pancreatitis remains controversial; however, it is accepted that alcohol appears to increase the sensitivity of the pancreas to injury from other environmental or genetic factors.

Although alcohol appears to be a significant aetiological factor for chronic pancreatitis, in significant numbers of patients the cause remains unclear despite sophisticated imaging and biochemical investigations. An epidemiological study of chronic pancreatitis in a German population reported that aetiology was unknown in 28% of cases.6 In two recent cohort studies performed by our group, 19.3% and 20.7% of patients with established chronic pancreatitis were classified as idiopathic.1 This is similar to the findings of a recent Danish study that examined the records of 580 patients with early-onset chronic pancreatitis and compared the incidence and aetiological factors during two time periods: 1980–88 and 1999–2004.7 The authors noted that idiopathic pancreatitis was significantly more common after 1999 than previously, accounting for 27.2% of cases in the second study period.

The necrosis–fibrosis hypothesis describes chronic pancreatitis as an initial, acute, inflammatory process that progresses to chronic irreversible damage as a result of repeated acute attacks. Although patients may present with symptoms suggestive of chronic pancreatitis, the clinical presentation alone is insufficient for making a diagnosis. Typical symptoms, such as weight loss, pain, steatorrhoea and malnutrition are vague, and not specific to chronic pancreatitis; therefore, diagnostic tests of pancreatic structure and function are required.

The development of chronic pancreatitis results in significant exocrine and endocrine perturbations that may be difficult to manage. Contemporary clinical algorithms have been proposed, with the emphasis on nutritional, exocrine and diabetic management.

Traditionally, surgical intervention has been limited to drainage or resectional procedures. However, recent work has proposed that organ-sparing drainage techniques and islet cell transplantation may have a role in the surgical portfolio. Furthermore, many have suggested that the role of surgery, which traditionally has been confined to the management of intractable pain or to resolve complications such as biliary and duodenal obstruction, should be expanded to not only manage existing symptoms but also to prevent further endocrine or exocrine deterioration.

References

1. 

Duggan SN, O’Sullivan M, Hamilton S, Feehan SM, Ridgway PF, Conlon KC. Patients with chronic pancreatitis are at increased risk of osteoporosis. Pancreas 2012; 41:119–24. https:/doi.org/10.1097/MPA.0b013e31824abb4d

2. 

Duggan SN, Smyth ND, O’Sullivan M, Feehan S, Ridgway PF, Conlon KC. The prevalence of malnutrition and fat-soluble vitamin deficiencies in chronic pancreatitis. Nutr Clin Pract 2014; 29:348–54. https:/doi.org/10.1177/0884533614528361

3. 

Ní Chonchubhair HM, O’Shea B, Kavanagh DO, Ryan BM, Duggan SN, Conlon KC. Chronic pancreatitis in primary and hospital based care in Ireland: the management of an orphan disease. J Pancreas 2016; 17:385–93.

4. 

Yadav D, Timmons L, Benson JT, Dierkhising RA, Chari ST. Incidence, prevalence, and survival of chronic pancreatitis: a population-based study. Am J Gastroenterol 2011; 106:2192–9. https:/doi.org/10.1038/ajg.2011.328

5. 

O’Farrell A, et al. Hospital admission for acute pancreatitis in the Irish population, 1997–2004: could the increase be due to an increase in alcohol-related pancreatitis? J Public Health 2007; 29:398–404. https:/doi.org/10.1093/pubmed/fdm069

6. 

Lankisch PG, Assmus C, Maisonneuve P, Lowenfels AB. Epidemiology of pancreatic disease in Luneburg county. Pancreatology 2002; 2:469–76. https:/doi.org/10.1159/000064713

7. 

Joergensen M, Brusgaard K, Crüger DG, Gerdes AM, de Muckadell OB. Incidence, prevalence, aetiology, and prognosis of first-time chronic pancreatitis in young patients: a nationwide cohort study. Dig Dis Sci 2010; 55:2988–98. https:/doi.org/10.1007/s10620-009-1118-4




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