Chronic pancreatitis is a disease characterized by progressive necrosis and fibrosis of the pancreatic parenchyma due to various causes, leading to a decline in both endocrine and exocrine functions. The average age of onset is 38 years, with men being more commonly affected than women. Clinical manifestations include recurrent, intractable upper abdominal pain, weight loss, steatorrhea, abdominal masses, jaundice, and glycosuria.
I. Etiology
Chronic pancreatitis is often caused by the prolonged presence of factors underlying acute pancreatitis, such as biliary tract diseases (including cholelithiasis, biliary ascariasis, Oddi’s sphincter stenosis, and tumors), alcohol consumption, nutritional and metabolic disorders, pancreatic stones, abdominal trauma and surgery, and certain cases of unknown etiology.
II. Clinical Manifestations
Clinically, chronic pancreatitis is divided into two categories: (1) chronic recurrent pancreatitis, in which 90% of patients experience severe abdominal pain; and (2) chronic painless pancreatitis, accounting for 10% of cases, characterized primarily by weight loss, steatorrhea, and exocrine and endocrine insufficiency.
Abdominal Pain: This is the most common and primary manifestation of the disease. The pain is often similar to that of acute pancreatitis and is extremely severe. Initial episodes are typically intermittent and are frequently triggered by alcohol consumption, heavy meals, or physical exertion. Episodes may occur 1–2 or 5–6 times per year initially, becoming more frequent over time until they eventually progress to persistent abdominal pain, accompanied by exocrine and endocrine pancreatic insufficiency. The pain is primarily located below the xiphoid process or in the upper-middle abdomen, followed by pain above the umbilicus and in the upper left abdomen; it may radiate to the back. During remission, patients may be pain-free or experience only mild discomfort; during an attack, they experience colicky or severe pain that worsens with walking, riding in a vehicle, or descending stairs. Patients often adopt a bent-over, bent-knee posture or a chest-knee position to alleviate the pain. The pain cannot be relieved by general antispasmodic medications.
Nausea and vomiting: During an attack, patients may experience nausea and vomiting; the vomitus consists of ingested food, but the abdominal pain does not subside after vomiting.
Weight loss: This refers to emaciation. Due to abdominal pain and vomiting—or because eating exacerbates the pain—patients may avoid eating. Some patients experience diarrhea resulting from reduced exocrine pancreatic secretion, which impairs digestion and absorption; others may develop diabetes due to endocrine insufficiency and insufficient insulin secretion, leading to progressive weight loss.
Diarrhea: This is a late-stage manifestation of the disease. It is caused by factors such as pancreatic duct obstruction, destruction of pancreatic acini, and severe decline in exocrine pancreatic function. It presents as an increased frequency of bowel movements—3 to 5 times daily—with loose, unformed stools; occasionally, oil droplets may be visible floating on the surface of the stool. Diarrhea is generally triggered or exacerbated after consuming greasy foods or alcohol. It may be alleviated with treatment using pancreatic enzyme preparations.
Abdominal Mass: Patients with pancreatic cysts may develop an abdominal mass, which can be palpated deep in the upper left abdomen. This is more clearly visible on ultrasound. The size of the mass varies; small ones measure only 2–3 centimeters, while large ones can reach a diameter of 20 centimeters or more.
Jaundice: Jaundice may occur in patients with chronic pancreatitis; its incidence ranges from 10–30% in Europe and the United States, is lower in Japan, and is higher in mainland China. The primary causes of jaundice include inflammation and edema of the pancreatic head or cysts compressing the distal common bile duct, as well as stones, edema, or narrowing of the common bile duct itself.
Diabetes: Destruction of islet cells leads to insufficient insulin secretion, resulting in diabetes, which manifests as hyperglycemia and glycosuria.
III. Diagnosis of Chronic Pancreatitis
Diagnosing chronic pancreatitis presents certain challenges. This condition should be considered in patients with the following characteristics: ① Long-term dull upper abdominal pain, with a history of alcohol abuse; ② Long-term, recurrent episodes of upper abdominal pain accompanied by dyspepsia and steatorrhea; ③ A history of unexplained jaundice, with test results inconsistent with cholelithiasis or pancreatic tumors; ④ Diabetes of unknown etiology. Relevant tests should be conducted, particularly assessments of pancreatic exocrine and endocrine function, abdominal X-rays, B-mode ultrasound, CT scans, or retrograde pancreaticobiliary cholangiography, which can aid in diagnosis.
IV. Treatment
The goals of treating chronic pancreatitis are:
(1) To alleviate the patient’s suffering;
(2) To promote unobstructed pancreatic secretion;
(3) To improve the exocrine and endocrine functions of the pancreas;
(4) To prevent disease progression and recurrence;
(5) To address nutritional deficiencies caused by dyspepsia.
Treatment options include non-surgical and surgical approaches.
Non-surgical Treatment
(1) Dietary therapy: Patients with severe cases should fast; those with mild cases may be given low-fat foods and a light diet;
(2) Abstinence from alcohol and alcoholic beverages. Alcohol increases gastric acid secretion, which in turn stimulates increased pancreatic exocrine secretion and causes pain;
(3) Medication: ① Pain relief: Small doses of anesthetics may be administered for severe pain; ② Pancreatic enzyme preparations: Such as pancreatic enzyme pills and multienzyme pills, which can alleviate or eliminate steatorrhea; ③ Adequate supplementation of multivitamins, which is highly beneficial for the treatment of this condition; ④ Antibiotics: During an acute attack, prompt administration of antibiotics is necessary to prevent secondary infections. Commonly used drugs include kanamycin, gentamicin, and ampicillin.
(4) Traditional Chinese Medicine (TCM) Treatment: During the acute phase of chronic pancreatitis, when severe abdominal pain is present, Qingpan Decoction with appropriate modifications may be used; if the patient experiences persistent dull pain, treatment should focus on promoting blood circulation to remove stasis and regulating qi to relieve pain. In such cases, Qingpan Decoction may be modified by omitting rhubarb and mirabilite, increasing the dosage of wood fragrant and corydalis, or adding ingredients such as manchurian armadillo shell, soapberry thorn, pollen of arrowhead, and five-spirit fat. If the patient exhibits postprandial fullness, loss of appetite, diarrhea, or nausea, aversion to drinking, dizziness, weakness in the limbs, and a white or yellow greasy tongue coating due to insufficient exocrine pancreatic function, the Qingyi Decoction may be modified by omitting rhubarb, mirabilite, and Coptis, and adding Poria, Atractylodes macrocephala, Atractylodes lancea, Agastache, Eupatorium, and Pinellia, among others. Alternatively, Pingwei San with appropriate modifications may be used for treatment. If the patient has a lack of appetite, generalized weakness, and a thin white or scant tongue coating, Sijunzi Decoction combined with Baohe Pills, with appropriate modifications, may be used; if the patient has a dry mouth and a red tongue with scant coating, Yangwei Decoction with appropriate modifications may be used.
Surgical Treatment
The goal of surgical treatment is to eliminate the cause of obstruction, ensure unobstructed pancreatic juice drainage, and alleviate suffering. There are two methods: direct surgery and indirect surgery.
V. Preventing Recurrence of Chronic Pancreatitis
In the early stages of chronic pancreatitis, recurrent episodes are common; therefore, preventing recurrence is crucial. It is essential to focus on the following measures:
(1) Strictly abstain from smoking and alcohol, especially alcohol, as alcohol can increase pancreatic secretion and trigger this condition.
(2) Avoid overeating and physical exhaustion: Overeating can also increase pancreatic secretion and trigger the disease, while physical exhaustion can lower the body’s resistance and promote recurrence.
(3) Treat biliary tract diseases to ensure unobstructed drainage of pancreatic and bile fluids, such as biliary stones, roundworms, or strictures.
(4) It is also very important to maintain a positive mental state and avoid intense anger or emotional distress.