Seminar Chronic pancreatitis Joan M Braganza, Stephen H Lee, Rory F McCloy, Michael J McMahon Lancet 2011; 377: 1184–97 Published Online March 11, 2011 DOI:10.1016/S01406736(10)61852-1 Department of Gastroenterology (J M Braganza DSc) and Department of Radiology (S H Lee FRCR), Manchester Royal Infirmary, Manchester, UK; Department of Education, Lancashire Teaching Hospitals, Preston, UK (R F McCloy FRCS); and University of Leeds and Nuffield Hospital, Leeds, UK (Prof M J McMahon FRCS) Correspondence to: Dr Joan M Braganza, c/o Mrs Jenny Parr, Core Technology Facility, 3rd Floor, Grafton Street, Manchester M13 9NT, UK [email protected] Chronic pancreatitis is a progressive fibroinflammatory disease that exists in large-duct (often with intraductal calculi) or small-duct form. In many patients this disease results from a complex mix of environmental (eg, alcohol, cigarettes, and occupational chemicals) and genetic factors (eg, mutation in a trypsin-controlling gene or the cystic fibrosis transmembrane conductance regulator); a few patients have hereditary or autoimmune disease. Pain in the form of recurrent attacks of pancreatitis (representing paralysis of apical exocytosis in acinar cells) or constant and disabling pain is usually the main symptom. Management of the pain is mainly empirical, involving potent analgesics, duct drainage by endoscopic or surgical means, and partial or total pancreatectomy. However, steroids rapidly reduce symptoms in patients with autoimmune pancreatitis, and micronutrient therapy to correct electrophilic stress is emerging as a promising treatment in the other patients. Steatorrhoea, diabetes, local complications, and psychosocial issues associated with the disease are additional therapeutic challenges. Introduction Definition Chronic pancreatitis is a progressive inflammatory disorder in which pancreatic secretory parenchyma is destroyed and replaced by fibrous tissue, eventually leading to malnutrition and diabetes. Two forms are recognised—a large-duct calcifying type1 and a small-duct variant.2–4 The disease is uncommon in Europe and the USA; its prevalence in France is 26 per 100 000 people.5 This prevalence is not dissimilar to the middle of three estimates from Japan,6,7 but considerably lower than the figure of 114–200 per 100 000 in south India.7 The main symptom of chronic pancreatitis is usually pain, which occurs as attacks that mimic acute pancreatitis or as constant and disabling pain. Despite decades of research, treatment of chronic pancreatitis remains mostly empirical, and thus patients are repeatedly admitted to hospital and have interventional procedures, which strains medical resources.8 This absence of progress in treatment is a sign of uncertainty about how the identified causative factors lead to the disease. Therefore, in this Seminar we focus on the pathophysiology and pathology of chronic pancreatitis before describing clinical management. Traditionally, chronic pancreatitis has been classed as fundamentally different from acute pancreatitis—the latter is usually characterised by restoration of normal pancreatic histology after full clinical recovery.1 However, acute, recurrent acute, and chronic pancreatitis are now regarded as a disease continuum.9,10 There are several reasons for this change: recurrent acute pancreatitis can develop into chronic pancreatitis;10–12 there is an overlap in causative factors, both genetic and environmental;10,13 experimental protocols can be modified to induce each condition;14 and the pancreatitis attack is stereotyped— patients have severe abdominal pain and increased blood amylase, lipase, and trypsinogen. Search strategy and selection criteria We searched PubMed and the Cochrane library (to August, 2010) for reviews on chronic pancreatitis. We used Google scholar for specific searches, with “chronic pancreatitis” as the key phrase combined with “epidemiology”, “pathology”, “aetiology”, “gene mutations”, “pathogenesis”, “classification”, “diagnosis”, “pancreatic function tests”, “pancreatic imaging tests”, “treatment of pain”, “pancreatic enzyme therapy”, “micronutrient therapy”, “antioxidant therapy”, “endoscopic treatment”, or “surgical treatment”. We selected the most up-to-date articles but did not disregard commonly referenced older publications. We also examined the reference lists of identified papers and selected those that we judged to be relevant. Review articles and book chapters are cited to give readers more details and references than this Seminar can accommodate. 1184 Pathophysiology and pathology Experimental studies since the 1950s have shown that an attack of pancreatitis begins as pancreastasis,13 prevention of apical exocytosis in the pancreatic acinar cell (figure 1).15 The acinar cell quickly releases newly synthesised enzyme via the basolateral membrane into lymphatics, by way of the interstitium, and directly into the bloodstream.16 Some zymogen granules also release their stored enzyme basolaterally.15 These events result in inflammation.17 Findings from prospective clinical studies concur with this pancreastasis–pancreatitis sequence.13,17 Experimental work has pinpointed a burst of reactive oxygen species (ROS) as the trigger of so-called pancreastasis18 and as the potentiator of inflammation by activating signalling cascades that convert the damaged acinar cell into a factory for chemokines and cytokines.19,20 ROS serve several physiological roles, including in signal transduction,13,21 but an excess of ROS compared with antioxidant capacity (electrophilic stress) is potentially very damaging. The exocytosis blockade seems to be caused by disruption of the methionine trans-sulphuration pathway that produces essential methyl and thiol (principally glutathione) moieties.17,22 This problem also occurs in clinical acute or acute-on-chronic pancreatitis.23–25 In patients who develop large-duct chronic pancreatitis, studies in the quiescent phase of the disease show that the composition of pancreatic fluid changes in a manner www.thelancet.com Vol 377 April 2, 2011 Seminar Normal Pancreastasis Pancreatitis Constitutive pathways E PAP/regIII PSP/reg ZG ZG L ZG ZG-L ZG-L GC RER D GC RER ZG RER Ph-elastase Ph-PLA2 Nucleus Nucleus Nucleus MO Constitutive pathway E E E MC PMN Foci of gland digestion Figure 1: Schematic representation of disturbances in the pancreatic acinar cell during experimental acute pancreatitis See text for a full description. The constitutive pathway at the basolateral pole normally transports a small fraction of newly synthesised enzyme, as do two pathways at the apical pole. E=amylase, lipase, trypsinogen, and other precursor proteases, and pro-phospholipase A2. RER=rough endoplasmic reticulum. GC=Golgi complex. ZG=zymogen granules. L=lysosomes. ZG-L=miniscule fraction of zymogens activated by co-localisation with lysosomal enzymes. D=centripetal dissolution of granules. PAP/regIII=pancreatitis associated protein. PSP/reg=pancreatic stone protein/islet regenerating protein. MC=mast cell. PMN=polymorphonuclear cell. MO=monocyte. Ph-PLA2=phospholipase A2 from phagocytes and mast cell. Adapted from Braganza.13 that, for uncertain reasons, facilitates protein deposits— the precursors to calcium carbonate stones.1 (1) There is an early increase in secretion of enzyme and calcium, but a decrease in the serine protease inhibitor Kazal type 1 (SPINK 1), bicarbonate, and citrate.1 (2) Concentrations of free radical oxidation products are raised in the pancreatic fluid,26 which suggests ongoing electrophilic stress, and in an apparent attempt to compensate, concentrations of the natural antioxidants27 lactoferrin and mucin are increased.1,2,28 (3) Concentrations are altered of two secretory stress proteins29 (increased concentration of pancreatitis associated protein [PAP]/regIII, which is activated by electrophilic stress; and variable concentration of pancreatic stone protein [PSP]/reg, formerly called lithostatin;1 figure 1) that tend to form fibrous lattices upon partial digestion by trypsin. (4) There is an increase of GP-2, which is a secreted component of zymogen granule membranes (analogous to the renal cast protein).30 (5) Concentrations of lysosomal enzymes are increased in ductal fluid, and traces of trypsin appear.31 Moreover, the methionine metabolic pathway remains fractured.32–34 On histology, the defining triad of stable disease (irrespective of main causes or location)35 is acinar loss, mononuclear cell infiltration, and fibrosis. The early lesions are distributed in patches; thus, normal findings on needle biopsy are unreliable. An unusual form of socalled groove (paraduodenal) pancreatitis has been identified.11 Each inflammatory attack can cause foci of fat necrosis that seem to lead to both pseudocysts and www.thelancet.com Vol 377 April 2, 2011 fibrosis.11 Nerves show breaching of the perineurium adjacent to inflammatory foci, while the expression of nociceptive chemicals in nerve endings is increased.36 Immunocytochemistry gives valuable insights into the development of chronic pancreatitis. Acinar cells, which are hyperplastic at disease outset,2 show strong expression of cytochrome P450 (CYP) monooxygenases,37–39 as do proliferated islets of Langerhans,37–39 and hepatocytes (figure 2).37,38 After birth, CYP enzymes are mainly located in the liver. CYP metabolises environmental lipophilic chemicals (xenobiotics). In the first phase, the enzyme uses ROS to hydroxylate the substrate, which then usually undergoes second-phase conjugation reactions, often with glutathione and catalysed by glutathione transferases. So-called enzyme induction might be accompanied by expansion of the endoplasmic reticulum so that, at least initially, the cell secretes more of its normal products. However, this defence reaction backfires if first-phase processing (eg, by CYP2E1, CYP1A, and CYP3A1 isoforms) produces a reactive xenobiotic metabolite. Cell injury depends on whether or not there is enough by way of defences to ROS and reactive xenobiotic species: antioxidant enzymes (including the selenium-dependent glutathione peroxidase), glutathione transferases, glutathione, and ascorbic acid (the bioactive form of vitamin C, which can substitute for glutathione).32,40 Immunochemistry shows that these defence mechanisms are insufficient to meet the increased oxidant load in acinar cells,32,37 which therefore 1185 Seminar show signs of electrophilic stress, such as excess lipofuscin and cytoplasmic microvesiculation.41 Fibrosis is a sign that interstitial stellate cells are activated in chronic pancreatitis; these cells play a central part in disease progression by regulating the synthesis and degradation of extracellular matrix proteins.42,43 Findings from histochemistry suggest a causal influence of two factors—an increase in lipid peroxidation products caused by an excess of ROS in adjacent acini,44 and the release of mast cell degranulation products,45 transforming growth factor β1 in particular.46 The two factors are linked in that ROS and their oxidation products are natural activators of mast cells.17 Activation of stellate cells is increased by cytokines from infiltrating leucocytes and the injured acinar cell.43 The end stage of chronic pancreatitis is identified by loss of all secretory tissue, disappearance of inflammatory cells, and intense fibrosis. This A progression resembles that from chronic active hepatitis to liver cirrhosis.2,12,47 The table summarises the histological features of ordinary chronic pancreatitis compared with features of three variants in which the lesions are diffuse. The pancreatic lesion in cystic fibrosis is a diffuse form of chronic pancreatitis wherein inflammatory stigmata disappear by birth,48 except in patients with mild mutations in the cystic fibrosis transmembrane conductance regulator gene (CFTR), who might have recurrent attacks.49 Uniform lesions also occur upstream of an obstructed duct1,11,48 and in autoimmune pancreatitis.50,51 The latter can involve the whole or part of the gland and has two subtypes. Characteristics of the more common type-1 autoimmune pancreatitis are a dense lymphoplasmacytic infiltrate with predominantly IgG4+ cells, periductal swirling sclerosis, and obliterative venulitis. In the type-2, duct-destructive form, hordes B D H D H A S A D 50 μm 50 μm Figure 2: Immunolocalisation of cytochrome P4503A1 in surgical material from a 27-year-old woman with calcific chronic pancreatitis The patient drank little alcohol, smoked 40 cigarettes a day, and worked as a forecourt attendant at a car and lorry-fuelling station. (A) The pancreatectomy fragment shows that the enzyme (brown stain) is strongly expressed in acinar cells (A) but absent from epithelium of dilated ducts (D) or expanded stroma (S). (B) The needle biopsy fragment of the liver showed that the enzyme is strongly expressed across the liver lobule (H) and weakly expressed in bile duct epithelium (D). Reproduced with permission from Foster et al.37 Ordinary* Cystic fibrosis† Obstructive‡ Autoimmune§ Distribution Patchy Diffuse Diffuse Diffuse Extent of gland Variable Total Total Total or focal Main duct Irregularly dilated Minimally dilated Smoothly dilated Constricted Protein plugs All ducts Intralobular and interlobular No No Calcifying tendency Yes No No Lesions Duct system No Epithelium destroyed (Groove form) No No Yes (type 2) Neutrophils No No No Yes (type 2) Inflammatory cells Mononuclear No No Plasmalymphacytic Fibrosis Mainly perilobular Perilobular, intralobular Perilobular, intralobular Perilobular, intralobular, periductal Pseudocyst Frequent No No No *Excludes the small-duct variant (as in at least 30% of cases) wherein characteristic features are focal acinar cell damage and tubular complexes.3 Groove pancreatitis is similar to the ordinary form, except for prominent destruction of ductal epithelium and cysts.1,11 †The earliest lesions occur in utero.48 ‡Diffuse lesions occur upstream from the obstruction.1,11 §See text for subtypes. Table: Main histological features of chronic pancreatitis subtypes (at diagnosis in stable disease) 1186 www.thelancet.com Vol 377 April 2, 2011 Seminar of neutrophils infiltrate the wall of the duct, accompanied by lymphocytes and plasma cells.51 Causes Panel 1 lists causative factors of chronic pancreatitis. In adults, excluding those with cystic fibrosis, 90–95% of patients are regarded as having alcoholic or idiopathic disease. Infective causes are rare.52 The connection between chronic pancreatitis and drugs (eg, valproate) is mostly anecdotal. Studies from Italy,53 China, and Japan54 report an association with gallstones in about 30% of patients. Alcoholic Alcohol has long been regarded as the leading cause of chronic pancreatitis in Europe, the USA, Brazil, Mexico, and South Africa, and is now regarded as the main cause of the disease also in Australia and South Korea.7 However, excess alcohol was the predominant factor in only 34% of cases of chronic pancreatitis in a recent multicentre study from Italy53 and in 44% of cases in an audit from the USA,55 with another study reporting that African-Americans are at particular risk.56 Whether these new data reflect differences in the definition of alcoholic disease55 or a genuine change in the cause of chronic pancreatitis is not clear.57 Experimental studies have shown that, although the pancreas processes ethanol efficiently (via a non-oxidative route that produces fatty acid ethyl esters, and by oxidation via the acetaldehyde pathway), its metabolites injure acinar cells and activate stellate cells in vitro.42,58 However, prolonged ethanol feeding does not induce chronic pancreatitis.58,59 Hence, the finding of a latent interval of 15 years or more in patients who consumed 150 g or more of ethanol per day—as most recently noted in India60—is unsurprising. Moreover, less than 10% of people who drink alcohol in excess develop the disease.61 Collectively, these findings suggest that other factors interact to amplify ethanol toxicity in vivo. In animal models, small doses of ethanol induce CYP2E1, thus increasing the toxicity from other chemicals to which the animal is simultaneously exposed.62,63 These results might rationalise the old observation that there is no threshold for the pancreatic toxicity of ethanol,1 but recent data suggest there is a threshold at 60 g per day.55 Moreover, CYP2E1 is the main pathway that metabolises ethanol upon chronic excessive ingestion,63 but this pathway releases ROS.64 Idiopathic 60–70% of cases of chronic pancreatitis in India and China are labelled as idiopathic, as are around half the cases in Japan.7 Tropical pancreatitis is a form of idiopathic pancreatitis that affects young people and has a propensity to diabetes and large calculi.65 This disease is mainly reported in developing countries of Asia, Africa, and Central America, where severe malnutrition and cyanogenic glycosides in cassava www.thelancet.com Vol 377 April 2, 2011 Panel 1: Causative factors Toxic Xenobiotics • Alcohol • Cigarette smoke • Occupational volatile hydrocarbons • Drugs: valproate, phenacitin, thiazide, oestrogen, and azathioprine Endogenous • Hypercalcaemia, hyperparathyroidism • Hyperlipidaemia, lipoprotein lipase deficiency • Chronic renal failure Infection or infestation • HIV, mumps virus, coxsackie virus • Echinococcus, Cryptosporidium Genetic* • CFTR mutation • PRSS1 mutation • SPINK1 mutation Obstruction of main pancreatic duct • Cancer • Post-traumatic scarring • Post-duct destruction in severe attack Recurrent acute pancreatitis Autoimmune Miscellaneous • Gall stones • After transplant • After irradiation • Vascular disease Idiopathic • Early or late onset • Tropical CFTR=cystic fibrosis transmenbrane conductance regulator. PRSS1=protease serine cationic trypsinogen. SPINK1=serine protease inhibitor Kazal. *Other, less common mutations have been described. (manioc) were implicated. The classic description of tropical pancreatitis was from Kerala, south India;66 however, hospital admission statistics revealed a decline in the disease by six times between 1962 and 1987,66 without a change in cassava consumption. Instead, the decline coincided with the introduction of electricity in this province, which removed the dependence on traditional lighting (see below). At present, tropical pancreatitis accounts for just 3·8 % of cases of chronic pancreatitis in India.60 Other toxic causes Cigarette smoke has emerged as a strong independent risk factor for chronic pancreatitis;55,67 the link was verified 1187 Seminar by inhalation toxicology experiments.68,69 A case-control study from the UK identified occupational volatile hydrocarbons as another independent risk factor.70 This connection is upheld by descriptive studies from Chennai, India,71 and Soweto, South Africa,72 which also reported regular contact with kerosene or paraffin, respectively, in cookers, heaters, or lamps in patients with chronic pancreatitis (potentially relevant to Kerala, see above). Toxic damage to the pancreas by petrochemicals has been documented in lower vertebrates.40 Moreover, the simplest animal model of chronic pancreatitis, which develops via an acute phase, involves just one parenteral injection of dibutyltin (which has many industrial uses) and the injury is amplified by alcohol.73 All these findings reinforce the pathological evidence (figure 2) that the pancreas is a versatile but also vulnerable xenobiotic-metabolising organ.40 Inhaled xenobiotics that survive the pulmonary circulation would pose the biggest threat (figure 2A) by striking the pancreas directly via its rich arterial supply. Autoimmune Autoimmune pancreatitis (2–4% of cases57) can be part of a multisystem disease (type 1) or can affect the pancreas alone (type 2).50,51 Aberrant human leucocyte antigen DR-1 expression on pancreatic ductal cells might present autoantigens to lymphocytes. Proposed pancreas-specific antigens include lactoferrin,28 carbonic anhydrase, SPINK1, and a peptide that is present in acinar cells that has homology to aminoacid sequences in the plasminogen-binding protein of Helicobacter pylori74 (which might represent molecular mimicry)51 and also in ubiquitin–protein ligase74 (a cofactor for steroid hormone receptors and an important peptide in the intracellular protein degradation pathway).75 1188 Idiopathic chronic pancreatitis is associated with a mutation in the CFTR gene.80,82,83 Patients can have one abnormal recessive allele, but possession of two confers a 40 times increased risk of developing idiopathic chronic pancreatitis, which rises to 500 times in patients who also have a SPINK1 mutation.83 Some patients with apparent idiopathic chronic pancreatitis who have CFTR mutations have an atypical form of cystic fibrosis.80 Three overlooked aspects of CFTR function have been reviewed recently.32 CFTR is present in the luminal pole of acinar cells where it might facilitate membrane recycling and exocytosis, like it does elsewhere. CFTR transports bicarbonate and glutathione—which facilitate the solubility of mucins in secretions—across the luminal membrane of ductal cells adjacent to the centroacinar space. CFTR is inactivated by electrophilic stress but is protected by thiols and ascorbic acid. Moreover, CFTR is mislocalised to the cytoplasm of ductal cells in patients with chronic pancreatitis; this misplacement is corrected in autoimmune disease by steroids, which also reduce inflammation, restore bicarbonate and enzyme secretion, and regenerate acinar cells.84 Mutations in CFTR and SPINK1 have also been described in patients with hypertriglyceridaemia or hyperparathyroidism who develop pancreatitis.32 At present, molecular deficits that contribute to chronic pancreatitis have been identified in less than 10% of alcoholic chronic pancreatitis and around 50% of cases overall.79 Pathogenesis There is no agreement as to how these diverse causative factors lead to chronic pancreatitis. There are many hypotheses about the pathogenesis of the disease,43 which fall into five main categories. Genetic Ductal theory Normally, if trypsinogen becomes prematurely activated within the pancreas, it is inhibited by SPINK1 and then self-destructs or is degraded by trypsin-activated proteases;31 the potent inhibitor gluthathione is available if all else fails.76 Hereditary pancreatitis is a rare condition that is caused by a gain-of-function mutation (autosomal dominant, 80% penetrance) in the cationic trypsinogen gene (PRSS1),9,10,42 which produces a degradationresistant form of trypsin.77 A transgenic mouse model of chronic pancreatic injury has proved this link.78 The PRSS1 mutation is not associated with alcoholic or tropical chronic pancreatitis.79 By contrast, a loss-offunction mutation in SPINK1 is strongly associated with idiopathic disease79–82 but is thought to be a predisposing or modifying factor rather than being directly causative.42,79,80 Mutations in other genes that could increase the threat from trypsin have also been described,79 as has a loss-of-function mutation in the PRSS2 gene (encoding anionic trypsinogen), which protects against pancreatitis.79,80 One hypothesis suggests that ducts are the primary target of the disease: theories centre on the primacy of calcifying protein deposits (protein plug hypothesis),1 stagnation of pancreatic juice, reflux of noxious bile and duodenal juice (facilitated by passage of gallstones), and primary autoimmune attack. Acinar theory Another hypothesis suggests that acini are the primary target: alcohol is thought to injure acinar cells directly (toxic metabolite hypothesis) or by increasing the cell’s sensitivity to cholecystokinin (CCK) or via CYP2E1, while also activating stellate cells, especially in the presence of endotoxin.42,58 Another suggestion is that the disease is caused by cyanide toxicity of the pancreas. Two-hits theory Two so-called hits are additionally suggested as causing the disease: variations include a duct-to-acinar sequence, vice versa, or double acinar hits. The last of these is the www.thelancet.com Vol 377 April 2, 2011 Seminar most popular theory and incorporates the idea that recurrent necrosis leads to periductal fibrosis.11 The first attack of pancreatitis is taken to represent autodigestion caused by unregulated trypsin activity in the acinar cell. If this attack is severe enough to recruit macrophages (sentinel acute pancreatitis event hypothesis), subsequent damage to the gland (by alcohol or electrophilic stress) leads to fibrosis via macrophage-primed stellate cells. Electrophilic stress theory The electrophilic stress theory is the pancreatic equivalent of paracetamol or carbon tetrachloride hepatotoxicity, which results from insufficient protection by glutathione against electrophilic attack (via CYP) on key macromolecules—not least, enzymes in the methionine trans-sulphuration pathway towards glutathione. However, in chronic pancreatitis electrophilic stress from toxic metabolites—and, thereby, recurrent pancreastasis—develops over many years as a result of repetitive exposures to multiple xenobiotics.41 Previous dietary insufficiency of micronutrients, especially methionine and ascorbic acid, facilitates the problem.41,85 The diversion of free radical oxidation products into the interstitium causes mast cells to degranulate, leading to inflammation, activation of nociceptive axon reflexes, and fibrosis.41 The realisation that compromised availability of methyl and thiol (glutathione) moieties underlies chronic pancreatitis has allowed an extension of the electrophilic stress concept to chronic pancreatitis that is associated with gene mutations.32 Thus, the daily exposure of acinar cells to traces of trypsin in people with PRSS1 or SPINK1 mutations is expected to strain glutathione reserves. Of particular note, those with a CFTR mutation would be left vulnerable not only to pancreastasis but also to intraductal calcifying protein plugs (large duct disease) when the residual CFTR protein is immobilised by electrophilic stress.32 constant pain; symptoms and signs of local complications of the disease (eg, pseudocyst, obstruction of adjacent organs, or vascular thrombosis); or complaints that suggest exocrine or endocrine pancreatic failure, or both, by which stage pancreatic calculi are often present. These features form the basis for the most recent classification system (figure 3).47 In alcoholic disease, the interval from first attack to steatorrhoea (signifying >95% loss of acini) is around 13 years, which is substantially shorter than in early-onset idiopathic disease12,86 or hereditary pancreatitis (≥26 years).12 Pancreatic calculi appear earliest in tropical pancreatitis,65 and earlier in alcoholic than idiopathic disease.86 Diabetes might precede, begin at the same time as, or start after steatorrhoea.65,88 Pain is the over-riding symptom in all but 10–15% of cases of chronic pancreatitis; these cases are usually elderly patients with idiopathic disease12,86 or patients with autoimmune pancreatitis who might present with steatorrhoea, diabetes, or jaundice.50,51 The pain is wearying and occurs in episodes that last about 1 week, or is constant. It starts in the epigastrium and moves through to the dorsal spine or localises to the left hypochondrium, radiating to the left infrascapular region. The pain is sometimes associated with nausea and vomiting and can be partially eased by sitting up and leaning forward or by application of local heat or other counterirritants to the dorsal spine or epigastrium. The pain can be so severe that patients fear food and lose weight. Most,12,86,89 but not all,88 studies have reported that pain diminishes markedly once the disease burns out (which suggests that viable acini are a prerequisite for pancreatic pain). However, by then patients often have become addicted to narcotic analgesics, which could cause them to lose their jobs, homes, or families.88,90 Panel 2 lists factors that might contribute to pain in patients with chronic pancreatitis:36 mast cell degranulation products and hydrogen sulphide are plausible mediators of the pancreatic component.91,92 The intensity of the pain contrasts with the absence of specific signs in Multiple-cause theory The final hypothesis states that different causative factors lead to damage via different pathways: this concept incorporates the other theories while noting that pancreatic ischaemia can aggravate the disease.43 Clinical features Alcoholic chronic pancreatitis presents in the fourth or fifth decade of life and mainly affects men.86 Idiopathic disease has early-onset (second decade) and late-onset (sixth decade) forms, which have equal gender distribution.12,86 Hereditary disease manifests at around 10 years87 and tropical pancreatitis at between 20 and 30 years,65 whereas the more common type-1 form of autoimmune disease affects men in the sixth decade.51 Presenting features of chronic pancreatitis usually fall into one of four groups: apparent acute or recurrent acute pancreatitis (the true diagnosis of chronic pancreatitis is suspected when attacks recur after cholecystectomy); www.thelancet.com Vol 377 April 2, 2011 Clinical criteria Attacks of apparent acute pancreatitis Pain A Early Complications • Bile duct stricture • Duodenal stricture • Vascular stricture • Portal hypertension • Pseudocyst • Pancreatic fistula • Pancreatic ascites • Rare, eg, colonic stricture B Intermediate Pancreatic failure Cause C End stage 1 endocrine 2 exocrine 3 both Figure 3: Proposal for a clinically based classification system for chronic pancreatitis For example, a patient may be described as having chronic pancreatitis (idiopathic), stage B, bile duct.47 1189 Seminar uncomplicated disease. Erythema ab igne is a useful pointer for diagnosis of chronic pancreatitis in these patients, as is meteorism in patients whose pain has led to dependence on narcotic analgesics (figure 4). An epigastric swelling suggests a pseudocyst, inflammatory mass, or cancer. Patients with multisystem involvement usually have the autoimmune form of chronic pancreatitis. Panel 2: Pain in chronic pancreatitis Caused by the disease Active inflammation* Altered nociception • Neurogenic inflammation* • Visceral nerve sensitisation* • Central nerve sensitisation • Psychological Hypertension • Ductal or tissue via increased cholecystokinin Tissue ischaemia Caused by complications • Inflammatory mass in head of gland • Obstruction of bile duct or duodenum • Pseudocyst • Cancer of the pancreas Caused by treatment • Opiate gastroparesis or constipation Caused by unrelated problems • Peptic ulcer • Gall stones • Mesenteric ischaemia • Small-bowel stricture • Somatic (eg, surgical scar) *Mast cell degranulation products and hydrogen sulphide are potential mediators (see text). A Ordinary chronic pancreatitis has a high mortality rate—nearly 50% within 20–25 years of disease onset,12 as a result of complications of an attack, coexisting disease, or the effects of alcoholism. Patients with chronic pancreatitis have an increased risk of pancreatic cancer,93 which accounts for 3% of deaths.86 Although the risk of pancreatic cancer is especially high in patients with hereditary pancreatitis,87 they do not have a higher mortality risk than the general population.94 Autoimmune pancreatitis also does not affect long-term survival.95 Diagnosis Routine laboratory tests might reveal incipient diabetes, type-1 hyperlipidaemia, or hypercalcaemia in patients with suspected chronic pancreatitis. If type-1 autoimmune disease is a possibility, serology will show raised concentrations of γ-globulin, IgG (IgG4 predominantly), and various antibodies, including antilactoferrin, anti-carbonic anhydrase, rheumatoid factor, and anti-nuclear antibody.50,51 An abnormal liver function profile suggests alcoholic liver disease, non-alcoholic steatohepatitis,96 sclerosing cholangitis,50,51,96 metastases from superimposed pancreatic cancer, gallstones, or, most commonly, constriction of the intrapancreatic bile duct, which occurs early in autoimmune pancreatitis,50,51 but is late otherwise.47 Confirmation of the diagnosis of (non-calcific) chronic pancreatitis is by histology of a wedge biopsy or resected specimen of pancreas. However, this is impractical. A reduction in bicarbonate with or without enzyme content of duodenal aspirates after intubation and hormonal stimulation (by secretin with or without CCK or its analogue caerulein), and abnormalities in the pancreatic duct system on endoscopic retrograde cholangiopancreatography (ERCP) are the most efficient alternative diagnostic techniques—with the former substantially better at detecting small-duct disease than the latter.2,4 However, the secretory test is available in only a few centres worldwide (and whether or not an B Figure 4: Clinical features in chronic pancreatitis (A) Erythema ab igne across the upper abdomen in a young patient with recurrent pancreatitis despite cholecystectomy for multiple gallstones (vertical scar). (B) Plain abdominal radiograph shows heavy calcification in the pancreatic head (arrow) and a loaded colon in a patient with abdominal distension who was addicted to opiates. 1190 www.thelancet.com Vol 377 April 2, 2011 Seminar endoscopic secretory test is as good is unclear).97 Moreover, ERCP for diagnosis has largely been abandoned in favour of magnetic resonance cholangiopancreatography (MRCP) because ERCP can precipitate pancreatitis in up to 4% of patients.9 There is no non-invasive test that can substitute for the hormonal test for chronic pancreatitis.2 By contrast, sophisticated imaging methods have rapidly developed, such that the traditional ultrasound scan to visualise the pancreas itself is virtually obsolete (but see figure 5). The repertoire of imaging techniques is impressive: multidetector CT (MDCT; figure 5); MRI;97 MRCP (figure 6), which provides excellent images of the main pancreatic duct98 but not always of the side-branch changes as shown by ERCP; secretin-enhanced MRCP, which also shows duodenal filling by pancreatobiliary secretions99 and is more accurate than standard MRCP in identifying small-duct disease;100 endoscopic ultrasound (EUS),101,102 which identifies both parenchymal and ductal alterations (figure 6; now classified as the Rosemont criteria),102 but which is observer-dependent and tends to overdiagnose the disease;67 diffusion-weighted MRI;103 and PET.104 The last two imaging techniques have not been properly assessed in chronic pancreatitis, whereas the role of EUS continues to advance. No investigation algorithm is suitable worldwide, because much depends on available resources and expertise, but a battery of tests should not be used for diagnosis of suspected chronic pancreatitis because this will generate many false positive outcomes and cause distress to the patient.2 Figure 7 presents a sequential scheme for diagnosis of the disease, on the basis of whether or not the secretin test is available. This scheme recognises that an abdominal radiograph will show pancreatic calculi (nearly 100% specificity; figure 4) in at least 30% of patients overall and in most patients with tropical pancreatitis. This stepwise approach is unnecessary in a patient who presents with fatty stools after a long history of pancreatitis attacks or pain. In this event, any of the following tests is probably sufficient for diagnosis: acid steatocrit (high value) on a spot stool sample (which obviates the need for the traditional 3-day faecal fat test);105 faecal elastase (low);105 recovery in expired air of ¹³C (low) from a ¹³C-labelled mixed triglyceride load;106 or serum trypsinogen (low).4 However, a CT scan is needed to identify the disease type. Imaging tests show distinctive changes in type-1 autoimmune pancreatitis. Both ultrasound and MDCT typically show a diffusely enlarged sausage-shaped gland (figure 5). ERCP shows long or multiple strictures of the pancreatic duct and sometimes a long stricture in the distal bile duct or sclerosing cholangitis.50,51 Findings from one study suggest that MRCP cannot replace ERCP for the diagnosis of autoimmune disease.107 These imaging features are sufficient to make the diagnosis in a patient with an increased concentration of IgG4 in serum. If diagnostic doubt exists (as in a patient with type-2 www.thelancet.com Vol 377 April 2, 2011 A B Figure 5: Examples of ultrasound and multidetector images in patients with chronic pancreatitis (A) Transabdominal ultrasound scan showing a uniformly swollen, hypoechoic pancreas (arrowed), typical of autoimmune pancreatitis. (B) Multidetector CT showing pancreatic calculi in an atrophic pancreas (long arrow) and a pseudocyst at the tail of the pancreas (short arrow). A B Figure 6: Examples of three-dimensional magnetic resonance cholangiopancreatogram and endoscopic ultrasound in patients with chronic pancreatitis (A) Three-dimensional magnetic resonance cholangiopancreatogram shows a minimally dilated biliary tree and moderately dilated irregular main pancreatic duct. (B) Endoscopic ultrasound scan shows a minimally dilated pancreatic duct in the head of pancreas (arrowed) consistent with mild chronic pancreatitis: the distal common bile duct appears normal (arrow head). disease, for which there are no serum markers), a therapeutic trial of steroids or histology (of core biopsy or resected specimen), or both might be needed.50,51 There are two difficult diagnostic issues that must be addressed. First, how can one distinguish between an inflammatory mass of ordinary chronic pancreatitis, focal autoimmune disease, and pancreatic adenocarcinoma with upstream chronic pancreatitis? Raised IgG concentrations can occur in all three settings and existing tumour markers are not specific enough to distinguish between them, although new molecular markers are being developed.108 EUS or MDCT-guided core biopsy can be used to confirm autoimmune pancreatitis, or a simple needle biopsy might identify tumour cells. ¹⁸F-fluorodeoxyglucose PET with CT facilitates the identification of cancer,104 but increased uptake is also a feature of autoimmune pancreatitis (as is increased uptake of gallium).50,51 A pancreatectomy specimen might have to be used as the final diagnostic test, as it is for detecting an intraductal papillary mucinous tumour in a patient who has suspected idiopathic large-duct disease.109 Second, should the clinician start a search for genetic mutations? 1191 Seminar Suspected chronic pancreatitis Plain radiograph for calculi Positive Negative Multidetector CT Positive Negative Suspected small-duct disease No Large-duct disease Secretin test available? Yes Positive Secretin test Magnetic resonance cholangiopancreatography after secretin stimulation Positive Negative Analgesics Negative Endoscopic ultrasound Negative Positive Reconsider other diagnoses Re-test at intervals Therapeutic trial of micronutrients? Chronic pancreatitis Figure 7: Algorithm for the diagnosis of chronic pancreatitis A recent review gives valuable guidance.80 PRSS1 mutation testing for diagnostic purposes is acceptable in symptomatic young individuals or in those with a family history of pancreatitis, but counselling and clinical followup are needed if the result is positive. There is no indication for SPINK1 mutation testing. At present there is no rationale for CFTR mutation testing in the setting of pancreatitis alone. Instead, a sweat test should be done if atypical cystic fibrosis is suspected, and patients should be referred to a specialist clinic when sweat chloride concentration is borderline (40–59 mmol/L) or abnormal (>60 mmol/L). However, the vulnerability of CFTR to electrophilic stress potentially explains both false positive sweat tests and abnormal nasal potential difference studies in a variety of conditions (eg, severe malnutrition).32 Treatment Treatment goals The goals of treatment for chronic pancreatitis are to relieve acute or chronic pain, calm the disease process to prevent recurrent attacks, correct metabolic consequences such as diabetes or malnutrition, manage complications when they arise, and address psychosocial problems. Endoscopic treatment, surgery, or both, are only needed when optimum medical treatment fails to relieve pain (figure 8) and to deal with specific complications (figure 3). A detailed discussion of complications is beyond the scope of this Seminar. 1192 When providing treatment to control the pain associated with chronic pancreatitis, the patient’s fears and misconceptions about the disease should be addressed sympathetically. Time should be spent discussing the disease with the patient at the first clinic visit, with particular attention paid to circumstances surrounding the first attack. Patients should be advised to avoid alcohol and cigarettes, although there is no evidence that abstinence from alcohol slows the disease and the effect of alcohol on pain is debated.67,89 A dietary assessment should be done (see later). Where warranted, the help of a psychologist or pain therapy specialist should be sought, and the primary-care practitioner must also be briefed on treatment strategy. Continuity of care is important to gain the patient’s trust and to minimise the risk of addiction to narcotics. Regular analgesics are superfluous in patients with sporadic attacks but are needed in those with background pain. Use of analgesics should broadly follow WHO guidelines for cancer pain.110 Briefly, analgesic treatment begins with paracetamol or a non-steroidal anti-inflammatory drug, or both, followed by a mild opioid such as tramadol, perhaps coupled with a neuroleptic antidepressant. Narcotic analgesics should be avoided if possible. A simple pain diary with a 10 cm visual analogue scale is useful, as is a baseline quality-oflife assessment. Analgesia devices to deliver morphine that are controlled by the patient should not be used, even in an attack. Such drugs can worsen pain by inducing mast cell degranulation111 and (possibly thereby17) cause gastroparesis4 and constipation (figure 4). Steroids and enzyme therapy Treatment with steroids is associated with rapid relief of symptoms in autoimmune pancreatitis.50,51 The starting dose is 30–40 mg per day of prednisolone, which is tapered over 3 months while monitoring serum IgG concentrations and imaging findings. Longterm maintenance with 5·0–7·5 mg per day of prednisolone is recommended to prevent relapses.50 Recurrences, which typically occur in type-1 disease,95 favour the development of pancreatic calculi.112 In patients with small-duct disease, pancreatic acinar cells are suggested to be under constant stimulation by CCK because subnormal delivery of pancreatic proteases into the duodenum allows improved survival of a CCKreleasing peptide from the duodenal mucosa.4 Hence, the following potential treatments have been successfully tested:4 oral pancreatic enzymes (non-enteric coated, two trials), subcutaneous octreotide (one trial), and oral dosing with the CCK-A receptor antagonist loxiglumide (one trial). However, this issue is contentious,113,114 and the explanation that these measures “allow the pancreas to rest”4 is at odds with the finding that the exocytosis apparatus is already paralysed in an attack (figure 1) and www.thelancet.com Vol 377 April 2, 2011 Seminar hindered thereafter.32 Other explanations might be that such treatments act by blunting an effect of CCK on pain pathways in the CNS36 or by ameliorating electrophilic stress (see later).115 Micronutrient therapy Micronutrient therapy is designed to supply methyl and thiol moieties that are essential for the exocytosis apparatus (figure 1) while protecting it against electrophilic attack, as by CYP-derived ROS or reactive xenobiotics species (figure 2).32 Findings from six clinical trials have reported that micronutrient therapy controls pain and curbs attacks in patients with chronic pancreatitis.116–122 Of these trials, three were descriptive116–118 and three were placebo-controlled.119–122 However, the different ways of expressing outcome precludes a meta-analysis.123 The study with the highest power (80%) to detect a difference between treatment and placebo was from Delhi:122 after 6 months’ treatment (which included pancreatic enzymes in all patients) there was a greater reduction in the number of painful days per month and in the use of analgesic tablets in the treatment group than in the placebo group; substantially more patients became pain free, and biochemical markers of electrophilic stress were lowered by active treatment. Studies from Manchester, UK, suggested that the micronutrient therapy formulation should include methionine and vitamin C,124 with the need for selenium assessed by measuring blood concentrations. Vitamin E and β carotene were included in the first trial because there was no commercial preparation that did not include them,119 and three of the other five trials also used this protocol.116,121,122 Improvement, as judged by the number of attacks, admission episodes, pain diaries, pain intensity, or permutations and combinations of these factors, occurred by 10–12 weeks.119,121,122 In the UK, the micronutrient therapy preparation Antox (Pharma Nord, Morpeth, UK) is a convenient means of dosing because it contains all the desired items. A starting regimen of two tablets of Antox three times per day provides daily doses of 2·88 g methionine (but up to 4 g might initially be needed in some patients),125 720 mg vitamin C, 300 μg organic selenium, and 210 mg vitamin E (which is unnecessary until steatorrhoea develops).126 This treatment has no significant side-effects now that β carotene has been withdrawn because of cosmetic problems:125 one patient (of >300) developed schizophrenia when on 4 g of methionine daily but, of note, this patient had a strong family history of psychiatric disease.125 Patients should also be given dietary advice on antioxidant-rich foods to aid the long-term management of the disease. It should be stressed that culinary practices—eg, frying vegetables at high temperature (as in south India41)—could compromise the bioavailability of antioxidants, notably of ascorbic acid.32 Blood monitoring is essential to ensure that plasma and erythrocyte www.thelancet.com Vol 377 April 2, 2011 Painful chronic pancreatitis Non-narcotic analgesia Alcohol and cigarette avoidance Dietary assessment Psychosocial issues Micronutrient treatment Pancreatic enzyme treatment Treatment not effective Large–duct disease Small–duct disease Pancreatic mass Cyst or pseudocyst No mass Suspected autoimmune pancreatitis Treatment not effective Suspected cancer Treatment not effective Neural manipulation* Trial of steroids Treatment effective CT guided or endoscopic ultrasound-guided biopsy Treatment effective Treatment effective Endoscopic or surgical duct drainage Solid mass Endoscopic drainage Treatment effective Exclude non-pancreatic pain Conservative treatment for 10 weeks Cancer confirmed Doubt persists Treatment effective Treatment not effective Pancreatectomy Figure 8: Algorithm for the management of painful chronic pancreatitis Note that the solid mass in autoimmune pancreatitis is often in the head of pancreas and suggests cancer, but that ducts are usually constricted. *Procedures include thoracic splanchnicectomy, coeliac plexus block, and neurostimulation. glutathione levels have increased and that concentrations of the prescribed micronutrients are not excessive, because this would compromise the physiological roles of ROS.127,128 Very recent reports indicate the need to keep track of blood homocysteine, and concentrations of vitamins (B6, B12, folic acid) that serve as cofactors of enzymes that govern homocysteine removal—either by facilitating its transmethylation back to methionine, or by ensuring its passage along the transsulphuration pathway towards glutathione.32,34,41,129 Of particular interest, elevated homocysteine has been recorded in people at Soweto (South Africa) who drank more than 100 g alcohol per day for many years130—a group that is traditionally regarded as being at high risk of chronic pancreatitis.55 Treatment for 10 weeks is recommended before any invasive procedure in patients with chronic pancreatitis, to calm the disease process. Full treatment is usually needed for 6 months, followed by a gradual dose reduction guided by biochemical data and patients’ symptoms.125 We recorded treatment failure in 10% of patients, usually 1193 Seminar because of non-compliance (eg, in patients who misuse alcohol) or a large cyst or pseudocyst;125 otherwise, symptom control was achieved by choline supplements to boost methyl supply.32 Moreover, micronutrient therapy has no effect on painful conditions that might be misdiagnosed as chronic pancreatitis (unpublished); once validated, this finding could form the basis for a therapeutic trial when the diagnosis remains equivocal after full testing (figure 7). Finally, there is increasing evidence to support the idea that a daily micronutrient supplement might abort the development of chronic pancreatitis in groups or even populations at risk of the disease.32,130 Micronutrient treatment is better at controlling pain and improving quality of life than conventional treatment.131 Moreover, long-term micronutrient treatment might curb disease progression.82 Excluding typical autoimmune pancreatitis, which can be treated with steroids, micronutrient treatment has been effective irrespective of cause (including mutations in PRSS1,118 CFTR,82 and SPINK182), disease duration,131 or ductal anatomy (large-duct calcifying or small-duct disease), and also when there is an inflammatory calcified mass.132 By contrast, the antioxidants allopurinol and curcumin have been ineffective for treatment of chronic pancreatitis in clinical trials.32 Two multicentre trials of Antox are in progress (Current Controlled Trials numbers ISRCTN21047731 and ISRCTN44912429). Treatment of steatorrhoea and diabetes The treatment of pancreatic steatorrhoea usually begins with 30 000 IU of lipase per meal in an acid-resistant enzyme preparation. In patients who do not respond to this treatment, a low-fat diet (50–75 g per day), dose increase, gastric proton-pump inhibitor, or a combination thereof should be recommended.67 A check on fat-soluble vitamin status is advisable.126 The main aim in the treatment of diabetes in patients with chronic pancreatitis is to prevent hypoglycaemia caused by deficiency of glucagon; simple insulin regimens are preferable. Endoscopic treatment Of the many potential indications for endoscopic treatment of chronic pancreatitis,133 two are undisputed. First, EUS can be used to facilitate transmural drainage of pseudocysts that are not connected to the pancreatic duct system, and endoscopically placed transpapillary stents in the duct are useful when they do134 or when a duct leak leads to pancreatic ascites or pleural effusion.135 Second, endoscopic stenting of the bile duct is a useful temporary measure in patients with a distal duct stricture. Limited comparative data suggest that surgery is more effective136 and has a more durable effect in controlling pain137 than endoscopic dilatation or stenting of the pancreatic duct. Findings from a randomised clinical trial showed that extracorporeal shock-wave lithotripsy with or without endoscopic clearance of stone fragments was equally effective at reducing pain over the subsequent 1194 2 years in patients with intraductal calculi;138 however, lithotripsy can occasionally precipitate acute pancreatitis.133 Thoracoscopic splanchnicectomy can provide good initial pain relief, but pain recurs by 15 months in more than 50% of patients.139 Surgery Historically, around 50% of patients with chronic pancreatitis referred to surgical clinics require an operation compared with around 25% on long-term follow-up in a specialist medical clinic.88 Micronutrient treatment seems to substantially reduce the need for surgery.82,125,132 The objectives of surgery are to decompress obstructed ducts (to relieve pain) and at the same time to preserve pancreatic tissue as well as adjacent organs (to preserve function), while recognising that the head of the pancreas constitutes the so-called pacemaker of chronic pancreatitis. The simplest operation—lateral pancreaticojejunostomy— provides immediate pain relief in many patients but pain tends to recur with the passage of time. Distal pancreatectomy, like pancreaticojejunostomy, does not address the problem of disease in the head of the pancreas, which can continue to deteriorate. Moreover, distal pancreatectomy can result in removal of the functionally most active part of the gland. Pancreaticoduodenectomy gives good pain relief, but is a major operation. It is indicated in groove pancreatitis if there is duodenal obstruction or when neoplasia cannot be ruled out preoperatively.140 Duodenum-preserving head resection combined, when appropriate, with lateral pancreaticojejunostomy has been a major advance: only 8·7% of patients continued to have pancreatic pain at a median of 5·7 years follow-up, whereas 93% of patients had pancreatic pain preoperatively.141 The operation was simplified by carving out an inverted cone from the pancreatic head, allowing the cavity and the distal duct to drain into a jejunal loop, thus removing the complex mass of obstructed ducts and inflammatory tissue that frequently lies within the head of the gland.142 A further simplification made this operation suitable for patients in whom there was little in the way of duct dilatation: a so-called ice-cream scoop is taken out of the pancreatic head to leave a thin rim of pancreas laterally and posteriorly. Pain improved in 55% of patients after 41 months of follow-up.143 A precise assessment of the merits of the different operations for painful chronic pancreatitis has been confounded by an absence of agreement about indications for surgery, details of the surgical techniques, and methods used to measure outcomes.144 However, there is no doubt that the safety of conservative operations (eg, lateral pancreaticojejunostomy combined with limited excision of the head of the gland) has improved: operative mortality, about 5% with traditional resection of the head of pancreas, has fallen to 0–3% and morbidity has been halved.145 There seems to be little if any advantage to be gained from total pancreatectomy with islet transplant.146 www.thelancet.com Vol 377 April 2, 2011 Seminar Conclusions Chronic pancreatitis remains a challenging disease. Resective surgery continues to be the definitive treatment for persistent pain, but is not ideal in a chronic inflammatory process. Micronutrient treatment might offer a viable alternative. Contributors All authors participated in writing this Seminar. All authors saw and approved the final manuscript. 22 23 24 25 26 Conflicts of interest We declare that we have no conflicts of interest. Acknowledgments We thank Prof J R Foster for the microphotographs (figure 2). References 1 Sarles H. Etiopathogenesis and definition of chronic pancreatitis. Dig Dis Sci 1986; 11 (suppl): S91–107. 2 Braganza JM. The pancreas. Recent Adv Gastroenterol 1986; 6: 251–80. 3 Walsh TN, Rode J, Theis BA, Russell RCG. Minimal change chronic pancreatitis. Gut 1992; 33: 1566–71. 4 Gupta V, Toskes PP. Diagnosis and management of chronic pancreatitis. Postgrad Med J 2005; 81: 491–97. 5 Lévy P, Barthet M, Mollard BR, Amouretti M, Marion-Audibert AM, Dyard F. Estimation of the prevalence and incidence of chronic pancreatitis and its complications. Gastroenterol Clin Biol 2006; 30: 838–44. 6 Otsuki M. 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