Chronic Pancreatitis
Chronic pancreatitis is a long-term inflammatory condition causing progressive, irreversible damage to the pancreas.
It commonly presents with chronic abdominal pain, malabsorption, and diabetes, and is frequently seen in patients with alcohol-related disease.
This guide focuses on how to recognise it early, investigate appropriately, and manage patients safely in everyday NHS practice.
What is chronic pancreatitis?
Chronic pancreatitis is:
Long-term inflammation leading to fibrosis and permanent loss of pancreatic function.
This causes:
- Exocrine failure → malabsorption
- Endocrine failure → diabetes
- Chronic pain
Unlike acute pancreatitis:
Damage is irreversible.
How does it present?
Presentation is often gradual.
Common symptoms:
- Recurrent or persistent epigastric pain
- Pain radiating to the back
- Worse after meals
- Weight loss
- Diarrhoea or pale, oily stools (steatorrhoea)
- Bloating
- New or worsening diabetes
Classic story:
Middle-aged patient with alcohol history + chronic pain + weight loss
On the ward or clinic, always ask
Could this be pancreatic insufficiency rather than just “IBS” or “gastritis”?
Because:
Chronic pancreatitis is often misdiagnosed for years.
Common causes (think practically)
Most common:
- Alcohol-related disease
Also important:
- Recurrent acute pancreatitis
- Gallstones
- Smoking
- Genetic causes
- Autoimmune pancreatitis
- Idiopathic
In the NHS, alcohol + smoking are the biggest risk factors.
Typical clinical clues
Look for:
- Low BMI
- Muscle wasting
- Malnutrition
- Diabetes
- Fat-soluble vitamin deficiency
- Chronic opioid use for pain
These suggest long-standing disease.
First priority = think function, not just imaging
Two key problems:
- Pain
- Pancreatic failure (malabsorption + diabetes)
Your job is to assess both.
Initial assessment (what juniors should actually do)
If chronic pancreatitis suspected:
Do:
- FBC, U&E
- LFTs
- HbA1c/glucose
- Nutritional markers
- Consider faecal elastase (exocrine function)
- Imaging (CT or MRI pancreas)
Imaging:
- CT pancreas → calcifications, atrophy, duct changes
- MRCP → duct abnormalities
Ultrasound is often insufficient.
Key concept = pancreatic insufficiency
Exocrine failure:
Leads to:
- Steatorrhoea
- Weight loss
- Malnutrition
- Vitamin deficiencies
Endocrine failure:
Leads to:
- Type 3c diabetes (pancreatic diabetes)
If you don’t treat these, patients continue to decline.
Management on the ward or clinic (practical steps)
Lifestyle:
- Alcohol cessation (critical)
- Smoking cessation
Nutrition:
- Dietitian referral
- High-calorie diet
- Vitamin supplementation
Pancreatic enzyme replacement:
- Creon (pancreatic enzymes) with meals
This often dramatically improves symptoms.
If patient has steatorrhoea or weight loss:
→ start enzymes
Don’t wait months.
Pain management:
- Simple analgesia first
- Avoid long-term opioids if possible
- Pain team input for chronic pain
Diabetes:
- Monitor HbA1c
- May require insulin
When to escalate or refer
Refer to gastro/hepatopancreatobiliary team if:
- Persistent pain
- Recurrent admissions
- Malnutrition
- Suspected complications
- Unclear diagnosis
Urgent escalation if:
- Severe pain
- Obstruction
- Jaundice
- Infection
- Suspected cancer
Complications you must think about
- Pancreatic insufficiency
- Diabetes
- Malnutrition
- Pseudocysts
- Biliary obstruction
- Pancreatic cancer
Chronic pancreatitis increases cancer risk.
New red flags → investigate urgently.
Common mistakes juniors make
- Labeling symptoms as IBS
- Missing malabsorption
- Not starting pancreatic enzymes
- Ignoring weight loss
- Over-relying on normal amylase
- Treating pain only without addressing cause
Amylase is often normal in chronic disease.
Take-home concept
Chronic pancreatitis is not just chronic pain.
Think pancreatic failure, replace enzymes early, optimise nutrition, and address alcohol and smoking.