Chronic pancreatitis is a progressive inflammatory condition of the pancreas that leads to irreversible structural changes, fibrosis, exocrine and endocrine insufficiency, and chronic abdominal pain. Unlike acute pancreatitis, which is reversible, chronic pancreatitis results in permanent damage, often affecting quality of life and metabolic function significantly.
Understanding its causes is essential for early identification, prevention of complications, and long-term management. In this detailed article, we decode the etiology of chronic pancreatitis using the highly memorable and educational mnemonic: “HE GET AIDS”.
What is Chronic Pancreatitis?
Chronic pancreatitis is defined by persistent inflammation of the pancreas, characterized by:
- Fibrosis and calcification
- Loss of acinar cells (exocrine function)
- Islet cell destruction (endocrine dysfunction → diabetes)
- Recurrent or persistent epigastric pain
It commonly affects individuals with a history of alcohol use, but multiple other causes exist—many of which are often underrecognized.
Mnemonic: “HE GET AIDS” – Causes of Chronic Pancreatitis
This smart mnemonic helps remember the most important causes:
| Letter | Cause |
|---|---|
| H | Hypercalcemia |
| E | Ethanol (Alcohol) |
| G | Gallstones |
| E | ERCP (Endoscopic Retrograde Cholangiopancreatography) |
| T | Trauma |
| A | Autoimmune |
| I | Idiopathic (e.g., Tapioca-associated) |
| D | Drugs (e.g., HCTZ, Bactrim, Azathioprine) |
| S | Scorpion sting / Steroids |
Let’s explore each component thoroughly.
H – Hypercalcemia
Hypercalcemia, particularly from hyperparathyroidism, leads to pancreatic ductal obstruction and enzyme activation. This process contributes to:
- Inflammation
- Pancreatic fibrosis
- Intraductal calcification
Serum calcium levels should always be evaluated in cases of recurrent pancreatitis, especially when no clear cause is found.
E – Ethanol / Alcohol Use
Chronic alcohol consumption is the most common cause of chronic pancreatitis in developed countries. It leads to:
- Direct toxic effect on pancreatic acinar cells
- Increases protein content in pancreatic juice → ductal obstruction
- Induces oxidative stress and inflammation
Alcohol-induced pancreatitis typically affects males aged 30–50 and often progresses with continued drinking. Even in the absence of acute episodes, alcohol can silently cause chronic inflammation.
G – Gallstones
While gallstones are a more common cause of acute pancreatitis, they may contribute to chronic pancreatitis in recurrent cases or if they cause:
- Repetitive bile reflux
- Pancreatic ductal obstruction
Gallstone pancreatitis is especially common in females over 40, and treatment often involves cholecystectomy to prevent recurrence.
E – ERCP (Endoscopic Retrograde Cholangiopancreatography)
ERCP is a diagnostic and therapeutic procedure used for biliary and pancreatic conditions. However, it can cause:
- Post-ERCP pancreatitis, particularly in high-risk patients
- If repeated, it may lead to chronic inflammation
Preventive strategies include the use of rectal NSAIDs, guidewire cannulation, and prophylactic pancreatic stenting.
T – Trauma
Trauma—especially blunt abdominal injuries or post-surgical insults—can lead to:
- Ductal damage
- Chronic inflammation
- Fibrosis and strictures
In children, trauma is an important cause, and should be considered when other causes are ruled out.
A – Autoimmune Pancreatitis (AIP)
Autoimmune pancreatitis is a rare but treatable cause, characterized by:
- IgG4-related systemic disease
- Painless jaundice or pancreatic mass (mimicking cancer)
- Responds well to corticosteroids
Two types exist:
- Type 1 AIP – associated with systemic IgG4 disease
- Type 2 AIP – pancreas-specific, seen in younger patients
I – Idiopathic (Including Tapioca-Related)
Idiopathic pancreatitis is diagnosed when no cause is identified after extensive evaluation. Some cases are linked to:
- Genetic mutations (e.g., PRSS1, SPINK1, CFTR genes)
- Tapioca consumption – observed in endemic regions; speculated to contain toxins damaging pancreatic tissue
In such cases, especially in children or adolescents, genetic screening may provide clarity.
D – Drugs (HCTZ, Bactrim, Azathioprine, etc.)
Several drugs have been implicated in drug-induced pancreatitis, some of which can lead to chronic inflammation:
| Drug Class | Example | Mechanism |
|---|---|---|
| Diuretics | HCTZ | Hypersensitivity, direct toxicity |
| Antibiotics | Sulfonamides (e.g., Bactrim) | Immune-mediated |
| Immunosuppressants | Azathioprine | Dose-dependent toxicity |
Others include valproic acid, didanosine, and estrogen.
S – Scorpion Sting / Steroids
Scorpion venom, especially from Tityus trinitatis (in the tropics), can cause severe pancreatitis by:
- Stimulating excessive acetylcholine and catecholamine release
- Triggering pancreatic enzyme secretion and auto-digestion
Steroids can induce or worsen autoimmune pancreatitis if not appropriately tapered, and in some cases, may cause pancreatitis as an adverse effect.
Pathophysiology of Chronic Pancreatitis
Regardless of the cause, the pathological changes converge on a common pathway:
- Ductal obstruction or acinar injury
- Premature enzyme activation
- Inflammation and fibrosis
- Loss of pancreatic tissue
This leads to:
- Exocrine insufficiency (malabsorption, steatorrhea)
- Endocrine insufficiency (diabetes mellitus – type 3c)
- Pancreatic calcification and ductal strictures
Clinical Features of Chronic Pancreatitis
| System | Features |
|---|---|
| Gastrointestinal | Epigastric pain radiating to back, worse after meals |
| Nutritional | Weight loss, malabsorption, vitamin deficiencies |
| Endocrine | New-onset diabetes, brittle glucose control |
| Exocrine | Steatorrhea (foul-smelling, oily stools), bloating |
| Complications | Pseudocyst, biliary obstruction, pancreatic cancer |
Pain is typically intermittent but may become chronic and severe. Some patients may be pain-free but still develop pancreatic insufficiency.
Diagnosis of Chronic Pancreatitis
| Investigation | Findings |
|---|---|
| CT Scan / MRI | Pancreatic calcifications, ductal dilation, atrophy |
| Endoscopic Ultrasound (EUS) | High-resolution imaging for early changes |
| Fecal Elastase | Low levels indicate exocrine insufficiency |
| Blood Tests | May show anemia, low fat-soluble vitamins (A, D, E, K) |
| Glucose Tolerance Test / HbA1c | For diabetes screening |
In early disease, imaging may be normal. Functional tests like fecal elastase or secretin stimulation test help detect subclinical disease.
Management of Chronic Pancreatitis
1. Lifestyle Changes:
- Complete abstinence from alcohol
- Stop smoking – smoking accelerates fibrosis
- Low-fat diet and frequent small meals
2. Pain Control:
Stepwise approach:
- Paracetamol/NSAIDs
- Tramadol or opioids
- Antioxidants (may reduce oxidative stress)
3. Enzyme Replacement:
- Pancreatic enzyme supplements (lipase-rich) with meals
- Helps reduce steatorrhea and improves weight gain
4. Diabetes Management:
- Insulin therapy preferred (oral agents often ineffective)
- Monitor for hypoglycemia, especially with enzyme therapy
5. Endoscopic / Surgical Intervention:
- ERCP + stenting for ductal strictures or stones
- Surgery (e.g., Puestow procedure) for pain relief and drainage
- Total pancreatectomy with islet cell autotransplant in refractory cases
Complications of Chronic Pancreatitis
| Complication | Description |
|---|---|
| Pseudocyst | Encapsulated collection of pancreatic fluid |
| Bile duct obstruction | Due to fibrosis or inflammation |
| Splenic vein thrombosis | Leads to left-sided portal hypertension |
| Pancreatic cancer | Risk increases significantly over time |
| Malabsorption and osteoporosis | Due to fat-soluble vitamin deficiency |
Prognosis
- Highly variable and depends on cause, duration, and compliance with lifestyle changes
- Alcohol cessation drastically slows disease progression
- Long-term complications include diabetes, malnutrition, and cancer
Preventive Tips
- Avoid alcohol and smoking
- Screen early in high-risk patients (family history, recurrent pancreatitis)
- Monitor calcium levels, especially in hyperparathyroid patients
- Rational prescribing of pancreatitis-associated drugs
Summary Table: “HE GET AIDS” Mnemonic
| Mnemonic | Cause |
|---|---|
| H | Hypercalcemia |
| E | Ethanol / Alcohol |
| G | Gallstones |
| E | ERCP |
| T | Trauma |
| A | Autoimmune Pancreatitis |
| I | Idiopathic (e.g., Tapioca-associated) |
| D | Drugs (e.g., HCTZ, Bactrim, Azathioprine) |
| S | Scorpion sting / Steroids |
Frequently Asked Questions (FAQs)
Q1: What is the most common cause of chronic pancreatitis?
A: Chronic alcohol consumption.
Q2: Can chronic pancreatitis be reversed?
A: No, the damage is permanent; treatment focuses on symptom control and preventing progression.
Q3: What foods should be avoided?
A: Alcohol, high-fat foods, red meat, and fried foods. Focus on low-fat, antioxidant-rich diets.
Q4: How is pain managed in chronic pancreatitis?
A: Stepwise analgesia, enzyme therapy, and sometimes nerve blocks or surgery.
Q5: What is the link between chronic pancreatitis and diabetes?
A: Pancreatic islet cell destruction causes type 3c diabetes (pancreatogenic diabetes).
