The pathogenesis of chronic pancreatitis

Chronic pancreatitis is uncommon in the developed world, but it exacts an inordinate toll in terms of morbidity, mortality and health economics. The control of pancreatic pain is the main challenge, and it is generally accepted that extirpation of diseased tissue is the only way to guarantee longterm relief.' In this institution, however, as a result of the development and validation of antioxidant therapy, pancreatic surgery for pain has virtually become obsolete. A recent audit of our 9-year experience' showed that the new medical treatment ameliorated symptoms in children and adults, irrespective of previous pain pattern (episodes of pancreatitis or increasing background pain), aetiology (alcoholism 45%, miscellaneous 10%, idiopathic 45%) and whether morphological studies showed large-duct or small-duct disease, calculi or an inflammatory mass. The corollary is that oxidative stress underlies chronic pancreatitis. This concept, a modification' of the original hepatic 'detoxification' proposal, rationalizes past and present observations on the natural history, pathology and pathophysiology of the disease, whilst accommodating other theories on pathogenesis (Table 1).