chronic pancreatitis ( cp ) as a chronic and progressive condition requires a specific approach for quality of life ( qol ) assessment . as a chronic disease with debilitating symptoms , consequences of diabetes mellitus , malabsorption and weight loss and possibility of complications ( including cancer ) , cp severely affects qol [ 13 ] . numerous studies have shown the heterogeneous character of the disease , with the interaction of physical , psychological and social factors . as long as the pathophysiological background of pain in cp remains uncertain , commonly used therapeutic methods of treatment remain insufficient because patients quality of life is highly impaired [ 13 ] . chronic pancreatitis can not be cured and may require many clinical interventions and frequent hospitalization . alcohol abuse and disease - related unemployment have negative impacts on coping with the disease . chronic pancreatitis affects all aspects of patients lives : work , leisure , travel and relationships . it is not surprising that the multidimensional approach should be taken with these patients [ 13 ] . it is well documented that quality of life is an important variable and should be measured in cp patients . however , the available data in this field are not comparable because different qol assessment methods were used [ 1,46 ] . the aim of the study was to assess qol in patients with chronic pancreatitis and the correlation with the disease activity and selected environmental / social factors . the study group comprised 43 patients with cp : m / f 37/6 ; mean age 47.98.6 ; range : 3074 yrs . patients with chronic pancreatitis were recruited from those hospitalized in the department of digestive tract diseases , medical university of lodz , poland . the diagnosis of chronic pancreatitis was made by a combination of imaging , functional , pathologic and clinical findings . the degree of pancreatic damage was assessed using the cambridge classification , where first degree ( i ) described less than 3 abnormal side branches of main duct ; ii  more than 3 abnormal side branches , iii  abnormal main duct and branches and iv  plus 1 or more of : large cavities ( > 10 mm ) , gross gland enlargement ( > 2 ) , intraduct filling defects or calculi , duct obstruction , stricture or gross irregularity and contiguous organ invasion ( 7 ) . in grades ii and iii there are 2 or more pathological signs according to computed tomography assessment : main duct enlarged ( < 4 mm ) , gland enlarged ( < 2 ) , cavities ( < 10 mm ) , irregular ducts , duct wall echoes increased , irregular head contour . alcohol etiology was diagnosed when alcohol intake exceeded 80 g per day for at least 5 years . qol was assessed using 8 domains of the 36-item short - form health survey ( sf-36 ) , which is a short form measure of generic health status in the general population , designed for self - administration ( 8,9 ) . sf-36 describes limitations in physical activity because of health problems ( physical functioning -pf ) , limitations in social activities because of physical or emotional problems ( social functioning sf ) , limitations in usual role activities ( role - physical  rp ) , presence of pain and limitations due to pain ( bodily pain gh ) , psychological distress and well - being ( mental health  mh ) , limitations in usual role activities because of emotional problems ( role - emotional  re ) , and energy and fatigue ( vitality  vt ) . pain assessment was performed according to talley et al , who proposed a pain index ( pi )  an additive model of pain frequency and intensity . the frequency of abdominal pain attacks was described by 04 points : 0 , once a year or less ; 1 , several times a year ; 2 , several times a month ; 3 , several times a week ; and 4 , daily . the intensity of abdominal pain was also described by 04 points from a uas score : 0 , no pain ; 1 , ( 125 ) ; 2 , ( 2650 ) ; 3 , ( 5175 ) ; and 4 , ( 76100 ) , where 0 means no pain and 100 means the worst pain . the pain index was defined as the sum of points for frequency and intensity of abdominal pain . the clinical and socio - demographic characteristics of the patients are shown in table 1 . the study protocol was approved by the local ethics committee of the medical university of lodz . statistical analysis was performed using the f - snedecor test , the t test , and the cochran - cox test . among patients studied , most ( 23 patients , 53% ) had normal weight ( bmi 1534 ; mean 23.1 kg / m2 ) ; 2 patients were obese , 13 were overweight and 5 had bmi under 18 . mean disease duration was 9 yrs ( range 146 ) , with 7.3 mean number of disease relapses ( range 030 ) . the pain index mean result was 3.3 points , with range between 0 to 8 points . frequency and intensity varied greatly , from 0 to maximum ( 4 points ) . however , most patients had the smallest intensity and frequency , what is also seen in pi points number of patients with cp scheduled for i degree according to cambridge classification was 5 ( 12% ) ; for ii degree , 6 ( 14% ) ; for iii , 6 ( 14% ) ; and for iv degree , 26 ( 60% ) . mean qol scores in cp were statistically lower compared to the control group in the following domains : physical functioning , role - physical , general health perception ( p<0.001 ) and vitality ( p<0.05 ) ( 74 vs. 95 ; 50 vs. 94 ; 45 vs. 69 ; 47 vs. 57 ; respectively ) ( figure 1 ) . mean qol scores in unemployed patients were statistically lower compared to working patients ( p<0.001 ; p<0.05 ) ( figure 2 ) . there was the negative correlation between mean qol scores and pain index results in all sf-36 domains ( table 2 ) . the number of the disease relapses was associated with qol impairment in 5 of 8 sf-36 domains : role - physical , role - emotional , social - functioning , bodily - pain and general health perception . the qol scores in the same 5 domains were positively correlated with body weight ( bmi ) ( p<0.001 ; p<0.05 , respectively ) ( table 2 ) . there was no statistical correlation between mean qol scores and population demographic features ( age , marital status , education level ) , cp etiology , smoking habits , disease duration and activity assessed using the cambridge classification , history of surgical or endoscopic treatment , and coincidence of diabetes mellitus ( table 2 ) . in addition , we have gained further insight into the relationship between disease status and qol . we used the sf-36 questionnaire , a generic instrument to assess qol , validated in poland . the questionnaire has psychometric reliability , and content , convergent and discriminant validity and internal consistency when used in patients with many different disorders , including chronic pancreatitis . our study revealed the deterioration of qol in cp in all sf-36 domains compared to healthy controls , particularly in physical functioning , role - physical , general health perception and vitality domains . similar findings were presented in the study by wehler et al , who conducted qol assessment in a 265 cp patients . decrements were most pronounced in role limitations caused by physical and emotional health problems and general health perceptions . similar results were obtained by pezzilli et al . , who described general health , role - physical and vitality as the most impaired domains . we observed significant negative correlation between mean qol scores and pain index in all sf-36 domains . our previous studies and most other similar studies have shown the significant pain - related impairment of qol results , despite the fact that pain was measured in various ways . among the clinical factors examined by pezzilli et al . , only pain significantly decreased all 8 domains of sf-36 . similarly , in the study of wehler et al , increasing severity of pancreatic pain significantly impaired qol in all sf-36 domains . . took into account the options pain / no pain , whereas in wehler et al and in our study the pain index was used according to talley et al . . as there is a lack of good quantitative pain measurement in cp , we chose the pain index that provided a combined score representing pain intensity and frequency . these results show how important the problem of pain is in cp and how often the management of these patients is not successful because the qol is still impaired . there is not a direct relationship between abdominal pain and the presence of pathological structural changes of the pancreas . since total pain relief is usually impossible , it is important to establish a solid doctor - patient communication . referral to a patient - based support group ( e.g. , national pancreas foundation ) is helpful . the structural pancreatic changes ( according to the cambridge classification ) were not associated with qol impairment . similarly , other studies using sf-36 did not reveal any correlation between cambridge stage and qol scores . pezzilii et al . did not find any correlation in sf-36 scores and calcifications or pseudocysts and the presence of wirsung duct dilatation . when eortc c30/pan 26 ( the specific instrument ) was used , cp activity had influence on worse global health status , pain , nausea and vomiting , appetite loss , digestive symptoms , fear about future health , indigestion and taste changes items . however , studies using the cp - specific measure showed qol impairment due to disease duration in a few domains . the possible reason for these differences is that sf-36 as a generic instrument may not indicate specific differences in cp signs and symptoms . on the other hand , the number of disease relapses was associated with qol impairment in 5 of 8 sf-36 domains . to our best knowledge diabetes , which is a late consequence of cp , did not affect our qol results , although other studies have shown its significant influence on qol . however , qol in chronic pancreatitis is highly impaired due to the basic disease ; it is possible that comorbidities such as diabetes do not add much to the final result . chronic diarrhea due to pancreatic exocrine insufficiency had an influence on the general health perception domain . wehler et al . found that chronic diarrhea appeared to be an independent predictor of poor qol results . in our previous study using eortc / pan , diarrhea also had an impact on a few items : insomnia , altered bowel habit and diarrhea domains . like other studies using the sf-36 questionnaire or eortc / pan26 , our study did not reveal any differences in qol according to surgical / endoscopic procedures . however , the aim of this study was not to assess the effect of treatment of cp . future studies should have long follow - up periods and the time between disease onset and evaluation should be also taken into consideration . bmi score correlated positively with qol role - physical , role - emotional , social - functioning , bodily - pain and general health perception domains . similarly , low body weight independently contributed to the physical component score of the sf-36 and was the factor most closely associated with poor health status perception in the study by wehler et al . . most ( 64% of patients ) were under age 50 and the majority of them were retired or unemployed due to cp . unemployment had a significant negative correlation with almost all sf-36 domains , with the exception of the mental health domain . similarly , using eortc qlqc30/pan26 , loss of work proved to have a negative influence on nausea and vomiting , insomnia and pancreatic pain domains . wehler et al demonstrated that unemployment and early disease - related retirement are independent and significant predictors of clinically important deterioration in most qol domains . in our population 44% of patients were retired due to cp , due to the requirements of the retirement system in poland . in a recent study by gardner et al , out of a total of 111 cp patients only 37% were currently employed , 74% had their work lives altered by cp , 60% reported an effect on their social lives , and 46% reported an effect on their spouse / significant other relationship . respondents reported that they had not been treated with respect and dignity , and had been labeled as an alcoholic or a drug seeker . the authors concluded that chronic pancreatitis had a profound impact on employment patterns and comprehensive efforts are needed to improve the health care experience of patients with this disease . severity of pain , low body weight , disease relapses and unemployment are the main factors adversely affecting qol . our findings suggest that pain represents the most important challenge for clinicians in everyday practice . since there are many different potential causes of pain in cp , no single therapy is effective in all patients . recently , the role of the central nervous system appears to be important in the development of pain . pain treatment should not focus solely on the pancreas , but also address medications with effects on the underlying pain mechanisms . using alternative therapies could be promising ; yoga has proved to be a tool improving the qol in cp . more individual effective therapies should be used to improve physical and emotional qol in these patients ; social factors have a particularly negative impact on qol . interactive , educational patient and family support groups for people with pancreatitis are needed . the information given by quality of life assessment should be routinely included in the work - up of patients affected by chronic pancreatitis to select those patients with severely impaired physical and mental scores , and to plan an intensive program of medical and psychological follow - up .
summarybackgroundquality of life ( qol ) has increasingly become a factor in management decisions in patients with chronic diseases . 
 chronic pancreatitis ( cp ) is a debilitating disorder that causes not only pain and endo / exocrine insufficiency but is also connected with some social issues . 
 the aim of this study was to assess qol in patients with chronic pancreatitis in correlation with the disease activity or the environmental / social factors that can influence their well-being.material/methodsthe study group comprised 43 patients with cp : m / f 37/6 ; mean age 47.98.6 ; range : 3074 yrs . 
 the control group consisted of 40 healthy volunteers of comparable demographics . 
 different degrees of cp activity were defined using the cambridge classification . 
 pain intensity and frequency were assessed using a pain index . 
 qol was assessed using the short - form-36 questionnaire.resultsmean qol scores in cp were lower compared to the control group in all sf-36 domains , particularly in general health perception , physical functioning , role - physical ( p<0.001 ) and vitality ( p<0.05 ) . 
 we observed correlation of qol results and pain index in all domains , and number of the disease relapses and body weight in 5 out of 8 domains ( p<0.001 and p<0.05 , respectively ) . 
 the worst qol scores were obtained in retired patients , as well as in unemployed persons in almost all sf-36 domains ( p<0.001).conclusionschronic pancreatitis significantly impairs patients quality of life . 
 severity of abdominal pain , low body weight , and loss of work were the factors most closely associated with poor health status perception .