Pancreatitis can appear in two very different ways. Acute pancreatitis is sudden while chronic pancreatitis is recurring or persistent. Some cases of pancreatitis may be mild and go away on their own without treatment. However, severe cases can lead to potentially fatal complications, including death.
Acute pancreatitis is estimated to affect between 4.5 and 35 individuals in every 100,000 individuals per year. The actual incidence is unknown, because many people may have mild pancreatitis that resolves on its own without medical evaluation. However, it is the most common cause of gastrointestinal hospitalization in the United States.
The pancreas is a long, flat gland located behind the stomach in the upper abdomen. It produces digestive enzymes and hormones, which regulate how the body processes glucose, for instance, insulin.
Although gallstones most often cause pancreatitis, the rise in alcohol misuse has led to an increase in incidence. Alcohol now accounts for around one-third of all acute pancreatitis cases in the U.S. and United Kingdom.
Here are some key points about acute pancreatitis. More detail and supporting information is in the main article.
- Pancreatitis is split into acute and chronic types.
- The pancreas carries out many tasks, including the production of digestive enzymes.
- Symptoms include pain in the center of the upper abdomen, vomiting, and diarrhea.
- The most common causes of acute pancreatitis are gallstones and alcohol abuse.
Causes of acute pancreatitis
Trypsin is a digestive enzyme produced in the pancreas in an inactive form; we know that alcohol misuse can cause trypsin to become active when it is still inside the pancreas, but scientists are not sure why. Researchers believe that ethanol molecules affect the pancreas cells, triggering them to activate trypsin prematurely.
Gallstones are small, pebble-like formations that develop in the gallbladder, often if there is too much cholesterol in the bile. Sometimes, the gallstones can get stuck as they make their way out of the bile ducts and into the intestines. This blokage will also affect the pancreas and prevent it from releasing its enzymes in the intestines. If the acute pancreatitis is linked to gallstones, then elective removal of the gallbadder is usually recommended before the patient leaves the hospital.
Examples of bacterial infections that can lead to acute pancreatitis include Salmonellosis, a type of food poisoning caused by the bacterium Salmonella, or Legionnaires' disease, an infection caused by the bacterium Legionella pneumophila found in plumbing, shower heads, and water-storage tanks. Acute pancreatitis can also be caused by certain viruses, such as hepatitis B, mumps, coxsackievirus, cytomegalovirus, and varicella-zoster virus.
Other possible causes of acute pancreatitis
- Some autoimmune conditions - such as lupus, or Sjogren's syndrome.
- Genetic mutations that predispose people to have recurrent severe episodes of pancreatitis.
- Injury to the pancreas.
- High triglyceride levels in the blood.
- High calcium levels in the blood.
- Idiopathic - more than 10 percent of all cases of acute pancreatitis are termed idiopathic, meaning there is no obvious cause.
Symptoms of acute pancreatitis
Acute pancreatitis is relatively rare but can be serious.
Typically, the patient will experience a sudden onset of pain in the center of the upper abdomen, below the breastbone (sternum). Rarely, the pain is first felt in the lower abdomen. It will gradually become more intense until it is a constant ache.
The ache may intensify further and become severe; it also spreads into the back in around half of cases. Eating may exacerbate the pain.
If it is caused by gallstones, everything will happen and develop very fast. When it is caused by alcohol, symptoms develop more slowly, over a number of days.
Leaning forward or assuming a fetal position (curling up) may help lessen the pain slightly. Anybody who experiences constant pain should seek medical attention.
The following symptoms may also be present:
- loss of appetite
- rapid pulse
- pain with coughing, vigorous movements, and deep breathing
- tenderness when the abdomen is touched
- fever - a temperature of at least 100.4 °F (38 °C)
- jaundice - the skin and whites of the eyes take on a yellowish tinge
- strong painkillers often fail to relieve the pain
- blood pressure may drop or rise, but will fall when the patient stands, sometimes causing faintness
Treatments for acute pancreatitis
Treatment for acute pancreatitis will depend on whether it is mild or serious. "Mild" means the doctor believes the risk of complications is small, while "serious" means the risk is significant.
Treatment for mild acute pancreatitis
The aim of treatment here is to make sure the body is working properly, and to ease symptoms while the pancreas is repairing itself. This will include:
- Painkillers - mild acute pancreatitis can be moderately or severely painful.
- Nasogastric tubes - a tube removing excess liquids and air as a treatment for nausea and vomiting can be used.
- Bowel rest - In mild pancreatitis, the gastrointestinal tract will be given a few days of rest, which means that the patient will not take any food or drink by mouth until the pain has improved.
- Preventing dehydration - Dehydration often accompanies pancreatitis, and it can worsen the symptoms and complications. Patients are usually given aggressive hydration intravenously for the first 24-48 hours (fluids will pass through a tube that is connected to a vein).
Patients usually go home after about 5-7 days.
Treatment for severe acute pancreatitis
Severe acute pancreatitis usually results in some tissue necrosis - some of the pancreas tissue dies. Tissue necrosis carries a very high risk of sepsis - a severe bacterial infection that causes systemic dysfunction (or a whole body reaction), which can eventually lead to multi-organ damage or failure.
Severe acute pancreatitis can also cause hypovolemic shock - severe blood and fluid loss, which makes the heart unable to pump enough blood to the body. Parts of the body can become rapidly oxygen-deprived; this is a life-threatening situation.
Treatment for this kind of pancreatitis includes:
- Being placed in an ICU (intensive care unit) - they will then be injected with antibiotics to stop any infection that could develop from the dead tissue.
- Receiving intravenous fluids - this helps to maintain hydration and prevent hypovolemic shock.
- Some patients may require help breathing - in this case, they will be connected to ventilation equipment.
- Feeding tubes - will provide nutrition as appropriate. In this case, early feeding improves outcomes.
- Surgery - in some cases, the dead tissue may need to be surgically removed.
When doctors are sure the patient is out of danger for risk of organ failure, hypovolemic shock, and sepsis, the patient will be taken out of the ICU.
As soon as the patient has recovered and doctors have determined that gallstones caused the acute pancreatitis, the patient might undergo surgery or an ERCP (endoscopic retrograde cholangiopancreatography). After the gallstones are removed, the patient may be advised to follow a special diet to lower blood cholesterol, because excess cholesterol encourages the growth of gallstones. The guideline recommendation from the American Gastroenterological Association is that all patients should have their gallbladders removed if they developed pancreatitis from gallstones.
Treating alcohol misuse
If doctors determine that alcohol misuse was the underlying cause of the acute pancreatitis, the patient may be offered a treatment program for alcohol misuse.
Acute pancreatitis diagnosis
Levels of amylase and lipase may be elevated in the early stages of pancreatitis.
The doctor will ask the patient about symptoms and examine their abdomen. If certain areas of the abdomen are sensitive when touched, this could be an indication of acute pancreatitis.
Patients with acute pancreatitis will have rigid abdominal wall muscles. When listening to the abdomen with a stethoscope, there may be very few or no intestinal sounds.
If blood levels of amylase and lipase are higher than normal, the patient will most likely be sent to the hospital. The pancreas produces elevated levels of both chemicals during acute pancreatitis.
However, blood tests may not be accurate if they are not obtained on the first or second day of illness. This is because lipase and amylase levels are highest within the first few hours and return to normal after a few days.
Amylase returns to normal within 3-7 days, and lipase returns to normal in 8-14 days.
Further testing in hospital
To determine the risk of complications, a doctor will want to ascertain how inflamed the pancreas is; the following tests may be performed:
- ERCP (endoscopic retrograde cholangiopancreatography) scan - an endoscope (a thin, flexible tube with a camera at the end) is inserted into the digestive system. An ERCP can help determine the exact location of a gallstone.
- An ultrasound scan - high-frequency sound waves create an image on a monitor of the pancreas, gallbladder, and their surroundings.
- CECT (contrast-enhanced computed tomography) scan - these are used to take pictures of the same area from many angles; these are then combined to produce a 3-D image. CECT scans can help identify inflammation of the pancreas, fluid collection, and any changes in the density of the gland.
- Chest X-ray - the doctor may order a chest X-ray to check for areas of collapsed lung tissue, or accumulation of fluid in the chest cavity.