Pancreatitis is the most common reason for gastrointestinal-related hospital stays in the United States.
The Role of the Pancreas
Your pancreas is a large gland behind your stomach and close to your duodenum, the first section of your small intestine. The pancreas secretes powerful digestive enzymes that enter the small intestine through a duct that then flows into the duodenum. These enzymes help you digest fats, proteins, and carbohydrates.
The pancreas also releases the hormones insulin and glucagon into the bloodstream. These hormones play an important role in metabolizing sugar.
Pancreatitis occurs when digestive enzymes become activated while still in the pancreas and begin attacking the organ, leading to inflammation and eventually damage if it persists.
Acute Pancreatitis
An estimated 40 to 50 cases of acute pancreatitis per 100,000 people occur in the United States each year. This disease occurs when the pancreas suddenly becomes inflamed and then gets better.
Some people may have more than one attack, but recover fully after each one.
Causes
Acute pancreatitis is commonly caused by the following:
Gallstones Chronic alcohol consumption
Gallstones are the most common cause of acute pancreatitis in the United States, and the risk of gallstone-related pancreatitis increases with age; it is also higher in women than men.
Other causes for acute pancreatitis include:
Prescription medications Trauma to the abdomen Abdominal surgery Hypertriglyceridemia (high triglycerides, a fat in the blood) Viral infections, such as mumps Bacterial infections, such as Salmonella Vascular abnormalities, such as vasculitis (inflammation of blood vessels) Hypercalcemia (high calcium levels in the blood) Inherited abnormalities of the pancreas or intestine Tumors or pancreatic cancer High exposure to agricultural chemicals, such as the insecticide organophosphate Autoimmune diseases, such as inflammatory bowel disease or celiac disease
In about 15% of cases, the cause is unknown. Smoking is a risk factor for acute pancreatitis, as are obesity and uncontrolled diabetes. Having type 2 diabetes also increases the risk of having a severe case of pancreatitis.
Symptoms
Acute pancreatitis usually begins with pain in the upper abdomen that may last for a few days. The pain is often severe, but it can also be mild. It may be constant pain just in the abdomen, or it may reach to the back and other areas.
The pain may be sudden and intense, or it may begin as a dull pain that is aggravated by eating and slowly gets worse. Other symptoms include:
Bloating Tender abdomen Nausea Vomiting Diarrhea Hiccups Indigestion Fever Increased pulse rate Feeling or looking very sick Jaundice, a yellowing of the skin and whites of the eyes Clay-colored stools
In severe cases, there may be bleeding into the gland, serious tissue damage, infection, and cysts. Enzymes and toxins may enter the bloodstream and seriously injure organs such as the heart, lungs, and kidneys.
The patient may become dehydrated and have low blood pressure. In the most severe cases, bleeding can occur in the pancreas, leading to shock and sometimes death.
Diagnosis
During acute attacks, high levels of amylase and lipase, digestive enzymes formed in the pancreas, are found in blood tests. Lipase is more specific for pancreatic inflammation than amylase. Changes may also occur in blood levels of calcium, magnesium, sodium, potassium, and bicarbonate.
Patients may have high amounts of sugar and lipids (fats) in their blood too. These changes help the doctor diagnose pancreatitis. After the pancreas recovers, blood levels of these substances usually return to normal.
Treatment
The treatment a patient receives depends on how bad the attack is. Unless complications occur, acute pancreatitis usually gets better on its own, so treatment is supportive in most cases. Usually, the patient is admitted to the hospital.
The doctor prescribes IV fluids to restore blood volume. The kidneys and lungs may be treated to prevent failure. Other problems, such as cysts in the pancreas, may need treatment too.
Sometimes a patient cannot control vomiting and needs to have a tube through the nose to the stomach to remove fluid and air. In mild cases, the patient may not have food for three or four days but is given fluids and pain relievers by vein. In severe cases, the patient may be fed through the veins for three to six weeks while the pancreas slowly heals.
An acute attack usually lasts only a few days, unless the ducts are blocked by gallstones.
Surgery may be needed if complications such as infection, cysts, or bleeding occur. Antibiotics may be given if there are signs of infection.
Attacks caused by gallstones may require removal of the gallbladder or surgery of the bile ducts, which are tubes that connect the liver to the small intestine. The bile ducts transport gallstones and blockages can occur.
When there is severe injury with the death of tissue, an operation may be done to remove said tissue.
After all signs of acute pancreatitis are gone, the doctor will determine the cause and try to prevent future attacks. In some patients, the cause of the attack is clear; in others, further tests need to be done.
The prevention plan will depend on the cause but may include some dietary changes, such as limiting fried foods and large meals, and avoiding alcohol.
When Gallstones Are Present
Ultrasound is used to detect gallstones and may provide an idea of how severe pancreatitis is. When gallstones are found, surgery is usually needed. It typically involves a cholecystectomy (removal of the entire gallbladder).
If a gallstone is blocking one of the pancreatic ducts, the gallstone will also need to be removed. If it is mild disease, the surgery should be done within seven days of acute pancreatitis. If it is severe disease, you may be advised to wait until after active inflammation subsides to try to prevent future episodes of pancreatitis.
A computer axial tomography (CAT) scan may also be used to find out what is happening in and around the pancreas and the severity of the problem. This is important information that the doctor will use to determine when to remove the gallstones.
After the gallstones are removed and inflammation subsides, the pancreas usually returns to normal.
Chronic Pancreatitis
Chronic pancreatitis may develop after only one acute attack, especially if the ducts become damaged or if the injury to the pancreas continues. Eventually the condition impairs a person’s ability to digest food and make pancreatic hormones.
An estimated 5 to 12 cases of acute pancreatitis per 100,000 people occur each year.
Causes
Causes of chronic pancreatitis include:
Continued heavy alcohol use Blocked pancreatic or bile ducts Genetic mutations due to cystic fibrosis Autoimmune disorders An inherited form of pancreatitis that may be due to enzyme abnormalities
Damage to the pancreas from drinking alcohol may cause no symptoms for many years, and then the person suddenly has an attack of pancreatitis.
Damage to the pancreas from drinking alcohol may cause no symptoms for many years, and then the person suddenly has an attack of pancreatitis. It is more common in men than women and often develops between ages 30 and 40.
Inherited forms of chronic pancreatitis appear to be due to abnormalities of pancreatic enzymes that cause them to autodigest the organ.
Symptoms
In the early stages, the doctor cannot always tell whether a patient has an acute or chronic disease. The symptoms may be the same.
Those with chronic pancreatitis may have the following symptoms:
Upper abdominal painNauseaVomitingDiarrheaWeight lossOily or fatty stoolsClay-colored or pale stools
Some patients do not have any pain, but most do. Pain may be constant in the back and abdomen; for some, the pain attacks are disabling.
In some cases, the abdominal pain goes away as the condition advances. Doctors think this happens because pancreatic enzymes are no longer being made by the pancreas.
Patients with this disease often lose weight, even when their appetite and eating habits are normal. This occurs because the body does not secrete enough pancreatic enzymes to break down food, so nutrients are not absorbed normally. Poor digestion leads to loss of fat, protein, and sugar into the stool.
Diabetes may also develop at this stage if the insulin-producing cells of the pancreas (islet cells) have been damaged.
Diagnosis
Diagnosis may be difficult but is aided by a number of new techniques. Pancreatic function tests help the physician decide if the pancreas can still make enough digestive enzymes. The doctor can see abnormalities in the pancreas using several imaging techniques:
Ultrasonic imaging Endoscopic retrograde cholangiopancreatography (ERCP) CAT scans
In more advanced stages of the disease, when diabetes and malabsorption (a problem due to lack of enzymes) occur, the doctor can use a number of blood, urine, and stool tests to help in the diagnosis of chronic pancreatitis and to monitor the progression of the condition.
Treatment
The treatment for chronic pancreatitis usually involves relieving pain and managing nutritional and metabolic problems. The patient can reduce the amount of fat and protein lost in stools by cutting back on dietary fat and taking pills containing pancreatic enzymes. This will result in better nutrition and weight gain.
Sometimes insulin or other drugs must be given to control the patient’s blood sugar.
In some cases, surgery is needed to relieve pain by draining an enlarged pancreatic duct. Sometimes, part or most of the pancreas is removed in an attempt to relieve chronic pain.
