Acute Pancreatitis

What is Pancreatitis?

The pancreas is a glandular organ located in the posterior aspect of the abdomen just below and behind the stomach. The pancreas produces digestive enzymes (exocrine function), which are emptied into the small bowel, as well as the hormone insulin (endocrine function), which enters the blood stream. Pancreatitis occurs when the pancreas gets irritated or swollen and causes severe upper abdominal pain that may also be felt in the back.

Most people who get pancreatitis experience a one- to two-week episode that resolves without any long-lasting effects. Some individuals, however, will experience repeated episodes and become quite sick.

Most attacks of acute pancreatitis do not lead to complications, and most people recover with medical care. A small proportion of people, however, will develop a more serious case that requires intensive medical care. In all cases, it is essential to determine the underlying cause of acute pancreatitis and, if possible, treat this condition to prevent a recurrence.

Some individuals will develop long-term or chronic pancreatitis; this is discussed separately.

What are the Symptoms of Pancreatitis?

The main symptom of pancreatitis is sudden onset of severe abdominal pain in the upper mid abdomen. In people with alcoholic pancreatitis, a very common cause, the symptoms of acute pancreatitis typically occur one to three days after an alcohol binge or after stopping drinking. Pain is accompanied by nausea and vomiting in most people.

What Causes Pancreatitis?

The two most common causes of acute pancreatitis are gallstones or alcohol abuse.

Gallstones are small stones that form inside the gallbladder. Gallstones can be tiny specks or become much larger, even as big as the whole gallbladder. Normally, the gallbladder fills with bile in between meals; then, when you eat, the gallbladder empties the bile into the intestine to help breakdown fatty foods. Gallstones can clog or block the duct leading from the pancreas and actually keep the liver or pancreas from draining. The digestive fluids produced by the pancreas and the gallbladder must flow through the same tube to the intestine. When the duct is blocked by a gallstone, the digestive fluids get backed up and cause swelling and inflammation of the pancreas, resulting in “gallstone pancreatitis”.

Alcohol is a common cause of acute pancreatitis in individuals who have a long history of alcohol abuse and often occurs one to three days after a binge.

Drugs used to treat medical conditions may cause acute pancreatitis.

Post-ERCP Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that is done to evaluate the gallbladder or pancreas. Acute pancreatitis occurs in about three to five percent of individuals who undergo ERCP.

Hereditary Conditions Acute pancreatitis can be caused by hereditary conditions, such as familial hypertriglyceridemia (high blood triglyceride levels) and hereditary pancreatitis. These conditions typically occur in younger individuals.

Idiopathic In about 20 percent of people with acute pancreatitis no cause can be identified; this condition is referred to as idiopathic pancreatitis.

How is Pancreatitis Diagnosed?

Pancreatitis is associated with increased levels of two digestive enzymes produced by the pancreas. Both of these enzymes, lipase and amylase, can be measured in the blood. Doctors may also be able to see evidence of pancreatitis on a MRI or CT scan.

Once a diagnosis of acute pancreatitis is made, additional tests are often required in order to determine the cause.

Endoscopic retrograde cholangiopancreatography (ERCP) is a specialized technique used to study the bile ducts, pancreatic duct, and gallbladder and can also be used to remove stones from the bile duct if your pancreatitis is due to gallstones or other problems with the bile or pancreatic ducts.

During ERCP, your doctor will pass an endoscope through the mouth, esophagus, and stomach into the duodenum (first part of the small intestine), and then a narrow plastic tube called a catheter through the endoscope and into the ducts coming from the liver and pancreas. The doctor will inject a contrast material (dye) into the pancreatic or biliary ducts and take images.

How is Pancreatitis Treated?

Pancreatitis treatment is complex and typically requires admission to the hospital. Treatment consists of controlling the pain, maintaining adequate nutrition and hydration, and identifying and treating the underlying cause. In more severe cases, patients can experience organ failure.

Mild cases of pancreatitis usually resolve with simple supportive care, which entails monitoring, drugs to control pain, and intravenous fluids. More severe pancreatitis requires extensive monitoring and supportive care because severe pancreatitis can lead to potentially life-threatening complications, including damage of the kidneys, heart, and lungs.

The following treatments may be utilized in the management of pancreatitis:

  • Intravenous fluids are administered to prevent dehydration.
  • Nutrition Many individuals will not be able to eat and can require nutrition delivered through a tube placed through the nose or mouth into the small intestine or intravenously. Patients resume eating gradually once pain resolves and bowel functions return to normal.
  • Antibiotics Approximately one in three people with severe acute pancreatitis will require treatment with antibiotics to treat infection that can develop in damaged pancreatic tissue.
  • Surgery can be required to remove infected tissue.

Treatment of the Underlying Cause

If it is determined that pancreatitis is caused by alcohol or a complication of a medical drug, those substances must be completely eliminated, or chronic pancreatitis can develop. For individuals with gallstone pancreatitis, a procedure to relieve the blockage is required.

Surgical removal of the gallbladder, or cholecystectomy, and ERCP are the two main treatment choices for gallstone pancreatitis. Removing the gallbladder (the source of the gallstones) may be preferable for patients who can tolerate the surgery, which may be performed laparoscopically. For elderly individuals and those with serious medical problems, it may not be safe to remove the gallbladder, and in that case ERCP can enlarge the bile duct opening. Individuals should discuss these options with their treating physician to determine which is best for their situation.

Refrences

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2 Kingsnorth A, O'Reilly D. Acute pancreatitis. BMJ 2006; 332:1072.

3 Heinrich S, Schäfer M, Rousson V, Clavien PA. Evidence-based treatment of acute pancreatitis: a look at established paradigms. Ann Surg 2006; 243:154.

4 Swaroop VS, Chari ST, Clain JE. Severe acute pancreatitis. JAMA 2004; 291:2865.

5 Jacobson BC, Baron TH, Adler DG, et al. ASGE guideline: The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory fluid collections of the pancreas. Gastrointest Endosc 2005; 61:363.

CONDITIONS OF THE GI TRACT