Pancreatitis means inflammation of the pancreas that 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 and do not require treatment. However, severe cases can lead to potentially fatal complications.

Acute pancreatitis is uncommon. According to the National Health Service (NHS), UK, less than 1 in every 100,000 people develops acute pancreatitis each year. It is slightly more common in men than in women.

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.

Although pancreatitis is mainly caused by gallstones, the rise in alcohol misuse in several countries has lead to an increase in incidence. Alcohol now accounts for over one third of all acute pancreatitis cases in the USA and UK.

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If the acute pancreatitis is linked to gallstones it tends to develop in elderly patients. Alcohol-linked acute pancreatitis mainly affects people in their late 30s.

What are the symptoms of acute pancreatitis?

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 then gradually become more intense until it is a constant ache. The ache may intensify further and become severe, and also spread into the back in 50% 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 will typically 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:

  • Vomiting.
  • Nausea.
  • Diarrhea.
  • Loss of appetite.
  • Coughing, vigorous movements, and deep breathing may be painful.
  • Tenderness when the abdomen is touched.
  • Fever – temperature of at least 100.4F (38C).
  • 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.

What are the causes and risk factors of acute pancreatitis?

  • Trypsin – if trypsin is activated while still in the pancreas, which it should not do, it will start breaking down pancreas cells, digesting the pancreas itself, causing irritation and inflammation. Trypsin is a digestive enzyme produced by the pancreas. Trypsin should not become active until it is released from the pancreas and enters the intestines.
  • Alcohol misuse – we know that alcohol misuse can cause trypsin to become active inside the pancreas, but scientists are not sure why? Scientists say that ethanol molecules affect the pancreas cells, triggering them to activate trypsin prematurely. Approximately 10% of people with chronic alcohol misuse develop acute pancreatitis. Chronic alcohol misuse means medium- or long-term consumption of at least 10 units of alcohol daily – the equivalent of over four pints of lager (beer) or five glasses of wine.
  • Gallstones – these are little pebble-like formations that develop in the gallbladder if there is too much cholesterol in the bile. Sometimes the gallstones can be dislodged and make their way out of the gallbladder, blocking the ducts to the pancreas. The blockage undermines the normal workings of the pancreas which sometimes activate the trypsin prematurely, while it is still inside the pancreas, causing it to become irritated and inflamed.
  • Infections (rare causes of acute pancreatitis) – examples of bacterial infections 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. Examples of viral infections include, mumps or hepatitis B.
  • Some autoimmune conditions – such as lupus, or Sjogren’s syndrome.
  • Injury to the pancreas
  • Idiopathic – about 15% of all cases of acute pancreatitis are termed idiopathic pancreatitis. This means that no obvious cause was identified.

How is acute pancreatitis diagnosed?

The GP (general practitioner, primary care physician) will ask the patient about symptoms and examine his/her 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 which the doctor will notice during the examination. When listening to the abdomen with a stethoscope, there may be very few or no intestinal sounds – also an indication of pancreatitis.

Blood tests – if blood levels of amylase and lipase are higher than normal, the patient will most likely be sent to hospital. The pancreas produces elevated levels of both chemicals during acute pancreatitis. However, blood tests are only useful early on because amylase and lipase levels increase on the first day of illness and then return to normal within 3 to 7 days.

Further testing in hospital

In order to find out how inflamed the pancreas is, which helps doctors determine the risk of complications, the following tests may be performed:

  • An ultrasound scan – high frequency sound waves create an image on a monitor of the pancreas and its surroundings.
  • A CT (computerized tomography) scan – X-rays are used to take many pictures of the same area from many angles, which are then placed together to produce a 3-D image. CT scans are useful in detecting inflammation of the pancreas, especially those with complications, such as extremely low blood pressure. CT images are very clear.
  • An ERCP (endoscopic retrograde cholangio-pancreatography) scan – an endoscope (thin, flexible tube with a camera at the end) is inserted into the digestive system. The doctor uses ultrasound to guide the endoscope through. An ERCP can help the doctor determine the exact location of a gallstone. Sometimes surgical instruments are threaded through the endoscope, which is hollow like a drinking straw, so that the gallstone can be removed.
  • 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.

What are the treatment options 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 are insignificant, 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, as well as to ease symptoms while the pancreas is repairing itself. This will include:

  • Treatment for pain – mild acute pancreatitis can be moderately or severely painful. The patient may be given painkillers.
  • Treatment for nausea, vomiting – this may include medication to control nausea and vomiting.
  • Feeding tubes – the pancreas needs to rest while it recovers. Patients may be fed by the way of feeding tubes so that nutrition goes straight to the blood, rather than the digestive system which would create more work for the pancreas. In some cases, though, feeding is via a nasogastric tube as well (through the nose and into the stomach).
  • Dehydration – acute pancreatitis often results in dehydration. The patient will be hydrated intravenously (fluids will pass through a tube that is connected to a vein).

The majority of patients go home after about five to seven 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 which gets into the bloodstream, causing multiple organ 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; a life-threatening situation.

  • Patients will be placed in an ICU (intensive care unit) and injected with antibiotics to stop any infection that could develop from the dead tissue.
  • The patient will also receive intravenous fluids to maintain hydration and prevent hypovolemic shock.
  • Some patients may require help breathing and will be connected to ventilation equipment.
  • Feeding tubes will provide nutrition straight into the bloodstream.
  • In some cases the dead tissue may need to be surgically removed.

When doctors are sure the patient is out of danger, i.e. the risk of organ failure, hypovolemic shock, and sepsis have passed, the patient will be taken out of the ICU. This could take two weeks, and sometimes longer.

Treating gallstones

As soon as the patient is recovered and doctors have determined that gallstones caused the acute pancreatitis, the patient will have to undergo surgery. After the gallstones are removed the he/she may be advised to follow a special diet to lower blood cholesterol. Gallstones are caused by excess cholesterol.

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.

On December - 29 - 2011

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