Pancreatitis



Last Review Date: September 5, 2017


What is it?

 

Pancreatitis can be an acute or chronic inflammation of the pancreas. Acute attacks often are characterised by severe abdominal pain that radiates from the upper stomach through to the back and can cause effects ranging from mild pancreas swelling to life-threatening organ failure. Chronic pancreatitis is a progressive condition that may involve a series of acute attacks, causing intermittent or constant pain as it permanently damages the pancreas.

The pancreas is a narrow, flat organ located deep in the abdominal cavity behind the stomach and below the liver. It is composed of exocrine tissues, which make powerful enzymes that help digest fats, proteins, and carbohydrates in the small intestine and bicarbonates that help neutralise stomach acids. It also has ‘islets’ of endocrine tissue that produce the hormones insulin and glucagon, vital for the transportation of glucose into the body's cells. For more detail see "What is the pancreas?" in Diseases of the pancreas.

Normally, the pancreatic digestive enzymes are created and carried into the duodenum (first part of the small intestine) in an inactive form. It is thought that during pancreatitis attacks, these enzymes are prevented or inhibited from reaching the duodenum, become activated while still in the pancreas, and begin to auto-digest and destroy the pancreas.

While the exact mechanisms of pancreatitis are not well understood, it is more frequent in men than in women and is known to be induced by chronic alcohol abuse and gall stones (gallstones that block the bile duct where it runs through the head of the pancreas and meets the pancreatic duct, just as it joins the duodenum). These two conditions are responsible for about two thirds of acute pancreatitis attacks and figure prominently in chronic pancreatitis. In the remainder of cases the cause is idiopathic (unknown, around 15-25 per cent) or may be due to conditions such as:

  • Hypertriglyceridaemia, hyperparathyroidism or hypercalcaemia
  • Drugs such as valproic acid and oestrogen
  • Viral infections such as mumps, Epstein-Barr, and hepatitis A and B 
  • Trauma to the pancreas

Signs and symptoms

Acute pancreatitis

About 75% of acute pancreatitis attacks are considered mild, although they may cause the patient severe abdominal pain, nausea, vomiting, weakness and jaundice. These attacks cause local inflammation, swelling, and haemorrhage that usually resolves itself with appropriate treatment and does little or no permanent damage.

About 25% of the time, complications develop, such as tissue necrosis, infection, hypotension (low blood pressure), difficulty breathing, shock, and kidney or liver failure. It is important to see your doctor if you have symptoms that suggest pancreatitis because symptom severity does not necessarily reflect the amount of damage that may be occurring and because other conditions (requiring different treatments) may cause similar symptoms.

Chronic pancreatitis

Patients with chronic pancreatitis may have recurring attacks with symptoms similar to those of acute pancreatitis; these attacks increase in frequency as the condition progresses. Over time, the pancreas tissue becomes increasingly scarred and the cells that produce digestive enzymes are destroyed, causing pancreatic insufficiency (inability to produce enzymes and digest fats and proteins), weight loss, malnutrition, ascites, pancreatic pseudocysts (fluid pools and destroyed tissue that can become infected), and fatty stools. As the cells that produce insulin and glucagon are destroyed, the patient may become permanently diabetic.

Pain with chronic pancreatitis may be severe and continual or intermittent. It may be made worse with eating, drinking and imbibing alcohol.


Tests

  • Lipase (the pancreatic enzyme that, along with bile from the liver, digests fats) increases in the blood within 4 to 8 hours of the beginning of an acute attack and peaks at 24 hours. It may rise to several times its normal level and remains elevated longer than amylase. As cells are destroyed with chronic pancreatitis and as lipase production drops to less than 10% of the normal level, steatorrhoea (fatty, foul-smelling stools) will form.
  • Amylase (the pancreatic enzyme responsible for digesting carbohydrates) used to be the most common blood test for acute pancreatitis but now is being replaced by lipase. It increases from 2 to 12 hours after the beginning of symptoms and peaks at 12 to 72 hours. It may rise to 5 to 10 times the normal level and will usually return to normal within a week. It is less specific for pancreatitis than lipase as amylase is also produced in other tissues (e.g. salivary glands). Amylase also may be monitored with chronic pancreatitis, it will often be moderately elevated until the cells that produce it are destroyed.
  • Stool chymotrypsin tests and more commonly stool elastase enzyme tests are used to check for pancreatic insufficiency and may be part of a work-up for chronic pancreatitis. Immunoreactive trypsin (IRT) is a blood test that may be used to check pancreatic sufficiency in those with chronic pancreatitis. Faecal fat may also be used to check for pancreatic sufficiency.

Other tests that may be used to check for complications of acute pancreatitis include:

Non-laboratory tests may include:

  • Abdominal ultrasound
  • CT (computed tomography) scan to look for complications of pancreatitis such as necrosis or pseudocyst formation
  • ERCP (endoscopic retrograde cholangiopancreatography), a flexible scope used to inject contrast dye into the bile, pancreatic and hepatic ducts from their opening in the duodenum to see and sometimes assist to remove gallstones
  • MRI (magnetic resonance imaging)
  • Secretin testing (not widely available) in which a tube is positioned in the duodenum to collect pancreatic secretions stimulated by IV secretin to test for pancreatic sufficiency in chronic pancreatitis

Prevention, early detection, and treatment


Pancreatitis demands prompt medical attention. During an acute attack, there is the potential for the pancreas to be destroyed within a matter of hours and complications can be life-threatening.

Acute pancreatitis

It usually is not possible to prevent most single incident acute pancreatitis attacks or to detect them early. If it is due to established alcoholism (it usually takes several years of moderate to heavy alcohol consumption to lead to this point), the attack is usually precipitated by an episode of binge drinking. While the acute attack may not have been preventable (given that the patient is still drinking), there may or may not have been earlier warning pains that could have been addressed by seeking medical attention. In the case of gallstones or other causes of acute pancreatitis, there usually is no warning before the attack.

Treatment usually consists of pain control, intravenous fluids and fasting and ‘resting’ the pancreas for several days to a few weeks until symptoms subside. Patients are hospitalised during this time period and all fluids and nutrition are given intravenously (IV). Complications are monitored and treated as they occur, such as with antibiotics for infection or with low calcium levels. If the acute pancreatitis is due to gallstones, ERCP may be required to remove the gallstone and surgery may be necessary to remove the gallbladder following the bout of acute pancreatitis to prevent reocurrence.

Chronic pancreatitis

Chronic pancreatitis is treated by trying to prevent future attacks, minimising pancreatic damage, and by addressing damage already done. Cessation of alcohol is critical in helping to prevent additional attacks. Cessation of smoking is also important. A low fat diet and small meal sizes may be prescribed to reduce the burden on the pancreas and pancreatic enzyme supplements may be given by mouth to alleviate insufficiencies and reduce malabsorption. The patient also may need to supplement fat-soluble vitamins (vitamins A, D, E and K) and calcium. Glucose (blood sugar) is often monitored, and insulin injections may be given if the patient has become diabetic (treatment with tablets does not usually work in these cases).

Pain control is an important part of treatment as patients may have ongoing moderate to severe pain. Patients may be given narcotics and medications to control nerve pain. As time progresses and pancreas function diminishes, the pain level may drop.

Surgery may be necessary in some cases to remove part or all of the pancreas and/or to remove or bypass obstructions. It should be noted that the pancreas is very difficult to operate on and requires a surgeon experienced in pancreatic surgery.

Those with chronic pancreatitis are at a higher risk for developing pancreatic cancer


Related pages

On this site
Tests: Amylase, lipase, sweat chloride, trypsin, trypsinogen
Conditions: Alcoholism, cystic fibrosis, diabetes, pancreas cancer, pancreatic disease, pancreatic insufficiency

Elsewhere on the web
Healthdirect Australia: Pancreatic diseases
Pancreas.org (US): Patient Information
University of Maryland Medical Center (US): Pancreatitis