Acute Pancreatitis And Chronic Pancreatitis Causes, Symptoms, Diagnosis, Treatment

Acute Pancreatitis And  Chronic Pancreatitis Causes, Symptoms, Diagnosis, Treatment


What is pancreatitis?


Pancreatitis is an inflammation of the pancreas. The pancreas is a large gland behind the stomach and close to the duodenum. The duodenum is the upper part of the small intestine. The pancreas secretes digestive enzymes into the small intestine through a tube called the pancreatic duct. These enzymes help digest fats, proteins, and carbohydrates in food. The pancreas also releases the hormones insulin and glucagon into the bloodstream. These hormones help the body use the glucose it derives from food for energy.

Normally, digestive enzymes do not become active until they reach the small intestine, where they begin digesting food. But if these enzymes become active inside the pancreas, they start "digesting" it.

Acute pancreatitis occurs suddenly and lasts for a short period of time and usually resolves. Chronic pancreatitis does not resolve itself and results in a slow destruction of the pancreas. Either form can cause serious complications. In severe cases, bleeding, tissue damage, and infection may occur. Cysts, which are fluid-filled sacs of tissue, may also develop. And enzymes and toxins may enter the bloodstream, injuring the heart, lungs, and kidneys, or other organs.

Acute Pancreatitis


Some people have more than one attack and recover completely after each, but acute pancreatitis can be a severe, life-threatening illness with many complications. About 80,000 cases occur in the United States each year; some 20 percent of them are severe.

Acute pancreatitis is usually caused by drinking too much alcohol or by gallstones. A gallstone can block the pancreatic duct, trapping digestive enzymes in the pancreas and causing pancreatitis. Some prescription drugs, pancreatic or intestinal abnormalities, abdominal trauma, or surgery can also cause pancreatitis. In some cases, recurrent pancreatitis is hereditary and caused by mutations in genes. In rare cases, the disease may result from infections, such as mumps, and in about 15 percent of the cases, the cause is unknown.

What are the causes of acute pancreatitis?


Acute pancreatitis is inflammation of the pancreas that occurs suddenly and usually resolves in a few days with treatment. Acute pancreatitis can be a life-threatening illness with severe complications. Each year, about 210,000 people in the United States are admitted to the hospital with acute pancreatitis.1 The most common cause of acute pancreatitis is the presence of gallstones - small, pebble-like substances made of hardened bile - that cause inflammation in the pancreas as they pass through the common bile duct. Chronic, heavy alcohol use is also a common cause. Acute pancreatitis can occur within hours or as long as 2 days after consuming alcohol. Other causes of acute pancreatitis include abdominal trauma, medications, infections, tumors, and genetic abnormalities of the pancreas.

Symptoms of Acute Pancreatitis


Acute pancreatitis usually begins with pain in the upper abdomen that may last for a few days. The pain may be severe and may become constant--just in the abdomen--or it may reach to the back and other areas. It may be sudden and intense or begin as a mild pain that gets worse when food is eaten. Someone with acute pancreatitis often looks and feels very sick. Other symptoms may include

  • swollen and tender abdomen
  • nausea
  • vomiting
  • fever
  • rapid pulse
Severe cases may cause dehydration and low blood pressure. The heart, lungs, or kidneys may fail. If bleeding occurs in the pancreas, shock and sometimes even death follow.

What happens in acute pancreatitis?


The digestive chemicals (enzymes) that are made in the pancreas become activated and start to 'digest' parts of the pancreas. They are normally only activated after they reach the part of the gut just after the stomach (the duodenum). This leads to a range of chemical reactions that cause inflammation in the pancreas. How the above causes actually trigger this sequence of events is not clear.

  • In most cases (about 4 in 5), the inflammation is mild and settles within a week or so. Symptoms may be bad for a few days but then settle and the pancreas fully recovers.
  • In some cases (about 1 in 5) the inflammation quickly becomes severe. Parts of the pancreas and surrounding tissues may die (necrose). Pancreatic enzymes and chemicals may get into the bloodstream and cause inflammation and damage to other organs in the body. This can lead to shock, respiratory failure, kidney failure and other complications. This is a very serious situation which can be fatal.

Diagnosis for Acute Pancreatitis


Besides asking about a person's medical history and doing a physical exam, a doctor will order a blood test to diagnose acute pancreatitis. During acute attacks, the blood contains at least three times more amylase and lipase than usual. Amylase and lipase are digestive enzymes formed in the pancreas. Changes may also occur in blood levels of glucose, calcium, magnesium, sodium, potassium, and bicarbonate. After the pancreas improves, these levels usually return to normal.

A doctor may also order an abdominal ultrasound to look for gallstones and a CAT (computerized axial tomography) scan to look for inflammation or destruction of the pancreas. CAT scans are also useful in locating pseudocysts.

What happens if acute pancreatitis is suspected?


You will need to be admitted to hospital if your doctor suspects that you have acute pancreatitis. There are lots of causes of tummy (abdominal) pain and being sick (vomiting) so tests are done to rule out other problems and to confirm the diagnosis. Blood tests can check the blood level of amylase and/or lipase (these are enzymes made by the pancreas). Although not 100% reliable, a high blood level of these enzymes strongly suggests that pancreatitis is the cause of your symptoms.

An ultrasound scan may be done to look for a gallstone if this is the suspected underlying cause. Other types of scans may be needed if an ultrasound scan does not give a clear answer.

Treatment for Acute Pancreatitis


Treatment depends on how bad the attack is. If no complications in the form of kidney failure or lung problems occur, acute pancreatitis usually improves on its own. Treatment is designed to support vital functions and prevent complications. A hospital stay will be necessary so that fluids can be replenished intravenously.

Acute pancreatitis can also cause breathing problems. Many people develop hypoxia, which means that cells and tissues are not receiving enough oxygen. Doctors treat hypoxia by giving oxygen through a face mask. Despite treatment, some people still experience lung failure and require a ventilator.

If pancreatic cysts occur and are considered large enough to interfere with the pancreas's healing, your doctor may drain or surgically remove the cysts.

Sometimes a person cannot stop vomiting and needs to have a tube placed in the stomach to remove fluid and air. In mild cases, a person may not eat for 3 or 4 days and instead may receive fluids and pain relievers through an IV (intravenous) line.

Unless the pancreatic duct or bile duct is blocked by gallstones, an acute attack usually lasts only a few days. In severe cases, a person may be fed intravenously for 3 to 6 weeks while the pancreas slowly heals. This process is called total parenteral nutrition. However, for mild cases of the disease, total parenteral nutrition offers no benefit.

If an infection develops, the doctor may prescribe antibiotics. Surgery may be needed for extensive infections. Surgery may also be necessary to find the source of bleeding, to rule out problems that resemble pancreatitis, or to remove severely damaged pancreatic tissue.

Before leaving the hospital, a person will be advised not to drink alcohol and not to eat large meals. After all signs of acute pancreatitis are gone, the doctor will try to decide what caused it in order to prevent future attacks. In some people, the cause of the attack is clear, but in others, more tests are needed.

Gallstones and Pancreatitis


Gallstones can cause pancreatitis and they usually require surgical removal. Ultrasound or a CAT scan can detect gallstones and can sometimes give an idea of the severity of the pancreatitis. When gallstone surgery can be scheduled depends on how severe the pancreatitis is. If the pancreatitis is mild, gallstone surgery may proceed within about a week. More severe cases may mean gallstone surgery is delayed for a month or more.

After the gallstones are removed and inflammation goes away, the pancreas usually returns to normal.

Preventing acute pancreatitis 


Gallstones

The most effective way of preventing gallstones is eating a healthy low-fat diet that includes plenty of fresh fruit and vegetables (at least five portions a day). Your diet should also include whole grains, which are found in wholemeal bread, oats and brown rice. This will help lower the amount of cholesterol in your body.
Being overweight also increases your chances of developing gallstones, so maintaining a healthy weight by eating a balanced diet and taking plenty of regular exercise can also help reduce your risk of the developing condition.

Alcohol

Limiting the amount of alcohol you drink can help prevent your pancreas being damaged and reduce your risk of developing acute pancreatitis. It can also lower your chances of developing other serious conditions, such as liver cancer.

It is recommended that men should not drink more than 3-4 units of alcohol a day and women should not drink more than 2-3 units a day. A unit of alcohol is equal to about half a pint of normal strength lager, a small glass of wine or a pub measure (25ml) of spirits.

Chronic Pancreatitis


If injury to the pancreas continues, from drinking alcohol, for example, chronic pancreatitis may develop. Chronic pancreatitis occurs when digestive enzymes attack and destroy the pancreas and nearby tissues, causing scarring and pain. The usual cause of chronic pancreatitis is many years of alcohol abuse, but the chronic form may also be triggered by only one acute attack, especially if the pancreatic ducts are damaged. The damaged ducts cause the pancreas to become infamed, tissue to be destroyed, and scar tissue to develop.

Damage from alcohol abuse may not appear for many years, and then a person may have a sudden attack of pancreatitis. In 70 to 80 percent of adult patients, chronic pancreatitis appears to be caused by alcoholism. This form is more common in men than in women and often develops between the ages of 30 and 40.

Chronic pancreatitis may also occur when the pancreatic duct is blocked or narrowed because of trauma or because pseudocysts have formed. Pseudocysts are cyst-like buildups of pancreatic fluid in the duct.

Some drugs can cause chronic pancreatitis too. In many cases, however, the cause is unknown. People with chronic pancreatitis may have one or even all three of the following problems: pain, diabetes, or malabsorption of food leading to weight loss.

In some cases, chronic pancreatitis is inherited. Hereditary pancreatitis usually begins in childhood but may not be diagnosed for several years. A person with hereditary pancreatitis usually has the typical symptoms that come and go over time. Episodes last from 2 days to 2 weeks.

A determining factor in the diagnosis of hereditary pancreatitis is two or more family members with pancreatitis in more than one generation. Treatment for individual attacks is usually the same as it is for acute pancreatitis. Any pain or nutrition problems are treated just as they are for chronic pancreatitis. Surgery can often ease pain and help manage complications.

What causes chronic pancreatitis?


The most common cause of chronic pancreatitis is long-term excessive alcohol consumption.

There's a direct relationship between the amount of alcohol consumed and the risk of developing chronic pancreatitis.

Other causes include:
  • repeated attacks of pancreatitis associated with gallstones
  • high levels of calcium in the blood
  • abnormalities in anatomy which are usually present at birth
  • cystic fibrosis
  • high blood fats (hypertriglyceridaemia)
  • in rare cases, some drugs can cause pancreatitis
  • in a number of cases no specific cause can be identified, a condition known as idiopathic pancreatitis.


Symptoms of Chronic Pancreatitis


Some people have no pain, but most do. Pain in the back and abdomen may be constant and disabling. In certain cases, abdominal pain goes away as the condition advances, probably because the pancreas is no longer making digestive enzymes.

People with chronic disease often lose weight, even when their appetite and eating habits are normal. The weight loss occurs because the body does not secrete enough pancreatic enzymes to break down food, so nutrients are not absorbed normally. Poor digestion leads to excretion of fat, protein, and sugar into the stool. If the insulin-producing cells of the pancreas (islet cells) have been damaged, diabetes may also develop at this stage.

Diagnosis for Chronic Pancreatitis


Diagnosis may be difficult, but new techniques can help. Pancreatic function tests help a doctor decide whether the pancreas is still making enough digestive enzymes. Using ultrasonic imaging, endoscopic retrograde cholangiopancreatography (ERCP), and CAT scans, a doctor can see problems indicating chronic pancreatitis. Such problems include calcification of the pancreas, in which tissue hardens from deposits of insoluble calcium salts. In more advanced stages of the disease, when diabetes and malabsorption occur, a doctor can use a number of blood, urine, and stool tests to help diagnose chronic pancreatitis and to monitor its progression.

Is chronic pancreatitis dangerous?


The major problem with chronic pancreatitis is pain control. The pain of chronic pancreatitis may be constant, severe and long lasting.

This may require the use of morphine-like drugs (pethidine, morphine (eg MST continus) and diamorphine).

There is always the risk of addiction to these drugs, particularly if their use is not controlled.

Chronic pancreatitis is associated with a reduction in life expectancy.

Only half of the patients with a diagnosis of chronic pancreatitis will survive for longer than seven years following diagnosis.

There is also an increased rate of cancer of the pancreas in patients with chronic pancreatitis and this accounts for a fifth of the deaths.

Other causes of death include complications of diabetes and complications from alcoholism.

Treatment for Chronic Pancreatitis


Relieving pain is the first step in treating chronic pancreatitis. The next step is to plan a diet that is high in carbohydrates and low in fat.

A doctor may prescribe pancreatic enzymes to take with meals if the pancreas does not secrete enough of its own. The enzymes should be taken with every meal to help the body digest food and regain some weight. Sometimes insulin or other drugs are needed to control blood glucose.

In some cases, surgery is needed to relieve pain. The surgery may involve draining an enlarged pancreatic duct or removing part of the pancreas.

For fewer and milder attacks, people with pancreatitis must stop drinking alcohol, stick to their prescribed diet, and take the proper medications.

Medicines


For chronic pancreatitis, your GP may prescribe the following medicines to help you manage your condition.

  • Painkillers to relieve chronic pain.
  • Synthetic pancreatic enzymes, such as pancreatin (eg Creon, Nutrizym, Pancrex), to replace the enzymes your pancreas can no longer make and to help reverse problems with absorption of fat
  • Insulin or other medicines to control your blood sugar level. If your pancreas isn't producing enough insulin, you may develop type 1 diabetes.
Always read the patient information leaflet that comes with your medicine and if you have any questions, ask your GP or pharmacist for advice.

Preventing symptoms worsening


Patients with chronic pancreatitis should avoid alcohol altogether.

If the pancreatitis is due to excess alcohol consumption, then this is essential.

If an underlying cause has been identified then this should be treated. Your doctor may recommend removal of the gall bladder if pancreatitis is thought to be caused by gallstones.

Rare disorders of calcium metabolism and of fat metabolism will be treated appropriately.

Preventing attacks for Chronic Pancreatitis


If a cause for attacks of pancreatitis can be found this should be treated.

It's vitally important drinking alcohol should be stopped in those patients where it is a factor.

Surgical removal of the gallbladder (cholecystectomy) may be advised for some patients.

Gallstones in the common bile duct between the liver and duodenum can be removed at ERCP.

Occassionally other endoscopic (internal tube) therapy may be used. Cutting the lower end of the bile duct to improve bile flow can reduce attacks of pancreatitis in some patients.

Removal of stones in the pancreatic duct to reduce blockage or insertion of stents to drain the pancreas can be used. These are difficult techniques that are usually performed in centres specialising in the pancreas as results can not be guaranteed and complication are always a risk.

Resting the pancreas by giving pancreatic supplements by mouth, such as Creon, may help reduce attacks of pancreatitis.

Control pain for Chronic Pancreatitis


This is a very important aspect of the treatment of chronic pancreatitis.

Pancreatic pain varies in severity from mild (controllable with simple analgesics such as paracetamol (eg Panadol)) to severe (requiring morphine-like drugs for control).

Severe pancreatic pain can be constant, unremitting and lead to depression and even suicide.

In addition to the preventive measures listed above, the basic principle is to use the drug lowest down the analgesic ladder which controls the pain.

Since the pain is often worse at night and since both body and mind are at their lowest ebb in the early hours of the morning, the lowest rung of the analgesic ladder may be pethidine or morphine (eg MST continus tablets).

Since the pain is chronic and severe, there's a fine line between adequate analgesia and addiction.

Newer pain relieving medicines, such as pregabalin, may be more effective for this nerve pain and have fewer side-effects. Risk of addiction is also lower.

Antidepressants may reduce the requirement for pain killers or even help with pain relief themselves.

Antidepressants may also help with the depression, so often associated with chronic pain itself.

Pain management in chronic pancreatitis often requires specialist help.

Most hospitals now have a dedicated pain clinic often run by anaesthetists with particular skills and helped by trained nurses.

Your GP or hospital gastroeneterologist can help with referral to the pain clinic.

As well as maximising the benefit from drug therapy the pain specialists may such blocking the nerves to the pancreas to reduce pain.

It involves the injection of agents via needle into and around the pancreas but requires great skill and careful consideration.


Hope through research


The National Institute of Diabetes and Digestive and Kidney Diseases' Division of Digestive Diseases and Nutrition supports basic and clinical research into gastrointestinal diseases, including the causes of pancreatitis and cell injury in the gastrointestinal tract. In addition, researchers are studying the genetics of hereditary pancreatitis and risk factors such as cystic fibrosis.

Participants in clinical trials can play a more active role in their own health care, gain access to new research treatments before they are widely available, and help others by contributing to medical research. For information about current studies, visit www.ClinicalTrials.gov.