Acute Pancreatitis (Pancreatitis)

What is Acute Pancreatitis (Pancreatitis)?

Acute pancreatitis refers to a sudden inflammation of the pancreas and is a leading cause for hospital visits linked to digestive issues in the U.S. The severity of this illness can fluctuate greatly. In some cases, it might be mild and only require standard treatment. But in severe cases, it can lead to serious health risks and even death. The death rate for people with minor pancreatitis is 3%, but in severe cases, where the pancreas tissue dies off (known as necrosis), it can be as high as 20%. Diagnosing quickly is relatively easy, but predicting how the disease will progress and what outcome can be expected is much more difficult. The length of the disease is helpful in figuring out the best level of care.

The Atlanta classification system splits acute pancreatitis into two main groups:

1. Interstitial edematous acute pancreatitis is characterized by inflammation of the pancreas tissue and surrounding tissues near the pancreas.
2. Necrotizing acute pancreatitis is when there is degeneration and death of pancreas tissue and nearby tissue.

The disease is then subdivided into three types based on severity:

1. Mild acute pancreatitis, where there are no local or systemic complications, and no organ failure.
2. Moderately severe acute pancreatitis involves local complications and possibly organ failure, but for less than 48 hours.
3. Severe acute pancreatitis has persistent organ failure for more than 48 hours, involving one or more organs.

The pancreas is a digestive organ located in close proximity to the spine of the lower back. It lies between the beginning part of the small intestine on the right and the spleen on the left, positioned horizontally across your body. The pancreas itself is split into four parts: the head, neck, body, and tail. The head of the pancreas rests against the large vein that carries deoxygenated blood to the heart and the right kidney vein and is encompassed by the loop of the small intestine. The tail of the pancreas stretches to the part of the spleen where vessels and nerves enter. The pancreas has two main roles: it releases pancreatic juice into the small intestine through ducts to help with digestion, and it also releases vital hormones like insulin into the bloodstream.

What Causes Acute Pancreatitis (Pancreatitis)?

Acute pancreatitis is a health condition often triggered by gallstones, excessive alcohol consumption, and high levels of fat in the blood, known as hypertriglyceridemia.

It’s important to note that the commonness of each cause can differ widely depending on where you live in the world and your social and economic background. Here are some widespread causes of acute pancreatitis:

1. Gallstones
2. Alcohol use
3. Hypertriglyceridemia (high levels of blood fat)
4. Drug-induced pancreatitis
5. Unknown causes (Idiopathic)
6. Post-procedure, such as after certain types of surgeries
7. Ampullary stenosis – this used to be called sphincter of Oddi dysfunction type I
8. Autoimmune pancreatitis, types I (systemic IgG4 disease-related), and II

There are also many infectious conditions, lifestyle factors, and genetic disorders that can lead to acute pancreatitis. These include:

1. Several types of viruses and bacteria
2. Smoking
3. Physical injuries
4. Inbuilt anomolies like “annular pancreas”
5. Genetic conditions like hereditary pancreatitis, cystic fibrosis, and a1-antitrypsin deficiency
6. High calcium levels in the blood
7. Parasitic infections
8. Renal disease
9. Exposure to certain toxins such as those from scorpion bites or organophosphate poisoning
10. Vasculitis conditions such as polyarteritis nodosa, or systemic lupus erythematosus

The causes of acute pancreatitis are generally categorized into three groups — mechanical causes (like gallstones or duct obstruction), toxic and metabolic triggers (like alcohol, drug reactions, or high fat levels in the blood), and others (like infections or inherited conditions).

Risk Factors and Frequency for Acute Pancreatitis (Pancreatitis)

Acute pancreatitis, an inflammation of the pancreas, is becoming more common in the United States and globally. This increase might be due to more cases being discovered or an actual rise in the incidence rate because of growing metabolic syndrome and hypertriglyceridemia, a condition characterized by high levels of fat in the blood. Despite the rise in cases, the death rate from acute pancreatitis in the United States is decreasing, with recent studies showing it to be around 2%. Acute pancreatitis typically affects people in their 50s and 60s, but the risk of dying from it increases with age.

The rates of acute pancreatitis can vary between different geographic areas and socio-economic classes. This might be due to differences in alcohol consumption and the prevalence of gallstones, as these are the two primary causes of acute pancreatitis. In the United States, the number of cases ranges from 600 to 700 per 100,000 people, leading to 200,000 to 250,000 hospital discharges due to this condition every year.

• Acute pancreatitis is becoming more common in the United States and around the world.
• The increase may be due to more cases detected or a rise in metabolic syndrome and high blood fat levels.
• Despite the increased incidence, the death rate from acute pancreatitis is decreasing at around 2%.
• People in their 50s and 60s are most commonly affected by acute pancreatitis.
• However, the risk of death from this condition increases with age.
• Geography and socio-economic class can affect the incidence due to differences in alcohol use and gallstones, which are the main causes of this condition.
• The incidence in the United States is between 600 and 700 per 100,000 people.
• Each year, this condition leads to 200,000 to 250,000 hospital discharges.

Signs and Symptoms of Acute Pancreatitis (Pancreatitis)

Patients experiencing acute pancreatitis often report moderate to severe pain in the upper middle part of their abdomen, coupled with nausea and a loss of appetite. The type of pain varies depending on the cause; if it’s from a blocked bile duct, the pain is usually sharp and radiates to the back, starting quite suddenly. However, if the cause is metabolic or toxicological, such as from alcohol or certain medications, the pain tends to be more generalized and dull, starting off more slowly. Generally, it takes over five years of heavy drinking to cause alcohol-related pancreatitis and smoking is also recognized as a major risk factor.

It is important to delve into a patient’s family history, especially when common causes do not seem to apply, as there are uncommon genetic cases of pancreatitis that run in families. In patients suffering from severe pancreatitis, physical examinations often show fever, rapid heart rate, and low blood pressure. Furthermore, tenderness in the upper middle part of the abdomen can be observed, along with potential stiffness and decreased gut sounds. In extremely severe cases, there may be signs of internal bleeding, such as the Grey-Turner’s sign, marked by bruising at the sides, or Cullen’s sign, signified by bruising around the belly button due to internal bleeding.

Testing for Acute Pancreatitis (Pancreatitis)

The Revised Atlanta Classification outlines three criteria for diagnosing acute pancreatitis, and at least two of these must be met:

1. Elevated lipase or amylase levels, three times higher than the usual range.
2. Abdominal pain associated with pancreatitis.
3. Imaging of the abdomen shows signs of acute pancreatitis. 

To determine the root cause of acute pancreatitis, doctors typically begin with a preliminary evaluation and then conduct lab tests. In the first stage of the assessment, the doctor will inquire about your medical history. They will ask about things like gallstone disease symptoms, sudden weight loss or diabetes development, alcohol abuse history, past surgeries or trauma, high levels of triglycerides or calcium in the blood, autoimmune diseases, or a family history of recurrent acute pancreatitis.

If acute pancreatitis is suspected, several lab tests can be conducted. These can include blood tests for triglycerides and calcium levels, liver function tests, optional genetic testing for those with a strong family history of the disease, and abdominal ultrasound to assess any gallstones or bile duct enlargement. For patients with moderate to severe symptoms, a chest x-ray is performed to check for fluid in the lungs, which could indicate a more serious form of the disease.

In cases where the diagnosis isn’t clear-cut, but pancreatitis is still suspected, a CT scan with a contrast agent might be advised to either confirm or rule out the condition. A CT scan would also be performed if a patient’s condition worsens or fails to improve after two days of adequate fluid treatment, as it can check for necrosis, or tissue death.

A detailed evaluation for suspected acute pancreatitis includes:

History:
– Gallstone disease
– Alcohol abuse
– Medication use
– Weight loss history
– New onset diabetes
– Prior surgery or trauma
– High blood levels of triglycerides or calcium
– Autoimmune disease
– Genetic causes

Physical Examination:

– Fever
– Rapid heart rate
– Tenderness or a noticeable mass in the upper stomach area
– Jaundice
– Symptoms known as Cullen’s or Turner’s sign

Laboratory Evaluation:

– High levels of serum amylase and lipase
– High white blood cell count
– High levels of serum triglycerides
– Low calcium levels (hypocalcemia)
– Elevated levels of serum bilirubin, AST, ALT, LDH, and alkaline phosphatase

Imaging:
– Chest and abdominal X-rays
– Abdominal ultrasound
– CT scan of the abdomen

Serological and Genetic Tests:
– IgG4
– PRSS1, SPINK1, CFTR, CTRC, CASR, Claudin-2

If the cause of pancreatitis remains uncertain even after these tests, you may be referred to a gastroenterology specialist for more advanced testing. This could include magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS). MRCP is safer since it’s not invasive and doesn’t require contrast. However, EUS is usually the preferred method as MRCP is less sensitive in detecting small biliary stones and chronic pancreatitis. If these tests can’t be done, then a CT scan specifically for the pancreas is chosen. An endoscopic retrograde cholangiopancreatography (ERCP) is not a routine procedure and is only conducted for patients with abnormal findings on an MRCP or EUS.

Treatment Options for Acute Pancreatitis (Pancreatitis)

Treating acute pancreatitis starts with early and aggressive fluid replacement. The usual treatment option involves giving the patient a fluid called Lactated Ringer’s solution in an initial batch of 15 to 20 mL per kg of body weight. This is followed by a steady rate of 3 mL/kg per hour (or about 250 to 500 mL per hour) in the first 24 hours. Monitoring is done regularly – usually every 4 to 6 hours – to adjust the fluid rate. If the patient does not respond to this initial fluid replacement, it may indicate a serious complication called Multiple Organ Dysfunction Syndrome, and the patient’s care level may need to be increased. However, a recent study suggests that aggressive fluid replacement doesn’t always improve patient outcomes and may sometimes cause fluid overload.

Another important way to manage acute pancreatitis is through diet. Doctors used to recommend patients not eat or drink until symptoms like abdominal pain, vomiting, and nausea improved. However, recent studies show that it’s safe – and may even be beneficial – to start feeding patients with mild pancreatitis early. Initially, patients are given a soft, low-residue, and low-fat diet which is switched to a normal diet as soon as they can tolerate it. In severe cases where patients can’t eat or drink, tube feeding is used. This works better than giving nutrition through a vein because it helps minimize bacterial migration by maintaining the stomach lining.

Usually, preemptive antibiotics aren’t needed. If there’s suspicion of an infection, doctors will start antibiotics until culture results come in. The use of antibiotics is limited to cases of infected pancreatic necrosis.

A significant priority in managing acute pancreatitis is pain management. Almost all patients experience abdominal pain at some point. Luckily, there are several pain management strategies available, like the World Health Organization’s pain relief ladder. However, the type, dosage, method of administration, and frequency of analgesics are not always clearly defined. The options include opioids like fentanyl and meperidine, and non-steroid anti-inflammatory drugs. Despite past concerns, recent studies show that opioids don’t pose a risk of complications or major adverse events and can be used safely in patients with acute pancreatitis.

Lastly, further treatment depends on what’s causing the pancreatitis. If gallstones are the cause, removal of the gallbladder is strongly recommended. For high blood fat levels, the goal is to reduce these levels to less than 500 mg/dL using methods like blood-cleansing procedures and insulin drips.

Acute pancreatitis can also cause local complications. Early ones (less than four weeks) include fluid accumulation around the pancreas and pancreatic necrosis – death of pancreatic tissue. Late complications (more than four weeks) include the formation of pancreatic pseudocysts and walled-off necrosis. If infected or rapidly enlarging, these pseudocysts need to be drained. Choices for drainage include endoscopic (through the abdomen or the pupil of the eye) or percutaneous (through a puncture in the skin), with the endoscopic method being the preferred one.

Managing necrotic collections is challenging. If they cause symptoms, it’s intervened, and around a third of these become infected. This can worsen the condition, prolong recovery, and increase the chance of fatality. If suspected, antibiotics are initiated and surgical removal of dead tissue performed if antibiotics aren’t effective. Patients in stable condition continue antibiotics for 4 to 6 weeks, and the dead tissue is removed once the surrounding tissues mature. The first choices for this procedure are less invasive ones, with surgical removal only reserved for unsuccessful cases.

What else can Acute Pancreatitis (Pancreatitis) be?

When trying to diagnose the cause of stomach pain, doctors consider that it may be due to acute pancreatitis – an inflammation of the pancreas. But a detailed medical history and physical exam can help them identify the exact cause of the pain. Doctors also consider many other conditions, including:

• Peptic ulcer disease (ulcers in the stomach or small intestine)
• Cholangitis (infection of the bile duct)
• Cholecystitis (inflammation of the gallbladder)
• Bowel obstruction
• Perforation (hole) in the bowel
• Mesenteric ischemia (poor blood flow to the intestines)
• Acute hepatitis (liver inflammation)
• Diabetic ketoacidosis (a serious diabetes complication)
• Basilar pneumonia (lung infection)
• Heart attack
• Aortic dissection (a tear in the aorta, a major blood vessel)
• Renal colic (pain caused by kidney stones)

To diagnose pancreatitis, doctors often measure the patient’s lipase level, a pancreas enzyme – if it’s three times higher than normal, it’s very likely the pain is due to pancreatitis. An ultrasound scan of the abdomen can identify gallbladder issues, while a CT scan can detect poor blood supply to the intestines. If a patient has risk factors for heart disease, doctors may also rule out a heart condition since it can sometimes cause stomach pain. Doctors always consider aortic dissection because although its pain is usually more severe and tearing, it needs urgent attention.

What to expect with Acute Pancreatitis (Pancreatitis)

The mortality rate for acute pancreatitis is roughly 1 to 2%. The rate is much higher for severe acute pancreatitis, but the exact number is uncertain.

Judging the severity of the condition and estimating the outcome are key to deciding the appropriate level of care. Although several clinical prediction scales have been developed and validated, they are complicated to use and require 48-hour data. According to the International Association of Pancreatology and American Pancreatic Association, patients with a systemic inflammatory response syndrome (SIRS) at admission and persistent for 48 hours have a higher likelihood of severe acute pancreatitis. If SIRS persistently occurs, the mortality rate increases to 25%, compared to 8% for a temporary SIRS.

The Bedside Index for Severity in Acute Pancreatitis (BISAP) is a relatively recent and simple tool, used to predict the severity and mortality of acute pancreatitis. It measures several factors, including one point for each: a BUN level over 25mg/dl, any abnormal mental status, evidence of SIRS, and age over 60 years. A BISAP score of 0 to 2 points suggests a lower mortality rate of less than 2%, while a score of 3 to 5 points suggests a higher mortality rate of over 15%.

On the other hand, the modified CT Severity Index (CTSI) helps predict mortality and spot any pancreatic necrosis, which is a predictor of high mortality. This score, combined with specific pancreatitis indicators, helps to determine the pancreatitis grade and guide the treatment. A total score of 0 to 2 means the condition is mild, 4 to 6 suggests it’s moderate, and 8 to 10 indicates it’s severe.

Possible Complications When Diagnosed with Acute Pancreatitis (Pancreatitis)

Here are the potential complications that may occur with acute pancreatitis:

• Abdominal compartment syndrome
• Gastric varices
• Acidosis
• Ileus
• Acute renal failure
• Mesenteric venous thrombosis
• Acute respiratory distress syndrome
• Pancreatic abscess
• Ascites
• Pancreatic arterial pseudoaneurysm
• Bowel infarction
• Pancreatic necrosis
• Chronic pancreatitis
• Pseudocyst formation
• Disseminated intravascular coagulation
• Splenic venous thrombosis
• Hemorrhagic pancreatitis

Preventing Acute Pancreatitis (Pancreatitis)

Patients should be educated about factors that may worsen their condition:

• If they have an episode, they shouldn’t try to drive themselves to the hospital.
• If they have pancreatitis and they consume alcohol, they may require assistance to quit drinking.
• They should carefully follow any instructions for taking medication.
• A low-fat diet is recommended – a dietitian can help with recommendations and meal plans.
• If they can, they should learn how to measure their own pulse and know when to seek medical help based on the readings.
• They should reach out to their healthcare provider if they encounter any of the following symptoms:
• Fever
• Severe belly pain
• Feeling sick to the stomach or throwing up
• Feeling dizzy or light-headed
• Yellowing of the skin or eyes, which could indicate jaundice
• Fast pulse
• Shallow, quick breathing
• Swellings or sensitive spots in the belly