What is Alcoholic Pancreatitis (Pancreatitis)?
Alcohol use syndrome is a leading cause of both acute and chronic pancreatitis, two conditions impacting the pancreas.
Acute pancreatitis is a condition that happens due to the destruction of pancreas cells by inflammatory cells. Doctors typically diagnose it when a patient shows specific symptoms, has high lipase levels, and peculiar findings on imaging tests. Since there’s no specific medication for this disease, the treatment mainly involves supportive care. Acute pancreatitis has different outcomes: it can completely heal by itself, lead to temporary organ failure, or, in severe cases, cause full-body inflammation and multiple organ failures. In such serious situations, patients might need antibiotics and other more aggressive treatments.
On the other hand, chronic pancreatitis is usually linked to repeated bouts of acute pancreatitis, and it results in various serious conditions like pancreatic insufficiency, fat in stool (steatorrhea), diabetes, hardening of the pancreas, and fibrosis. Although alcohol and its by-products don’t directly lead to this condition, they can make the pancreas more susceptible to damage. Therefore, one major way to prevent repeat attacks is to counsel patients on how to quit alcohol and smoking.
What Causes Alcoholic Pancreatitis (Pancreatitis)?
Drinking alcohol regularly is responsible for 17% to 25% of sudden pancreatitis cases globally, making it the second most common cause after gallstones. This typically happens in those who have been using alcohol significantly (about 4-5 drinks per day) over a period of at least five years. It seldom results from a single incident of excessive drinking. Interestingly enough, the type of alcoholic beverage doesn’t change the risk of developing pancreatitis.
Although alcohol does make the pancreas more prone to damage due to factors like genetics, unhealthy diets, smoking, and infections, very few people (less than 5%) with alcohol use disorder actually develop pancreatitis. However, heavy smokers who drink more than 400g of alcohol per month are four times more likely to get acute pancreatitis.
Chronic alcohol use is the leading cause of persistent pancreatitis, accounting for about 40% to 70% of all cases. It also increases the likelihood of developing pancreatic cancer. Chronic drinkers are more likely to have recurring bouts of pancreatitis, which can lead to chronic pancreatitis. Most studies even suggest that some degree of damage to the pancreas already exists when acute pancreatitis sets in.
In men, the risk of both acute and chronic pancreatitis rises with increased alcohol use. However, the relationship between alcohol use and the onset of acute pancreatitis is not as straightforward in women.
Risk Factors and Frequency for Alcoholic Pancreatitis (Pancreatitis)
Acute pancreatitis is one of the leading reasons people are admitted to hospitals for stomach-related issues in the U.S. It’s a costly condition, with a total of 2.6 billion dollars spent on treating it every year. It also leads to 279,000 hospital admissions annually. Most patients (80%) have a mild form of the disease which doesn’t last long. Pancreatitis related to alcohol consumption is a bigger issue in western countries and Japan.
- The number of new cases of acute pancreatitis every year ranges from 13 to 45 per 100,000 people.
- Chronic pancreatitis affects about 5 to 12 out of every 100,000 people annually.
- It’s most common in males aged 35 to 54.
- The death rate for pancreatitis is about 2%, generally associated with severe episodes.
Signs and Symptoms of Alcoholic Pancreatitis (Pancreatitis)
Alcohol-induced pancreatitis is a condition that often happens due to long-term alcohol use. It shares similar characteristics with both acute and chronic pancreatitis.
The symptoms of this condition include:
- Abdominal pain, often in the upper stomach area, that may spread to the back. This pain can be less sudden and less focused in alcohol-related pancreatitis compared to pancreatitis caused by gallstones.
- Nausea or vomiting
- Loss of appetite
- Chronic pancreatitis may additionally cause poor absorption of fat leading to fatty stools, and diabetes due to damage to insulin-producing cells in the pancreas.
Upon physical examination, the doctor might observe the following:
- No abnormalities (in some cases)
- A natural response to protect the painful area
- Tenderness due to inflammation
- Yellowing of the skin and eyes (Jaundice)
- In severe circumstances, signs such as Cullen’s sign (bruising around the belly button) or Grey Turner’s sign (bruising on the flank or sides) may appear due to severe internal bleeding.
Serious manifestations of acute pancreatitis can involve inflammation of the abdominal lining, severe infection, a serious lung condition called acute respiratory distress syndrome, or shock.
Testing for Alcoholic Pancreatitis (Pancreatitis)
To diagnose acute pancreatitis, two out of three specific criteria need to be present, according to the Revised Atlanta Classification system. These criteria include characteristic symptoms, laboratory proof, and imaging that suggests pancreatitis.
The typical symptoms of this condition are constant pain in the upper abdomen that may or may not radiate or spread to the back. Another symptom is a tender abdomen when touched.
Lab tests are also important for diagnosis. These include a serum lipase test, which should show at least three times the normal upper limit for a positive result. Lipase is a more effective test than the amylase test because it shows results faster, stays elevated for a longer time, and is more accurate. Additional tests like a hepatic panel, calcium level, and triglyceride level can help distinguish between alcoholic pancreatitis and other causes. However, it’s worth noting that testing for both lipase and amylase doesn’t increase the accuracy of the diagnosis.
For imaging, a computerized tomography (CT) scan of the abdomen with IV contrast is usually the best option. This scan might show an enlarged pancreas, loss of pancreatic borders, fluid around the pancreas, or strands in the fat tissues. Areas without enhancement on the scan indicate dead pancreatic tissue. However, it’s also possible for the imaging to appear normal in 15% to 30% of mild pancreatitis cases. Hence, imaging is not always needed, especially in cases of mild pancreatitis.
Only when a patient doesn’t respond to treatment after 48 hours, additional imaging might be needed. This helps rule out other abdominal issues or complications. It’s also worth mentioning that a specific procedure called ERCP isn’t useful in alcohol-induced pancreatitis, except when there are signs of additional bile duct conditions.
Treatment Options for Alcoholic Pancreatitis (Pancreatitis)
Treatment for pancreatitis involves several key steps, including stopping alcohol consumption — one of the main causes of the condition. Other necessary steps involve a quick diagnosis, preventing the condition from reoccurring, and avoiding or managing any complications.
Patients will likely need intravenous fluids to hydrate their body. They may also require painkillers and medication to stop vomiting, as well as the replacement of electrolytes — minerals in the body that are necessary for key functions like nerve signaling and balancing the amount of water in your body.
Next comes the reintroduction of food into the patient’s diet. While there used to be a practice of keeping the patient from food (nill per mouth or NPO), current recommendations are to start trialing food within 24 hours of the disease’s onset. The exact type of diet is unclear and varies by the patient — but generally, it’s found that small, low-fat meals can help shorten a hospital stay over a clear liquid diet that slowly advances to solid foods.
If the patient can’t eat on their own, they’ll have enteral feeds — food provided through a feeding tube. That’s a preferable alternative to total parenteral nutrition, where nutrients are given through an intravenous tube.
The American Gastroenterological Association (AGA) currently advises against using antibiotics to prevent severe effects of pancreatitis, including the tissue death that comes with necrotizing pancreatitis.
Moreover, intervention to help stop alcohol use during the hospital stay or consistent counseling afterward in a primary care or gastrointestinal clinic is shown to reduce alcohol use, decrease hospital readmissions for recurrent pancreatitis, and prevent the development of chronic pancreatitis.
For patients with chronic pancreatitis, pain can be managed by using painkillers (preferably avoiding strong opioids) and/or medication that replaces the enzymes usually produced by the pancreas. Antioxidants, substances that can prevent or slow damage to cells, might be useful in cases where other drug options fail.
If the aforementioned treatments continue to fall short, there are several other options available. These include endoscopic therapy — a non-surgical procedure using an endoscope, a long, flexible tube equipped with a light and camera to visualize the patient’s digestive tract. This procedure can help lessen blockages by making a small incision in the muscle that controls the flow of digestive fluids (sphincterotomy), inserting a tube to keep the duct open (stenting), or stretching strictures, which are abnormal narrowings in the body’s tube-like structures. The lithotripsy procedure, another non-invasive treatment, uses shock waves to break down stones in the bile and pancreatic ducts.
In severe cases, patients may also undergo neurolysis (nerve destruction) or a nerve block to mitigate pain or undergo surgery.
What else can Alcoholic Pancreatitis (Pancreatitis) be?
When a patient presents with abdominal pain, the doctor has to consider many possible conditions that might be causing the pain. These could include:
- Pancreatitis due to other factors
- Inflamed stomach lining or stomach flu
- Problems with the bile duct, caused by blockages or infections
- Perforation or blockage in the bowel
- Kidney stones
- Abnormal pregnancy outside the uterus (ectopic pregnancy)
- Heart disease
- Pneumonia
- Disorders related to the aorta
All these conditions can lead to similar symptoms, especially pain in the upper belly. Clues like frequent alcohol use, specific patterns of pain, increased levels of a substance called lipase, and results from imaging tests like X-rays and ultrasound, can help doctors pinpoint the actual cause.
It’s also important to remember that there might be other conditions at play. For instance, sickle cell crisis (a pain episode in people with sickle cell disease) and diabetic ketoacidosis (a serious complication of diabetes) should be also considered if the patient’s medical history suggests these conditions.
What to expect with Alcoholic Pancreatitis (Pancreatitis)
Several methods have been developed to forecast how severe a case of acute pancreatitis might be, based on a patient’s symptoms, lab results, and radiology reports. However, tools such as Ranson’s criteria, the APACHE II score, BISAP, and the CT severity index, often produce inaccurate predictions or are unable to definitively predict severe cases.
Different medical organizations, like the American Pancreatic Association and the American College of Gastroenterology, also use varying standards to predict the severity of the disease.
Even though hospitalizations for acute pancreatitis are on the rise, with 15% to 25% of cases being severe, the good news is that the death rate has significantly fallen to just 1% to 2% over the past decade.
A recent study found that after their first bout of acute pancreatitis caused by alcohol, patients had a 24% chance of experiencing it again and a 16% chance of developing chronic pancreatitis.
Possible Complications When Diagnosed with Alcoholic Pancreatitis (Pancreatitis)
This disease can lead to many complications that can affect either a specific area (localized) or the whole body (systemic). There are several types of localized effects:
- Acute fluid collection near the pancreas, seen in CT scans. Shows up as a lump of fluid next to the pancreas, usually within four weeks of when symptoms begin.
- Pancreatic pseudocyst, which can be seen as a fluid-filled lump with a wall, typically more than four weeks after symptoms begin.
- Necrotizing pancreatitis, which occurs in 5% to 10% of cases, and can be seen as a mix of liquid and dead tissue inside or outside the pancreas
- Walled-off necrosis, seen as a lump of fluid and dead tissue with a defined boundary, usually occurring more than four weeks after symptoms start.
Systemic complications spread throughout the body and include:
- Sepsis
- Bacteremia caused by bacteria from the intestine
- Pleural effusions (fluid in the chest cavity)
- ARDS (a severe lung disease)
- Shock
Long-term pancreatitis patients also have an increased risk of the following conditions:
- Pancreatic cancer
- Diabetes related to the pancreas
- Bile duct blockages
- Blood clot in the splenic vein
Preventing Alcoholic Pancreatitis (Pancreatitis)
As previously stated, patients dealing with either sudden (acute) pancreatitis or long-term (chronic) pancreatitis resulting from alcohol use should have a short session about alcohol when admitted to the hospital. Alternatively, they should receive advice on alcohol during regular healthcare or digestive health clinic visits. This advice can help them understand the implications of their alcohol consumption on their pancreas health.
