What is Pancreatitis?

Acute pancreatitis is a sudden reaction to harm to the pancreas. Chronic pancreatitis can lead to lasting damage to the pancreas’s structure and its hormone and digestive enzyme production functions. Each year in the United States, around 200,000 hospital admissions are due to acute pancreatitis, and this number is on the rise.

What Causes Pancreatitis?

In the United States, the two main reasons for sudden inflammation of the pancreas, or acute pancreatitis, are gallstones (responsible for 35%-40% of cases) and alcohol consumption (30% of cases). There are many other possible causes including an autoimmune reaction, high levels of fat known as triglycerides in the blood, complications following a type of X-ray procedure, certain genetic mutations, injuries, and specific drugs such as azathioprine, 6-mercaptopurine, didanosine, valproic acid, certain blood pressure medications, and mesalamine. Uncommon causes can include different forms of blocked bile flow, high levels of calcium in the blood, certain infections, toxins, blood vessel disease causing a lack of blood supply to the pancreas, growths forming in a duct of the bile system, and cases with unknown causes.

The American College of Gastroenterology recommends testing for high levels of triglycerides in people suffering from pancreatitis but without a history of gallstones or significant alcohol use. If levels are higher than 1000 mg/dl, triglycerides could be the cause. They also propose considering the possibility of a pancreatic tumor in patients older than 40, and genetic testing for people under 30 with a family history of pancreatic disease and no clear cause of pancreatitis.

The most frequent reason for persistent inflammation of the pancreas, or chronic pancreatitis, is excessive alcohol use. Smoking also greatly increases the risk. Other causes encompass conditions like tropical pancreatitis, idiopathic pancreatitis, blockages (caused by a malformed pancreas, fluid-filled sacs, stones, tumors, and injuries), specific gene mutations, inherited pancreatitis and certain widespread diseases such as systemic lupus erythematosus.

Risk Factors and Frequency for Pancreatitis

Acute pancreatitis is a medical condition that leads to roughly 275,000 hospital admissions each year. Despite these statistics, 80% of those admitted with this disease usually have a mild form and are discharged within a few days. The overall death rate from acute pancreatitis is about 2%. The rate of acute pancreatitis returning in a patient varies from 0.6% to 5.6% and largely depends on what caused the pancreatitis. The return rate is usually highest if the pancreatitis was triggered by drinking alcohol.

Chronic pancreatitis happens at a rate of 5 to 12 out of every 100,000 people each year.
About 50 out of every 100,000 people have chronic pancreatitis.
It most commonly affects people who are between 30 and 40 years old.
Males are more likely to be affected by chronic pancreatitis than females.

Signs and Symptoms of Pancreatitis

Acute pancreatitis typically shows up as abdominal pain, often located in the upper abdomen and extending to the back. Patients may describe it as severe, sharp pain, accompanied by nausea and vomiting.

In medical check-ups, doctors should inquire about any past occurrences of gallbladder disease or pancreatitis, high cholesterol levels, as well as the patient’s lifestyle, particularly alcohol consumption. They should also confirm if the patient has recently undergone any medical procedures like ERCP (Endoscopic Retrograde Cholangiopancreatography) and have an up-to-date medication list. In addition, it’s important for them to learn about any family history of pancreatic disorders.

The physical examination starts with checking the patient’s vital signs: heartbeat, blood pressure, breathing rate, and temperature. These indicators can also evaluate the patient’s level of hydration. Signs of jaundice could suggest a blockage in the bile ducts. During an abdominal examination, doctors might notice sensitivity, rigidness, and quieter than normal bowel sounds if there is a blockage. Detectable bruising in the flanks (Grey-Turner’s sign) or around the belly button (Cullen’s sign) could denote significant pancreas damage causing blood in the abdomen. In severe cases of pancreatitis, the patient might also exhibit changes in mental clarity.

Chronic pancreatitis could present similar symptoms including abdominal pain, nausea, and vomiting. But in certain instances, there might be no pain, instead, patients could experience greasy, foul-smelling stools (steatorrhea) and weight loss.

Testing for Pancreatitis

To diagnose acute pancreatitis, the current guidelines by the American College of Gastroenterology (ACG) suggest checking for at least two of these symptoms: abdominal pain that matches what’s seen in acute pancreatitis, a serum lipase level that is at least three times more than the normal limit, and signs of acute pancreatitis in abdominal imaging tests. However, it’s not necessary to conduct imaging tests for every patient right away. These tests, which may include a computed tomography (CT) scan or magnetic resonance imaging (MRI), are done if the symptoms don’t improve or if the diagnosis is still unclear about 2 to 3 days after hospital admission.

When someone with acute pancreatitis is hospitalized, doctors should assess the severity of the condition, including checking for organ failure, especially in the breathing system, heart, or kidneys. The Atlanta classification, which was revised recently, can help classify the patients as having mild, moderately severe, or severe pancreatitis.

Doctors usually order laboratory tests when the patient is admitted, which include a full metabolic panel, complete blood count, serum lipase, lactate, serum triglycerides, and C-reactive protein (CRP) tests. To monitor the progress of acute pancreatitis, they may check if the blood urea nitrogen (BUN) level or the hematocrit level are rising. Doctors may also use the systemic inflammatory response syndrome (SIRS) criteria to assess the patient’s overall health.

For chronic pancreatitis patients, the amylase and lipase levels might be high or normal. The doctor might also order tests for fecal fat, stool elastase, and the alpha-1-antitrypsin level. A test for the HbA1c level can provide information about potential hormone issues caused by chronic pancreatitis. If the patient is young or has a family history of this disease, additional tests may include IgG4/ANA levels and genetic tests. For imaging, they may use magnetic resonance cholangiopancreatography (MRCP) or CT scans. These studies can help in spotting pancreatic calcifications, blockages in the pancreatic duct or dilations.

Treatment Options for Pancreatitis

The first crucial step in treating acute pancreatitis is fluid replacement. Doctors usually recommend using Lactate Ringer’s (LR) via an intravenous (IV) drip, with an initial dose of 20ml per kilogram of body weight, followed by a continuous rate of 3ml per kilogram per hour. According to guidelines from the American College of Gastroenterology, LR is often the preferred choice as it has been shown to decrease inflammation in patients with acute pancreatitis. However, the fluid dosage may need to be adjusted in case the patient has heart or kidney issues. Ongoing checks should be conducted to adjust fluid requirements, and blood urea nitrogen (BUN) and red blood cell concentration (hematocrit) levels can be utilized to gauge the hydration status of the patient.

When it comes to feeding a patient with acute pancreatitis, regular food can be given right away if the patient can handle it. In severe cases, direct feeding via a tube into the stomach or intestine (enteral feeding) is preferred over feeding via an IV line (parenteral feeding) since it presents a lower risk of infections, reduces the need for surgical interventions and lowers the mortality rate. Pain relief, which could include injectable opioids, is another crucial aspect of pancreatitis treatment.

In cases where acute pancreatitis and cholangitis (an inflammation of the bile duct) occur simultaneously, a specialist consultation is recommended, and an urgent ERCP (a procedure to examine the pancreatic and bile ducts) is usually performed within 24 hours. If gallstones are present in the gallbladder, they can be surgically removed during the same hospital stay. However, if there’s a severe form of pancreatitis with tissue death (necrotizing pancreatitis), surgery might be postponed until the inflammation subsides.

Acute pancreatitis caused by high levels of triglycerides can be managed by giving the patient insulin, which activates an enzyme that breaks down lipoprotein. Drugs called fibrates may also be given, and the option of cleansing the patient’s blood of excessive lipoproteins (apheresis) can be considered. It’s important to note that antibiotics are not a part of acute pancreatitis treatment unless there are complications involving infections.

Chronic pancreatitis treatment involves managing pain, advice about quitting smoking and drinking, and providing pancreatic enzyme replacements. A low-fat, small-portion diet is strongly recommended. If standard treatments are not effective, options like a nerve-blocking injection to alleviate pain (celiac plexus block), surgery, or destruction of pancreatic duct stones using sound waves (extracorporeal shock wave lithotripsy) can be suggested.

When diagnosing acute pancreatitis, doctors have to consider various other illnesses that can cause the same type of severe pain in the upper stomach. These could include:

Peptic ulcer disease (ulcers in the stomach or upper intestine)
Choledocholithiasis (stones in the common bile duct)
Cholecystitis (gallbladder inflammation)
Perforated viscus (a hole in a hollow organ in the abdomen)
Acute mesenteric ischemia (lack of blood flow to the intestines)
Intestinal obstruction (blockage of the intestines)

When looking at chronic pancreatitis (long-term inflammation of the pancreas), other medical conditions that doctors might consider include:

Acute recurrent pancreatitis (frequent episodes of pancreas inflammation)
Pancreatic malignancy (cancer of the pancreas)
Chronic mesenteric ischemia (long-standing lack of blood flow to the intestines)

What to expect with Pancreatitis

The death rate from acute pancreatitis is around 2%. After experiencing an episode of this condition, roughly 20% to 30% of patients may develop endocrine and exocrine insufficiency, which refers to the pancreas not being able to produce some crucial substances and enzymes. Factors that can trigger repeated episodes include the cause of the initial attack, how severe it was, and how much structural damage was done to the pancreas.

Various scoring systems are used to measure the severity of acute pancreatitis. These include APACHE II, APACHE-O, Glasgow scoring system, HAPS, PANC 3, JSS, POP, and BISAP. However, these systems are not necessarily better than regular check-ups by doctors. In fact, they have often shown to have a high rate of falsely indicating the presence of the disease.

Possible Complications When Diagnosed with Pancreatitis

Acute pancreatitis, or inflammation of the pancreas, can cause both local and systemic complications. Local complications are those that occur within or around the pancreas, while systemic complications affect the entire body.

The local complications for acute pancreatitis typically include:

Peripancreatic fluid collections in less than 4 weeks after the onset
Pancreatic pseudocysts appearing after 4 weeks
Walled-off necrosis forming over 4 weeks
Acute necrotic collections forming within 4 weeks

On the other hand, the following are systemic complications:

Acute respiratory distress syndrome (ARDS), a severe lung condition
Compartment syndrome, a painful and potentially serious condition caused by pressure buildup from internal bleeding or swelling of tissues
Acute kidney injury, a sudden episode of kidney failure
Disseminated intravascular coagulation (DIC), a clotting disorder that can lead to organ damage

Chronic pancreatitis, or long-term inflammation of the pancreas, can also cause various complications such as:

Formation of pseudocysts, or large, fluid-filled sacs
Diabetes, a chronic disease that affects your body’s ability to use sugar
Pseudoaneurysms, or bulging weak spots in the wall of a blood vessel
Splenic vein thrombosis, a blood clot in the splenic vein
Recurrent episodes of pancreatitis
An increased risk for developing pancreatic cancer

Preventing Pancreatitis

Patients who are hospitalized due to pancreatitis should be thoroughly advised about the risks of needing to be readmitted. This advice should cover stopping alcohol intake and quitting smoking. In addition to this, changes in dietary habits and lifestyle, such as losing weight, adopting a low-fat diet, and exercising regularly should also be stressed. These changes are important to avoid further hospitalization and to improve the individual’s overall health.

Frequently asked questions

Pancreatitis is a sudden reaction to harm to the pancreas, which can lead to lasting damage to its structure and functions.

Acute pancreatitis leads to roughly 275,000 hospital admissions each year.

Signs and symptoms of pancreatitis include: - Abdominal pain, often located in the upper abdomen and extending to the back. This pain is typically described as severe and sharp. - Nausea and vomiting. - Past occurrences of gallbladder disease or pancreatitis, high cholesterol levels, and alcohol consumption should be inquired about during medical check-ups. - Confirmation of recent medical procedures like ERCP and an up-to-date medication list is important. - Family history of pancreatic disorders should be learned about. - Vital signs such as heartbeat, blood pressure, breathing rate, and temperature should be checked during physical examination. - Signs of jaundice could suggest a blockage in the bile ducts. - Abdominal examination may reveal sensitivity, rigidness, and quieter than normal bowel sounds if there is a blockage. - Detectable bruising in the flanks (Grey-Turner's sign) or around the belly button (Cullen's sign) could denote significant pancreas damage causing blood in the abdomen. - Changes in mental clarity may be exhibited in severe cases of pancreatitis. - Chronic pancreatitis may present similar symptoms including abdominal pain, nausea, and vomiting. - In certain instances of chronic pancreatitis, there might be no pain, instead, patients could experience greasy, foul-smelling stools (steatorrhea) and weight loss.

There are several ways to get pancreatitis, including gallstones, alcohol consumption, autoimmune reaction, high levels of fat known as triglycerides in the blood, complications following a type of X-ray procedure, certain genetic mutations, injuries, and specific drugs.

Peptic ulcer disease, Choledocholithiasis, Cholecystitis, Perforated viscus, Acute mesenteric ischemia, Intestinal obstruction.

The types of tests that may be needed to diagnose pancreatitis include: - Abdominal imaging tests (such as a CT scan or MRI) to look for signs of acute pancreatitis - Serum lipase level test to check for elevated levels (at least three times the normal limit) - Assessment of symptoms, including abdominal pain that matches what's seen in acute pancreatitis - Laboratory tests, including a full metabolic panel, complete blood count, serum lipase, lactate, serum triglycerides, and C-reactive protein (CRP) tests - Monitoring of blood urea nitrogen (BUN) level and hematocrit level to track the progress of acute pancreatitis - Evaluation for organ failure, especially in the breathing system, heart, or kidneys - Additional tests for chronic pancreatitis may include amylase and lipase levels, fecal fat test, stool elastase test, alpha-1-antitrypsin level test, HbA1c level test, IgG4/ANA levels, and genetic tests - Imaging tests such as magnetic resonance cholangiopancreatography (MRCP) or CT scans may be used for chronic pancreatitis to identify pancreatic calcifications, blockages in the pancreatic duct, or dilations.

Pancreatitis is treated by fluid replacement, feeding adjustments, pain relief, specialist consultation, ERCP procedure, surgical removal of gallstones if present, insulin administration for pancreatitis caused by high triglyceride levels, management of pain in chronic pancreatitis, advice on lifestyle changes, and pancreatic enzyme replacements. Antibiotics are not typically used unless there are complications involving infections.

When treating pancreatitis, there can be both local and systemic complications. The side effects or complications associated with treating pancreatitis include: Local Complications: - Peripancreatic fluid collections in less than 4 weeks after the onset - Pancreatic pseudocysts appearing after 4 weeks - Walled-off necrosis forming over 4 weeks - Acute necrotic collections forming within 4 weeks Systemic Complications: - Acute respiratory distress syndrome (ARDS), a severe lung condition - Compartment syndrome, a painful and potentially serious condition caused by pressure buildup from internal bleeding or swelling of tissues - Acute kidney injury, a sudden episode of kidney failure - Disseminated intravascular coagulation (DIC), a clotting disorder that can lead to organ damage Chronic pancreatitis can also cause various complications, including: - Formation of pseudocysts, or large, fluid-filled sacs - Diabetes, a chronic disease that affects your body's ability to use sugar - Pseudoaneurysms, or bulging weak spots in the wall of a blood vessel - Splenic vein thrombosis, a blood clot in the splenic vein - Recurrent episodes of pancreatitis - An increased risk for developing pancreatic cancer

The prognosis for pancreatitis varies depending on the type and severity of the condition. Here are some key points: - Acute pancreatitis: About 80% of patients with acute pancreatitis have a mild form and are discharged within a few days. The overall death rate from acute pancreatitis is about 2%. The rate of acute pancreatitis returning in a patient varies from 0.6% to 5.6% and largely depends on the cause, with alcohol-triggered pancreatitis having the highest return rate. - Chronic pancreatitis: Chronic pancreatitis occurs at a rate of 5 to 12 out of every 100,000 people each year. It most commonly affects people between 30 and 40 years old, and males are more likely to be affected than females. The long-term prognosis for chronic pancreatitis can involve lasting damage to the pancreas's structure and its hormone and digestive enzyme production functions.

A gastroenterologist.

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