Acute and Chronic Pancreatitis

Illustration of the location of the pancreas, liver, and gallbladder

The pancreas is a gland located in the upper part of the abdomen. It produces two main types of substances: digestive juices and digestive hormones. Inflammation of the pancreas is termed pancreatitis and its inflammation has various causes.

Once the gland becomes inflamed, the condition can progress to swelling of the gland and surrounding blood vessels, bleeding, infection, and damage to the gland. There, digestive juices become trapped and start "digesting" the pancreas itself.

If this damage persists, the gland may not be able to carry out normal functions. Pancreatitis may be acute (new, short-term) or chronic (ongoing, long-term). Either type can be very severe, even life-threatening. Either type can have serious complications.

• Acute pancreatitis usually begins soon after the damage to the pancreas begins. Attacks are typically very mild, but about 20% of them are very severe. An attack lasts for a short time and usually resolves completely as the pancreas returns to its normal state. Some people have only one attack, whereas other people have more than one attack, but the pancreas always returns to its normal state unless necrotizing pancreatitis develops and becomes life-threatening.
• Chronic pancreatitis begins as acute pancreatitis. If the pancreas becomes scarred during the attack of acute pancreatitis, it cannot return to its normal state. The damage to the gland continues, worsening over time.

The reported annual incidence of acute pancreatitis has ranged from 4.9 to 80 cases per 100,000 people. About 80,000 cases of acute pancreatitis occur in the United States each year. Pancreatitis can occur in people of all ages, although it is very rare in children. Pancreatitis occurs in men and women, although chronic pancreatitis is more common in men than in women.

The most common symptom of acute pancreatitis or pancreas pain is abdominal pain. Almost everybody with acute pancreatitis experiences abdominal pain.

• The pain may come on suddenly or build up gradually. If the pain begins suddenly, it is typically very severe. If the pain builds up gradually, it starts out mild but may become severe.
• The pain is usually centered in the upper middle or upper left part of the belly (abdomen). The pain is often described as if it radiates from the front of the abdomen through to the back.
• The pain often begins or worsens after eating.
• The pain typically lasts a few days.
• The pain may feel worse when a person lies flat on his or her back.

People with acute pancreatitis usually feel very sick. Besides pain, people may have other symptoms and signs.

• Nausea (Some people do vomit, but vomiting does not relieve the symptoms.)
• Fever, chills, or both
• Swollen abdomen which is tender to the touch
• Rapid heartbeat (A rapid heartbeat may be due to the pain and fever, dehydration from vomiting and not eating, or it may be a compensation mechanism if a person is bleeding internally.)

In very severe cases with infection or bleeding, a person may become dehydrated and have low blood pressure, in addition to the following symptoms:

• Weakness or feeling tired (fatigue)
• Feeling lightheaded or faint
• Lethargy
• Irritability
• Confusion or difficulty concentrating
• Headache
• Cullen's sign (bluish skin around the belly button)
• Grey-Turner sign (reddish-brown skin discoloration along the flanks)
• Erythematous skin nodules

If the blood pressure becomes extremely low, the organs of the body do not get enough blood to carry out their normal functions. This very dangerous condition is called circulatory shock and is referred to simply as shock.

Severe acute pancreatitis is a medical emergency.

Pain is less common in chronic pancreatitis than in acute pancreatitis. Some people have pain, but many people do not experience abdominal pain. For those people who do have pain, the pain is usually constant and may be disabling; however, the pain often goes away as the condition worsens. This lack of pain is a bad sign because it probably means that the pancreas has stopped working.

Other symptoms of chronic pancreatitis are related to long-term complications, such as the following:

• Inability to produce insulin (diabetes)
• Inability to digest food (weight loss and nutritional deficiencies)
• Bleeding (low blood count, or anemia)
• Liver problems (jaundice)

What are the risk factors for pancreatitis?

The major risk factors for pancreatitis are excessive alcohol intake and gallstones. Although the definition for excessive alcohol intake can vary from person-to-person, most health-care professionals suggest that moderate consumption is no more than two alcoholic beverages a day for men and one a day for women and the elderly. However, people with pancreatitis secondary to alcohol intake are usually advised to avoid all alcohol intake.

Other risk factors include

• a family history of pancreatitis,
• high levels of fat (triglycerides) in the blood,
• cigarette smoking,
• certain inherited disorders such as cystic fibrosis, and
• taking certain medicines (for example estrogen therapy, diuretics, and tetracycline).

Alcohol abuse and gallstones are the two main causes of pancreatitis, accounting for 80% to 90% of all individuals diagnosed with pancreatitis.

Pancreatitis from alcohol use usually occurs in individuals who have been long-term alcohol drinkers for at least five to seven years. Most cases of chronic pancreatitis are due to alcohol abuse. Pancreatitis is often already chronic by the first time the person seeks medical attention (usually for severe pain).

Gallstones form from a buildup of material within the gallbladder, another organ in the abdomen (please see previous illustration). A gallstone can block the pancreatic duct, trapping digestive juices inside the pancreas. Pancreatitis due to gallstones tends to occur most often in women older than 50 years of age.

The remaining 10% to 20% of cases of pancreatitis have various causes, including the following:

• medications,
• exposure to certain chemicals,
• injury (trauma), as might happen in a car accident or bad fall leading to abdominal trauma,
• hereditary disease,
• surgery and certain medical procedures,
• infections such as mumps (not common),
• abnormalities of the pancreas or intestine, or
• high fat levels in the blood.

In about 15% of cases of acute pancreatitis and 40% of cases of chronic pancreatitis, the cause is never known.

In most cases, the pain and nausea associated with pancreatitis are severe enough that a person seeks medical attention from a health-care professional. Any of the following symptoms warrant immediate medical attention:

• Inability to take medication or to drink and eat because of nausea or vomiting
• Severe pain not relieved by nonprescription medications
• Unexplained pain
• Difficulty breathing
• Pain accompanied by fever or chills, persistent vomiting, feeling faint, weakness, or fatigue
• Pain accompanied by presence of other medical conditions, including pregnancy

The health-care professional may tell the person to go to a hospital emergency department. If a person is unable to reach a health-care professional, or if a person's symptoms worsen after having being examined by a health-care professional, an immediate visit to an emergency department is necessary.

The types of doctors that usually treat pancreatitis are emergency medicine doctors, primary care physicians, internal medicine specialists, hospitalists, critical-care specialists and occasionally gastroenterologists and/or surgeons, depending upon the severity of the disease.

When a health-care professional identifies symptoms suggestive of pancreatitis, specific questions are asked about the person's symptoms, lifestyle and habits, and medical and surgical history. The answers to these questions and the results of the physical examination allow the health-care professional to rule out some conditions and make the correct diagnosis.

In most cases, laboratory tests are needed. The tests check the functioning of several body systems, including the following:

• Pancreas, liver, and kidney functions (including levels of pancreatic enzymes amylase and lipase)
• Signs of infections, for example, fever or fatigue
• Blood cell counts indicating signs of anemia
• Pregnancy test
• Blood sugar, electrolyte levels (an imbalance suggests dehydration) and calcium level

Results of the blood tests may be inconclusive if the pancreas is still making digestive enzymes and insulin.

Diagnostic imaging tests are usually needed to look for complications of pancreatitis, including gallstones.

Diagnostic imaging tests may include the following:

• X-ray films may be ordered to look for complications of pancreatitis as well as for other causes of discomfort. This may include a chest X-ray.
• A CT scan is like an X-ray film, only much more detailed. A CT scan shows the pancreas and possible complications of pancreatitis in better detail than an X-ray film. A CT scan highlights inflammation or destruction of the pancreas. Occasionally an MRI is ordered.
• Ultrasound is a very good imaging test to examine the gallbladder and the ducts connecting the gallbladder, liver, and pancreas with the small intestine.
  • Ultrasound is very good at depicting abnormalities in the biliary system, including gallstones and signs of inflammation or infection.
  • Ultrasound uses painless sound waves to create images of organs. Ultrasound is performed by gliding a small handheld device over the abdomen. The ultrasound emits sound waves that "bounce" off the organs and are processed by a computer to create an image. This technique is the same one that is used to look at a fetus in a pregnant woman.
• Endoscopic retrograde cholangiopancreatography (ERCP) is an imaging test that uses an endoscope (a thin, flexible tube with a tiny camera on the end) to view the pancreas and surrounding structures.
  • ERCP is usually used only in cases of chronic pancreatitis or in the presence of gallstones.
  • To perform an ERCP, a person is first sedated. After sedation, an endoscope is passed through the mouth, to the stomach, and into the small intestine. The device then injects a temporary dye into the ducts connecting the liver, gallbladder, and pancreas with the small intestine (biliary ducts). The dye makes is easier for the health-care professional to see any stones or signs of organ damage. In some cases, a stone can be removed during this test.

The diet for people with acute pancreatitis consists of bowel rest for a few days. Bowel rest means no food or liquid intake by mouth. Consequently, patients need to be provided fluids and nutrition intravenously in the hospital while the pancreas is given time to recover. The patient is then slowly advanced to oral intake starting off with clear fluids and then soups.

Patients with chronic pancreatitis are suggested to have a low-fat diet (maximum 20 g/day), high carbohydrates in are advised to eat small sized and more frequent meals (about 5 to 6 per day). If the pancreas develops a flare, the patient should go back to bowel rest for about a day or so but not to become dehydrated by taking oral fluids. If symptoms don't resolve, medical care should be sought immediately. Patients with either chronic or acute pancreatitis strongly advised not to drink any alcoholic beverages.

For most people, self-care alone is not enough to treat pancreatitis. People may be able to make themselves more comfortable during an attack, but they will most likely continue to have attacks until treatment is received for the underlying cause of the symptoms. If symptoms are mild, people might try the following preventive measures:

• Stop all alcohol consumption.
• Adopt a liquid diet consisting of foods such as broth, gelatin, and soups. These simple foods may allow the inflammation process to get better.
• Over-the-counter pain medications may also help. Avoid pain medications that can affect the liver such as acetaminophen (Tylenol and others). In individuals with pancreatitis due to alcohol use, the liver is usually also affected by the alcohol.

In acute pancreatitis, the choice of treatment is based on the severity of the attack. If no complications are present, care usually focuses on relieving symptoms and supporting body functions so that the pancreas can recover.

• Most people who are having an attack of acute pancreatitis are admitted to the hospital.
• Those people who are having trouble breathing are given oxygen.
• An IV (intravenous) line is started, usually in the arm. The IV line is used to give medications and fluids. The fluids replace water lost from vomiting or from the inability to take in fluids, helping the person to feel better.
• If needed, medications for pain and nausea are prescribed.
• Antibiotics are given if the health-care professional suspects an infection may be present.
• No food or liquid should be taken by mouth for a few days. This is called bowel rest. By refraining from food or liquid intake, the intestinal tract and pancreas are given a chance to start healing.
• Some people may need a nasogastric (NG) tube. The thin, flexible plastic tube is inserted through the nose and down into the stomach to suck out the stomach juices. This suction of the stomach juices rests the intestine further, helping the pancreas recover.
• If the attack lasts longer than a few days, nutritional supplements are administered through an IV line.

In chronic pancreatitis, treatment focuses on relieving pain and avoiding further aggravation to the pancreas. Another focus is to maximize a person's ability to eat and digest food.

• Unless people have severe complications or a very severe episode, they probably do not have to stay in the hospital.
• Medication is prescribed for severe pain.
• A high carbohydrate, low fat diet; and eating smaller more frequent meals help prevent aggravating the pancreas. If a person has trouble with this diet, pancreatic enzymes in pill form may be given to help digest the food.
• People diagnosed with chronic pancreatitis are strongly advised to stop drinking alcohol.
• If the pancreas does not produce sufficient insulin, the body needs to regulate its blood sugar, and insulin injections may be necessary.

If the pancreatitis is caused by gallstones, an operation to have the gallbladder and gallstones removed (cholecystectomy) is likely.

If certain complications (for example, enlargement or severe injury of the pancreas, bleeding, pseudocysts, or abscess) develop, surgery may be needed to drain, repair, or remove the affected tissues.

The following recommendations may help to prevent further attacks or to keep them mild:

• Completely eliminate alcohol because it is the only way to reduce the chance of further attacks in cases of pancreatitis caused by alcohol use, to prevent the pancreatitis from worsening, and to prevent the development of complications that can be very serious or even fatal.
• Eat small frequent meals. If in the process of having an attack, avoid solid foods for several days to give the pancreas a chance to recover.
• Eat a balanced diet high in carbohydrates and low in fats because may help individuals decrease the risk for pancreatitis since it is likely these actions will decrease the risk for gallstones, a major risk factor for pancreatitis.
• If pancreatitis is due to chemical exposure or medications, the source of the exposure will need to be found and stopped, and the medication will need to be discontinued.
• Don't smoke
• Maintain a healthy weight
• Exercise regularly

Most people with acute pancreatitis recover completely from their illness unless they develop necrotizing pancreatitis. The pancreas returns to normal with no long-term effects. Pancreatitis may return, however, if the underlying cause is not eliminated.

Some 5%-10% of people develop life-threatening pancreatitis and may be left with any of these chronic illnesses, or even die due to complications of pancreatitis:

• Kidney failure
• Breathing difficulties
• Diabetes
• Brain damage

Chronic pancreatitis does not resolve completely between attacks. Although the symptoms may be similar to those of acute pancreatitis, chronic pancreatitis is a much more serious condition because damage to the pancreas is an ongoing process. This ongoing damage can have any of the following complications:

• Bleeding in or around the pancreas: Ongoing inflammation and damage to the blood vessels surrounding the pancreas can lead to bleeding. Fast bleeding can be a life-threatening condition. Slow bleeding usually leads to low red blood cell count (anemia).
• Infection: Ongoing inflammation makes the tissue vulnerable to infection. The infection can form an abscess that is very difficult to treat without surgery.
• Pseudocysts: Small fluid-filled sacs can form in the pancreas as a result of ongoing damage. These sacs can become infected or rupture into the lower abdominal cavity (peritoneum), causing a serious infection called peritonitis.
• Breathing problems: The chemical changes in the body can affect the lungs. The effect is to reduce the amount of oxygen the lungs can absorb from the air a person breathes. The level of oxygen in the blood drops to lower than normal (hypoxia).
• Pancreas failure: The pancreas may become so severely damaged that it is unable to carry out its normal functions. Digestion of food and regulation of blood sugar - both very important functions - are affected. Diabetes and weight loss often result.
• Pancreatic cancer: Chronic pancreatitis can encourage the growth of abnormal cells in the pancreas, which can become cancer. The prognosis for pancreatic cancer is very poor.