Pancreatitis, Acute

Basic Information

A gland which is located behind the stomach, the pancreas is responsible for secreting digestive enzymes and the hormones insulin and glucagon. When the digestive enzymes are not produced, fat is unable to be digested and absorbed and insulin production is decreased. Acute pancreatitis is an acute inflammation of the pancreas during which corrosive pancreatic enzymes are released -- the pancreas can no longer supply needed digestive juices and hormones and as a result the possibility exists for severe complications including:

possible hemorrhage (not common, but extremely serious)
tissue destruction (When it is severe and destruction is adjacent to the pancreas, other organs may be affected as well.)
vascular collapse

Also at least one of the following complications occurs in up to 30% of patients with acute pancreatitis:

renal, respiratory or cardiovascular failure
uremia
hyperglycemia
acute fluid collection
pancreatic necrosis
splenic artery aneurysm (hemorrhage -- rare)

Acute pancreatitis is one of four conditions that fall into what is called the acute abdominal pain syndrome -- the other three conditions include appendicitis, diverticulitis and gallstone attack and, as with these three conditions, acute pancreatitis varies in symptomatic pain from acute to excruciating.

Up to 90% of patients with acute pancreatitis have one of the two following conditions:

chronic alcoholism (in over 50% of patients)
gallstones or biliary tract disease (in 30 to 60% of patients)

Other causes in the remaining 10% of cases can include:

duodenal ulcer (penetrating)
hyperlipidemia
trauma
tumors, strictures (obstructions)
use of certain drugs
viral infections
hypercalcemia
occupational exposure to chemicals
scorpion bites

The incidence of acute pancreatitis is increasing and is twice as likely to strike patients in urban areas where there are an estimated 20 cases per 100,000 persons. Eighty percent of patients have interstitial pancreatitis and 20% have necrotizing pancreatitis.

Who is at risk for acute pancreatitis?

The typical patient is a male with a history of heavy drinking for 6 to 10 years.
Risk for acute pancreatitis is approximately 5 to 10% after 6 to 10 years of heavy drinking.
inadequate or poor nutrition
obesity
Gallstone-caused acute pancreatitis usually occurs in later life and tends to affect more women and the elderly -- but is considered more dangerous than alcoholic-induced pancreatitis.

Symptoms

In an acute attack almost all patients suffer severe abdominal pain developing suddenly, reaching its peak within a few minutes and:

In 50% of patients pain radiates straight through to the back.
Pain is generally described as being steady and boring.
Pain can last for numerous hours and even several days without relief.
Relief from pain is usually not alleviated by changing positions although a few patients have reported that sitting or leaning forward or upward or moving into a fetal position has mitigated the pain somewhat.
In some cases the onset of pain can be more gradual and can reach its plateau after a few hours rather than a few minutes.
Coughing or quick movements and deep breathing might make pain worse.
vomiting
nausea
shallow breathing
sweating
increased pulse rate
moderate fever (occasionally)
upper abdominal extension (20%)

Diagnosis/Treatment

The patient with acute pancreatitis usually is severely ill. If the patient is bearing the pain stoically, it is probably not acute pancreatitis.

Diagnostic tests for acute pancreatitis include:

total serum amylase measurement to look for elevated or abnormal concentrations
CBC (complete blood count)
serum lipase level (remains elevated for one week)
bilirubin level (to look for duct stones)

It is important for other causes of upper abdominal pain to be ruled out. But if the patient has an acute attack of abdominal pain with elevated serum amylase level, acute pancreatitis is probable.

Other diagnostic tests of value include:

abdominal films
CT (computed tomography)
ultrasonography
ERCP (endoscopic retrograde cholangiopancreatography)

Treatment is geared towards supportive care and reducing complications from the attack. Prognosis is generally good -- in fact it is curable with proper, diligent care.

Acute pancreatitis normally requires hospitalization where the gastrointestinal tract can be rested completely and IV fluids can be administered. Most patients recover after IV fluid replacement. While in the hospital health care providers will also manage pain, make sure vomiting ceases and replace calcium and/or magnesium if necessary. To control nausea and vomiting, removal of air and gastric fluids by nasogastric tube has often been beneficial.

While you are in an acute stage, avoid taking food or liquid by mouth to give the bowels a rest. Your physician will make an evaluation when you are ready to return to solids and liquids, making the decision based on whether your pain has stopped and you no longer have abdominal tenderness and your serum amylase returns to normal. Often when you feel hunger returning it is a sign that you may begin to take food by mouth again. Good nutrition when the patient is able to resume eating is essential. The patient may usually resume intake of food and liquids based on physical evaluation by the health care provider as opposed to taking specific tests.

With gallstone-induced acute pancreatitis surgery may be needed. Surgery may also be indicated for perforated ulcer or for draining an infection.

Death occurs in 5 to 10% of patients (usually with biliary tract acute pancreatitis). When death does occur in the first few days it is caused by:

cardiovascular problems with refractory shock and renal failure
respiratory failure
heart failure

Death occurring after the first week is usually caused by:

tissue infection (pancreatic or infected necrosis)
hemorrhage

But the great majority of patients survive, even if they have been extremely ill. Nearly half of patients have a relatively mild form of the disease and it does not recur. But hyperlipidemia must be treated and drinking alcohol must stop or further attacks will probably be forthcoming.

Your prognosis can often be gauged by the test called Ranson's 11 prognostic signs. These 11 signs will indicate the severity of the disease.

There is some controversy about the use of antibiotics as a prophylaxis against further pancreatic infection -- of course antibiotics are useful in treating specific infections related to the disease but there is no hard evidence that pancreatic infections will not reoccur even with antibiotic prophylaxis. Antibiotics are indicated for patients with gallstone pancreatitis.

What you can do:

avoid alcohol
eat small, regular meals when allowed to return to eating
Many patients are substance abusers and have depression or behavioral problems. A therapist or a psychiatrist can be recommended by your health care provider, as well as a nutritionist, so that by instituting lifestyle changes and following up with your health care provider and medical team to monitor your progress can help prevent recurrent attacks.
Avoid taking drugs associated with causing or exacerbating pancreatitis.
Avoid caffeine if possible.
Eat a diet that is low in fat but nutritionally complete -- work with a nutritionist knowledgeable about diseases of the pancreas.
Remember to take calcium supplementation if you have hypocalcemia or if calcium supplementation has been recommended by your health are professional and/or nutritionist.
If you have diabetes melitis, it is important to treat the condition and monitor it regularly.
When returning from the hospital, get plenty of bed rest or alternate bed rest with rest in a chair so that bedsores do not develop.
Slowly resume your normal routine as symptoms begin to subside.

If you have what you feel is your first attack of acute pancreatitis, after only having experienced one or two mild symptoms associated with the disease over a period before the attack, you may have chronic pancreatitis (See article on Pancreatitis, Chronic.) and not be aware of it. Be certain you understand the difference between acute and chronic pancreatitis. Be sure to ask your health care provider to explain the difference between the conditions and to evaluate you for both kinds of pancreatitis.

If you have an attack of acute pancreatitis call your health care provider or 911 immediately. It is likely you will need to be treated at a hospital.