Acute Pancreatitis

Acute pancreatitis is a serious condition that can be fatal or cause serious long-term complications. Given that acute pancreatitis can be in many cases prevented by proper lifestyle, it is an issue worth explaining.

 

Pancreas is a gland located in the abdomen. Anatomically, it has a very close relationship to the small intestine and the biliary ducts. The pancreas has two main functions. Some cells produce hormones important for our metabolism including insulin. However, the majority of the tissue is focused on digestion as the cells produce pancreatic juice rich on digestive enzymes (amylase, lipase, trypsin, chymotrypsin, etc) that allow digestion of fats, proteins and sugars in the small intestine. Digestive pancreatic juice flows through the pancreatic duct and before entering the small intestine, it joins the bile duct and the bile and pancreatic juice flow into the intestine together. This is very important for the digestion as the pancreatic enzymes are produced in inactive forms and they are activated by contact with the bile. 

Causes

There are many possible causes of acute pancreatitis. The most common include:

Gallstones

These are probably the most common causative factors of acute pancreatitis. The stones are usually formed in the gallbladder, but they can get into the bile duct and obstruct the common terminal part of bile duct and pancreatic duct. In such case, bile and pancreatic enzymes can not be drained into the intestine, the two liquids are mixed and this can lead to a premature activation of pancreatic enzymes. Activated pancreatic enzymes can attack and digest the tissue of pancreas causing its non-infectious acute inflammation.

Biliary pancreatitis
This diagram shows terminal block of the bile duct and pancreatic duct by a stone

 

Alcohol

Acute pancreatitis is often caused by an alcoholic excess, i.e. by binge drinking. This can happen in both chronic alcoholics and people with only an intermittent intake of alcohol.

Pancreas injury

Acute pancreatitis may occur due to a blunt abdominal trauma. It is for example the case of a bicycle accident when the upper belly is suddenly hit by the handlebars.

High levels of blood fats

High concentration of serum fats (triacylglyceroles) is reportedly related to increased risk of acute pancreatitis.

High level of calcium in the blood

The mechanism is no exactly clear, but hypercalcemia is often accompanied by attack of acute pancreatitis. A typical example is untreated primary hyperparathyroidism.

Mumps

Mumps virus attacks many glands in our body. It usually affects the salivary glands, but pancreas may be damaged as well. However, the inflammation is usually only mild.

Peptic ulcers

Long-term untreated peptic ulcer may spread throughout the gastric or duodenal wall to the surrounding tissues and organs. Anatomically, the pancreas, stomach and duodenum are in a close contact and the ulcer may grow right into the pancreas causing the inflammation.

ERCP

ERCP is a both diagnostic and therapeutic procedure, which is performed for various reasons (e.g. in diseases of the biliary tract). However, it is an invasive procedure that often irritates the pancreas causing acute pancreatitis. The ERCP is performed by a endoscopic device inserted through mouth to esophagus, stomach and duodenum. In the small intestine, the doctor locates the outlet of pancreatic and bile duct and inserts into it a thin wire. This enables him to use special instruments to visualize and drain the biliary tract (inserting special tube-like stent, removing the gallstones, etc.).

Symptoms

The manifestations of acute pancreatitis are very dramatic. The classic symptom is severe abdominal pain located in the upper abdomen spreading as a belt to the sides. The pain is accompanied with nausea, vomiting and at least temporary paralytic ileus.  Severe cases of acute pancreatitis may progress into a shock condition when the inflammatory process causes leakage of fluid out of the blood vessels leading to a circulatory collapse. The patient suffers from drop of blood pressure, palpitations, accelerated breathing, pallor, unconsciousness, coma and death.

 

Complications of inflammation can result in focal necrosis and-or the penetration of bacteria into the damaged pancreas and resulting in a dangerous infection. Both conditions are potentially life-threatening.

 

Longer-term complications of acute pancreatitis may be long-term deterioration of pancreatic function due to prolonged death of its cells. This can disrupt the proper digestion of proteins and fats causing occurrence of bulky fatty oily stool and the weight loss. This condition is known as chronic pancreatitis. With the destruction of most cells of the pancreas and decreased production of insulin, diabetes may develop having similar attributes as the type 1 diabetes. Chronic pancreatitis is also a risk factor for pancreatic cancer.

Diagnosis

The patient should be examined by a doctor including cautious physical examination of the abdomen. The doctor should ask about any previous problems with gallstones or recent alcohol excess. In blood smear, there are elevated serum levels of certain pancreatic enzymes (amylase, lipase). The pancreatic tissue can be visualized by ultrasound or computed tomography to evaluate the condition and to find any complications (bile duct dilation, pancreatic necrosis, etc.).

Treatment

Patients with acute pancreatitis should be hospitalized and treated in an inpatient department. The most important thing is an aggressive hydration therapy by intravenous infusions. The fluid intake must be even over 5 liters per day to reduce the risk of a shock development. In acute phase, it is advisable to stop the oral nutrition and give the nutrition in form of intravenous nutritional solutions or enteral nutrition by a tube inserted through nose into the small intestine. Avoiding oral intake of food decreases the need of production of pancreatic enzymes and eases the symptoms. Severe pancreatitis with development of infected necrotic areas should be treated by antibiotics and when the therapy is ineffective, the patient should be treated surgically. The surgeons remove the necrotic pancreatic tissue and ensure local drainage.

 

In some cases, the treatment involves ERCP. The procedure should be used in cases when the acute pancreatitis is caused by an obstruction caused by a gallstone. The ERCP helps to visualize the gallstone and also enables its removal. The ERCP must be, however, indicated wisely, as it is invasive procedure that alone can cause the acute pancreatitis (see above).