Category Archives: Inflammation of The Pancreas
Chronic Pancreatitis
Chronic pancreatitis is a progressive inflammatory condition of the pancreas continuing over a long period, and resulting in permanent structural and functional damage to the pancreas.
- Continuous or intermittent pain in the upper part of the abdomen is the usual symptom.
- In addition to the typical symptoms, imaging tests and blood tests may help in diagnosis.
- Treatment of chronic pancreatitis include diet modifications, giving complete rest to the pancreas, administration of pain relieving drugs and supplements of pancreatic enzymes.
Alcoholism is the major cause of chronic pancreatitis in the United States, accounting for almost half the cases. People who carry the gene for a condition called cystic fibrosis, and those who have this disease, account for most of the other cases. Pancreatitis may be caused by autoimmune disease or heredity too. In a few cases, when the reason for the chronic pancreatitis cannot be identified, it is known as idiopathic. If an episode of severe acute pancreatitis had narrowed the pancreatic duct, it can lead to the development of chronic pancreatitis. In certain tropical countries like Nigeria, Indonesia and India, chronic pancreatitis is found to occur without any apparent reason. This is known as tropical pancreatitis. It usually affects youngsters and children.
Symptoms
Chronic pancreatitis has the same symptoms which occur in acute pancreatitis. Two distinct patterns are usually observed. One of them is an almost constant pain of varying intensity felt in the upper part of the abdomen. When people have this type of pattern, there is a high possibility of complications due to chronic pancreatitis being present. Formation of a cyst, an inflammatory lump, or cancer of the pancreas, may be the usual complication. In the other pattern, intermittent attacks, usually referred to as flare ups, occur. Each episode exhibits symptoms of acute pancreatitis of mild or moderate intensity. The duration of the flare ups may vary, with severe pain lasting several hours, to even several days, at a time. Irrespective of the pattern of symptoms, the pain may finally stop when the chronic disease steadily progresses to cause severe damage to the enzyme-secreting tissues of the pancreas, eventually destroying them. It may take a period of 6 to 10 years for the disease to reach this stage.
When the gradual destruction of the pancreatic tissue results in the decreased production of the digestive enzymes, pancreatic insufficiency develops. Without sufficient amount of digestive enzymes, the breakdown of food cannot be complete. Inadequately digested food cannot be absorbed by the small intestine and this condition leads to malabsorption. Bulky and extremely foul-smelling light colored stools usually indicate malabsorption. Fatty stools termed steatorrhea may have visible droplets of oil. The stool may contain many undigested and partially digested food particles, especially muscle fibers. Malabsorption may result in deficiency diseases and weight loss. People develop diabetes when the insulin-producing endocrine glands of the pancreas get destroyed with the progress of the chronic pancreatitis.
Diagnosis
When a patient who has acute pancreatitis complains of frequent flare ups or worsening of symptoms, chronic pancreatitis is suspected. When a person with a history of alcoholism comes with the typical symptoms, then also the possibility of chronic pancreatitis needs to be investigated. High blood levels of pancreatic enzymes lipase and amylase may be indicative of chronic pancreatitis. High blood glucose levels are another indication. But blood tests cannot be treated as confirmation of diagnosis.
Further investigations include Computed tomography, or CT scan, to detect the changes or abnormalities typically caused by chronic pancreatitis. If the result of this test is inconclusive, other tests such as endoscopic retrograde cholangiopancreatography or endoscopic ultrasonography may be done. In endoscopic ultrasonography, the probe is introduced into the duodenum with the help of an endoscope inserted through the mouth. Magnetic resonance cholangiopancreatography, or MRCP for short, is a specially designed MRI test which gives clearer pictures of the pancreatic and bile ducts than a CT scan. Because of this, MRCP is often preferred to CT scan.
The risk of developing pancreatic cancer is very high in people who have chronic pancreatitis. If the usual symptoms of pancreatitis are found to worsen, cancer is suspected and further investigations are done. The diagnostic tests for pancreatic cancer include CT scan and endoscopic evaluation in addition to blood tests. MRI scan also may be done.
Chronic Pancreatitis Treatment
The repeated episodes of chronic pancreatitis are treated by resting the digestive system completely. People with chronic pancreatitis should strictly avoid alcohol consumption even when their condition had not developed due to alcoholism. During flare ups, the patient is hospitalized and all nutritional support is given intravenously. Resting the pancreas may relieve the abdominal pain to some extent, but opioid analgesics may be necessary. People may need large amounts of opioid medication to get relief from pain, which can make them addicted to the drugs. In the case of chronic pancreatitis, drug therapy is not usually a satisfactory measure for pain relief.
After a period of fasting, oral feeding is restarted when the symptoms subside. Avoiding large meals, and taking several small meals low in fats, usually helps in avoiding frequent flare-ups. An effort is made to reduce malabsorption by taking supplements of pancreatic enzymes. It may reduce steatorrhea and improve digestion and absorption of nutrients. To reduce the acid production by the stomach, proton pump inhibitors or histamine-2 (H2) blockers may be given. The overall condition of the patient improves with this treatment and weight gain may be achieved. If the improvement is not satisfactory, further reducing the fat content in the food may help. To avoid the deficiency of fat-soluble vitamins such as vitamins A and D, they should be taken as supplements. Vitamin E and K are also fat-soluble.
If pain does not subside in spite of the drug therapy and diet modifications, further investigations are done check for complications. Possible complications include the formation of a pseudocyst, which is an accumulation of the debris of pancreatic cells, fluids and enzymes around the pancreas. If pain is caused by a rapidly enlarging pseudocyst, it is surgically drained. If an inflammatory mass in the pancreas is the reason of pain, it is removed surgically.
When such complications are not detected, pain management may involve the injection of alcohol and an anesthetic drug bupivacaine combined, directly into the nerves leaving the pancreas. It may bring relief from pain by blocking the impulses of pain so that they do not reach the brain. If anesthetic injection does not help, surgery may be considered. If there is enlargement of the pancreatic duct, a bypass surgery to connect the pancreas to the duodenum usually helps reduce the pain in 70 to 80% percent cases. If the duct is not enlarged, surgical removal of a portion of the pancreas is the option. When the surgery is performed, insulin-secreting cells of the pancreas are also lost, resulting in the development of diabetes. This option is considered in the case of patients who have quit alcohol consumption and are capable of managing the resultant diabetes.
Diabetes caused by chronic pancreatitis does not respond to taking oral antidiabetic drugs. Since the secretion of insulin as well as that of its counterpart glucagon is affected by chronic pancreatitis, taking insulin shots for blood sugar control poses some risks. The decreased levels of glucagon in the blood can cause excess insulin to remain in the blood, leading to coma due to hypoglycemia.
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What Is Acute Pancreatitis
Acute pancreatitis is an inflammatory condition of the pancreas which appears suddenly and subsides after a short period. It is often accompanied by severe pain.
- The first and foremost symptom of acutely inflamed pancreas is severe pain in the abdomen.
- Acute pancreatitis is usually caused by excess alcohol consumption or by the presence of gall stones.
- X-rays and CT scans are the usual imaging tests which help in diagnosing pancreatitis. Blood tests often indicate the condition.
- Hospitalization is necessary to treat acute pancreatitis, irrespective of the severity of the inflammation.
People who have biliary tract disease or gallstones are prone to acute pancreatitis. Excess alcohol consumption is another major cause of this condition. Around 80% cases of acute pancreatitis results from the above mentioned reasons. Acute pancreatitis resulting from gallstones is more common in women.w
The pancreatic fluid secreted by the pancreas contains enzymes in an inactive form which get activated on its way to the duodenum. The fluid also contains certain inhibitors which can stop the action of the enzymes, to protect the pancreatic tissue from damage due to exposure to digestive enzymes. But if the pancreatic duct, which carries the fluid secretion to the duodenum, is blocked at the sphincter of Oddi due to gallstones, the activated pancreatic fluid starts causing injury to the tissue. If the block clears up fast enough, the damage will be minimal and temporary. But if the blockage persists, the enzymes overcome the action of the inhibitors present in the pancreatic fluid, and start directing their digestive action on the pancreatic cells, causing severe widespread damage to the organ resulting in acute inflammation.
The tiny ductules which drain the pancreatic fluid into the pancreatic duct may get clogged if regular alcohol consumption exceeds three and a half ounces, for an extended period longer than 3 – 5 years.
One and a half ounce alcohol is approximately equivalent to:
- Wine – 1 bottle
- Beer – 8 bottles
- Hard liquor – 10 ounces
When the digestive fluid stagnates in the pancreas due to lack of proper drainage, it results in acute pancreatitis. Since the presence of food in the stomach activates the digestive glands into producing more enzymes, a large meal can trigger an episode of acute pancreatitis. Binging on alcohol is another trigger which brings about sudden inflammation.
Several other reasons also cause an acutely inflamed pancreas. Hereditary factors may contribute to the development of this condition. Some people are predisposed to developing this condition due to certain gene mutations. People who have the gene responsible for a condition called cystic fibrosis, as well as those who have that disease, are at a very high risk of developing both acute and chronic pancreatitis.
Pancreatitis resulting from viral infections is often self-limiting. Drugs which cause irritation to the pancreas may result in pancreatitis. but it is usually reversible with the discontinuation of the offending drug.
Symptoms
Severe pain located in the upper part of the abdomen just below the sternum is the typical symptom of acute pancreatitis. It is almost always felt by those who develop this condition. In about half the cases, the pain may be felt as penetrating towards the back. A few people feel it in the lower part of the abdomen initially. In acutely inflamed pancreas due to gallstones, severe pain appears suddenly, and increases rapidly. On the other hand, in acute pancreatitis due to excess alcohol consumption, the pain usually develops gradually over several days and then persists for several more days. It is usually a steady, penetrating kind of severe pain.
Taking deep breaths, coughing, and moving vigorously, can increase the pain. Sitting in an upright position and leaning slightly forward, usually brings certain amount of relief. Nausea and vomiting are some of the other symptoms of acute pancreatitis and people continue to retch without bringing up anything, which is known as dry heaves. The pain is not relieved by pain killers; even opioid analgesics injected in high doses may not completely block the pain. Ironically, some people developing acute pancreatitis due to alcoholism do not exhibit any of the severe symptoms except a moderate amount of pain.
Severe symptoms felt by some people include fast heart rate and shallow breathing. People may look very sick and sweat profusely. Those who have a condition called pleural effusion usually have rapid breathing. In this condition, the accumulation of fluid in the chest cavity makes the inflation of the lungs difficult, resulting in rapid but shallow breath. If the lungs have become inflamed, or if some areas of the lungs have collapsed, the breathing may become rapid and shallow. The blood oxygen levels drop as the absorption of oxygen by the lung tissue decreases.
There may not be any fever initially, but later on, low grade fever from 100° F to 101° F may develop. A person may faint when standing up, due to sudden dropping of blood pressure. As the condition worsens, people may become disoriented and confused; some may even become unconscious. Yellowish discoloration of the white part of the eye is another symptom that may be present in some cases.
Complications: Pancreatitis may cause certain toxins called cytokines and the digestive enzymes to enter the blood vessels, lowering the blood pressure as a result. It can damage organs such as kidneys and lungs, which are far away from the site of inflammation. However, the insulin producing parts, as well as the other endocrine tissues in the pancreas, are not usually affected by the inflammation.
In two out of every ten cases of acute pancreatitis, a swelling develops in the upper part of the abdomen. It may be due to the displacement of the stomach by the swelling of the pancreas or because of the distension of the stomach. Accumulation of the contents of the stomach or the intestine may result from the temporary paralysis of the intestine called ileus.
Necrotizing pancreatitis is a condition which usually develops in cases of severe acute pancreatitis. A portion of the pancreas dies, spilling its fluids as well as blood into the cavity of the abdomen. It is a potentially fatal condition as the loss of blood and fluids result in dangerously low blood pressure leading to shock. It also increases the risk of developing peritonitis, which is the inflammation and infection of the abdominal cavity.
The inflammation of the pancreas increases the risk of infections. When the condition of a person, who has been recovering from an episode of acute pancreatitis, suddenly deteriorates, it may indicate an infection developing. It usually happens in the second week of pancreatitis. Increase in the WBC count, and development of fever, are typical symptoms of infection.
Another complication is the development of a pseudocyst around the pancreas due to the accumulation of the pancreatic fluids and tissue fragments there. Pancreatic pseudocyst may disappear without any intervention in half the cases, but it can also develop infections. Surgical drainage of the pseudocyst may be necessary if it grows too big, or causes symptoms like pain.
Diagnosis
Acute pancreatitis is suspected from the typical abdominal pain associated with the condition. Since alcoholics and people having gallbladder disease are especially at risk of developing acute pancreatitis; those who are known to be having such conditions are always investigated for the development of acutely inflamed pancreas. Physical examination by the doctor may show rigidity of the muscles of the abdominal wall. Bowel sounds may be very few or completely absent when the doctor examines the abdomen using the stethoscope.
There are no specific blood tests to diagnose this condition, but the results of some tests may indicate the inflammation of the pancreas. The enzymes lipase and amylase secreted by the pancreas may increase on the first day and if higher levels detected by a blood test, pancreatitis may be suspected. But the blood levels of the enzymes may become normal within a few days to a week. However, it is not a dependable test as elevated blood enzyme levels may not be present if the person has had previous episodes of pancreatitis. This is because the damage already caused to the pancreas may have destroyed most of the enzyme producing cells. An elevated WBC count usually indicates inflammations.
When an x-ray of the abdomen is taken, the intestine may show enlarged loops. Gallstones may be seen occasionally. An x-ray of the chest may show pleural effusion, which is the accumulation of fluid in the pleural cavity. The collapse of some areas of the lung also may be seen. Gallstones present in the gallbladder, or in the bile duct, may show on the ultrasound scan, in addition to the enlargement of the inflamed pancreas.
When people have severe acute pancreatitis, or when complications like dangerously low blood pressure develop, a computed tomography scan is done to determine the exact condition of the pancreas. The CT scan is the ideal test for acutely inflamed pancreas as it gives very clear images which help the doctor in arriving at an accurate diagnosis.
When infection is suspected, a needle is inserted into the pancreas through the skin and a fluid and tissue sample is taken out for further testing. A modified MRI scan called Magnetic resonance cholangiopancreatography, or MRCP for short, is also done.
Prognosis
Prognosis depends on the extent of inflammation. In most cases, a CT scan may be able to assess the extent of the disease, and tissue damage caused. If there is large scale destruction of the pancreatic tissue, the prognosis is poor. But if the inflammation is mild, the chances of recovery are good. The fatality rate in people with mild acute pancreatitis is less than 5%, but it can increase with the severity of the inflammation. When the inflammation has spread to other organs such as kidneys and lungs, the death rate can climb up to 50%. Mortality in the first week of the disease is usually due to heart failure or because of lung or kidney failure. After the first week, death may be due to the infection of the pancreas or it may result from the rupture or bleeding of the pseudocyst.
Treatment
Acute pancreatitis is almost always treated with the patient hospitalized. In mild cases of acutely inflamed pancreas, only the symptoms are treated. Analgesic drugs are administered to get relief from pain. The digestive system is rested for a few days by complete fasting. Fluids and essential nutrients are administered intravenously. Normal diet is restored after the symptoms subside spontaneously. The treatment usually takes two to three days to a week in the hospital.
In acute pancreatitis which is moderate or severe, hospitalization is necessary, and it usually lasts for several days to several weeks, depending on the extent of the inflammation. Food and drinks stimulate the glandular tissues of the pancreas to produce more digestive enzymes. To give complete rest to the pancreas, all oral feeding is stopped, and intravenous administration of fluids is started. The fasting may extend to several days to several weeks. Drugs to decrease the pain as well as nausea are also given intravenously. The vital signs of people with severe acute pancreatitis, such as breathing rate, pulse rate and blood pressure, have to be constantly monitored. Hence they are kept in the intensive care units for close observation. Urine output is checked at regular intervals. Blood tests are done periodically to check blood glucose levels, hematocrit and WBC count, blood electrolyte levels, as well as the levels of pancreatic enzymes lipase and amylase, in the blood. A nasogastric tube is introduced into the stomach for the removal fluid and gas accumulated there, especially if ileus has developed or if vomiting is continuing.
Proton pump inhibitors or H2 blockers are given to stop or decrease the production of digestive acids by the stomach.
When the blood volume is lowered, blood pressure may drop to dangerously low levels, hence the volume of blood should be maintained with intravenous administration of fluids to prevent shock. Oxygen is also administered to some people, but a few critically ill people may need ventilator support. It is essential to monitor heart function parameters closely.
Antibiotic therapy is necessary to treat infections, and sometimes, the diseased tissue may have to be removed surgically to improve the chances of controlling the infection and the resultant inflammation of pancreas.
If a pseudocyst is causing the inflammation, it is surgically drained using a catheter. The location of the pseudocyst determines the type of procedure used to drain it. Sometimes the catheter is inserted through a cut in the skin, but in some cases, it can be introduced with the help of an endoscope which is threaded down into the intestine through the mouth. Pseudocysts may have to be drained for a long period of time extending into weeks.
When gallstones have caused acute pancreatitis, different treatment methods are employed according to the severity of the condition. In mild cases of acute pancreatitis, the gall bladder is removed only after the inflammation subsides. Majority of people who have developed pancreatitis due to gallstones spontaneously pass the gallstones without surgical intervention. But occasionally, to treat severe cases of pancreatitis due to gallstones, a minimally invasive procedure called endoscopic retrograde cholangiopancreatography may have to be done. In this procedure, the stones are located using a dye and then removed with the endoscope. Larger stones may have to be broken down by lithotripsy. After the removal of the stones, the gallbladder is surgically removed.
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What Is Pancreatitis
What Is Pancreatitis ? Pancreatitis is the inflammatory condition of the digestive gland pancreas.
The glandular organ called pancreas is a 5 inch-long, leaf-shaped, fleshy structure which lies between the stomach, and the first part of the intestine called duodenum. It has endocrine and exocrine functions, producing both hormones and digestive enzymes.
The three main functions of pancreas are:
- Secretion of digestive enzymes into the small intestine
- Secretion of sodium bicarbonate in large amounts for the neutralization of stomach acids entering into the small intestine
- Secretion of hormones glucagon and insulin necessary for the regulation of blood sugar.
There may be several reasons for developing pancreatitis including viral infections and gall stones. The action of alcohol, certain drugs, as well as digestive enzymes, may precipitate pancreatitis. Usually, acute pancreatitis develops suddenly and resolves after a few days of inflammation, but if the condition persists over a long period of time, causing steady damage to the pancreas, the condition is referred to as chronic pancreatitis.