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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Yasser Elnahas

MD, PHD, Professor Of CardioVascular Surgery
Dr. Yasser Elnahas, Is an associate Professor of Cardiovascular Surgery. Dr. Elnahas was trained as a fellow At Texas Heart Institute And Mayo Clinic Foundation.Dr. Elnahas is dedicated to educating the general public about different disease conditions and simplifying the medical knowledge in an easy to understand terminology.

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