Pancreatitis

Definition

The pancreas is a long, flat gland tucked behind your stomach between the upper part of your small intestine (duodenum) and your spleen. It plays important roles in both digestion and metabolism. These functions may be affected by pancreatitis, an inflammatory condition that occurs when pancreatic digestive enzymes become active within the gland and attack the pancreas itself.

Pancreatitis can be acute — appearing suddenly and lasting for a few days — or it can be chronic, developing gradually and persisting over many years. Both acute and chronic pancreatitis are marked by mild to severe abdominal pain, often with nausea, vomiting and fever. And both can lead to serious complications.

Heavy alcohol use and gallstones are the primary causes of pancreatitis, but other factors, including certain medical conditions, some drugs and genetic mutations also can lead to the disorder. Sometimes the cause is never found.

Mild attacks of acute pancreatitis often improve on their own or after simple dietary changes, but more severe cases may require immediate medical care to avoid fatal complications. Chronic pancreatitis is usually treated with lifestyle changes, with enzyme supplements to improve digestion and sometimes with surgery.

Symptoms

Acute pancreatitis comes on suddenly, usually with mild to severe pain in your upper abdomen that may radiate to your back and occasionally to your chest. The pain may be nearly constant for hours or even days and is likely to become worse when you drink alcohol or eat. Bending forward or curling into a fetal position may provide temporary relief.

Other signs and symptoms of acute pancreatitis include:

• Nausea and vomiting
• Fever
• Rapid pulse
• Swollen, tender abdomen
• In severe cases, dehydration and low blood pressure, internal bleeding, and shock

You may have repeated episodes of acute pancreatitis and recover fully from each one. Still, every attack is a serious illness that can damage your pancreas and cause life-threatening complications.

Chronic pancreatitis
Ongoing damage to your pancreas can lead to a chronic condition that destroys the pancreas and nearby tissues, although it may be years before signs and symptoms appear. A few people with chronic pancreatitis never experience discomfort, but most have intermittent bouts of abdominal pain that can be severe. The pain may also become constant.

In addition to pain, you may experience the following with chronic pancreatitis:

• Nausea and vomiting
• Fever
• Weight loss, even when your appetite and eating habits are normal
• Oily, malodorous stools resulting from poor digestion and malabsorption of nutrients, particularly fats (steatorrhea)
• Diabetes

Hereditary pancreatitis
The inherited form of pancreatitis is marked by recurrent attacks of pain, nausea, vomiting and fever lasting anywhere from two days to two weeks. In the majority of cases, the acute bouts progress to chronic pancreatitis. Although the genetic defect that causes the condition is present at birth, pancreatitis symptoms often don't appear until the first or second decade of life. However, most people with hereditary pancreatitis will develop pancreatitis before the age of 20.

Digestive system

Digestive system

The pancreas is a long, flat gland that lies horizontally behind your stomach. It has a role in digestion and in regulating the level of sugar in your blood.

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Causes

The pancreas serves two distinct and vital functions. It produces digestive juices and enzymes that help break down proteins, carbohydrates and fats in your small intestine. It also secretes the hormones insulin and glucagon, which regulate the way your body metabolizes sugar (glucose).

Most of your pancreas is composed of cells called exocrine cells that produce digestive enzymes. These cells are arranged in clusters and connected to a series of small ducts. Pancreatic enzymes and juices flow from the cells through the ducts into the main pancreatic duct, which leads to your duodenum. The last portion of the bile duct, which carries bile from your liver and gallbladder, joins with the pancreatic duct just before it empties into your small intestine.

Your pancreas also contains small "islands" of endocrine cells located within the exocrine tissue. These cells, called the islets of Langerhans, secrete insulin and glucagon, along with another hormone, somatostatin, into your bloodstream.

What happens in pancreatitis
Mild acute pancreatitis usually doesn't permanently affect digestion or blood sugar levels, although a single severe attack can damage your pancreas and trigger chronic pancreatitis, which destroys the cells that produce both enzymes and insulin.

Ongoing damage to enzyme-producing tissue in chronic pancreatitis leads to poor absorption (malabsorption) of nutrients, especially fats, to weight loss, and to oily, malodorous stools. And damage to or destruction of insulin-producing cells means blood sugar isn't metabolized properly, often leading to diabetes.

Contributing factors
A combination of environmental and genetic factors likely plays a role in the development of most cases of pancreatitis. Nevertheless, long-term alcohol abuse remains a leading cause of both acute and chronic pancreatitis in industrialized nations.

It's not clear in all instances just how alcohol affects the pancreas. But scientists do know that alcohol causes digestive enzymes to be released sooner than normal. It also increases the permeability of the small ducts that convey enzymes within the pancreas, which allows digestive juices to leak into and damage healthy tissue. What's more, excessive alcohol intake leads to the formation of protein plugs — precursors to small stones — that block parts of the pancreatic duct.

Gallstones also can block the pancreatic duct and are another leading cause of acute pancreatitis. Formed when bile in your gallbladder becomes chemically unbalanced, gallstones sometimes migrate from the gallbladder to the common bile duct, which merges with the pancreatic duct near the entrance to your small intestine. There the stones can block the flow of pancreatic juices into the duodenum. As a result, digestive enzymes become active in your pancreas, where they "digest" healthy tissue, rather than in the duodenum, where they normally break down food.

Other factors that can cause or contribute to pancreatitis include:

• Increased blood levels of fats called trigylcerides (hyperlipidemia) or of calcium (hypercalcemia)
• Certain medications, including corticosteroids and nonsteroidal anti-inflammatory drugs, blood pressure lowering drugs (thiazides), antibiotics such as tetracyclines and sulfonamides, and medications that suppress the immune system such as azathioprine and 6-mercaptopurine
• Surgery, usually of the abdomen
• Structural abnormalities of the pancreas or the common bile duct
• Abdominal trauma, which can compress the pancreas against your spine
• Viral infections, including mumps, hepatitis and Epstein-Barr virus
• Bacterial infections
• Pancreatic cancer, which can obstruct the flow of pancreatic enzymes
• Some inherited diseases, especially cystic fibrosis
• Gene abnormalities, leading to a hereditary form of the disease

Pancreatitis and gallstones

Pancreatitis and gallstones

Acute pancreatitis is often caused by gallstones obstructing the pancreatic duct. This can cause digestive juices produced by the pancreas to move into the pancreas itself, where they attack healthy tissue.

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Risk factors

One of the primary risk factors for pancreatitis is long-term alcohol abuse, though not everyone with alcoholism develops this disease. For that reason, researchers believe that more than one factor may be involved in pancreatitis, including:

• Gallbladder disease. Gallstones that lodge in the lower portion of the bile duct can block the pancreatic duct, causing digestive juices to back up into the pancreas, where they destroy healthy tissue.
• Ethnicity. Black Americans are more likely to develop acute pancreatitis than white Americans are.
• Your sex. Pancreatitis occurs more frequently in men, possibly because men are more likely to abuse alcohol than are women.
• Genetic mutations. Abnormalities in one or more genes may predispose some people to pancreatitis.
• Other medical conditions. Certain inherited diseases, particularly cystic fibrosis, increase your risk of pancreatitis.

When to seek medical advice

If you have intense, persistent abdominal pain, see your doctor to determine whether pancreatitis or some other medical condition is the cause. It's important to diagnose pancreatitis early before severe and irreversible damage to your pancreas occurs.

Tests and diagnosis

Because diagnosing pancreatitis can be difficult, you're likely to have several tests to help pinpoint the problem. The type of test may depend on whether your pancreatitis is acute or chronic.

Acute pancreatitis
If your doctor suspects that you have acute pancreatitis, a sample of your blood may be analyzed for abnormalities such as:

• Elevated levels of the pancreatic enzymes, amylase and lipase
• Elevated white blood cell count
• Elevated liver enzymes and bilirubin, a substance that results from breakdown of red blood cells
• High blood sugar (hyperglycemia)
• Low calcium level — high calcium levels can cause pancreatitis, but low levels of calcium in the blood, called hypocalcemia, are a common result

Because laboratory tests can't confirm a diagnosis of acute pancreatitis, your doctor may request an ultrasound or computerized tomography (CT) scan of your abdomen to examine your pancreas and to check for gallstones, a duct problem, or destruction of the gland. You may also have X-rays of your abdomen and chest to rule out other reasons for your symptoms.

Chronic pancreatitis
Diagnosing chronic pancreatitis can be challenging because some tests may yield normal results, even though you have the disease. It can also be difficult to distinguish acute from chronic pancreatitis. Even so, certain tests can help rule out other problems and aid in the diagnosis. These include:

• Blood tests. These tests can identify abnormalities associated with chronic pancreatitis and help rule out acute inflammation.
• Stool test. This measures the fat content in your feces. Chronic pancreatitis often causes excess fat in your stool because the fat isn't digested and absorbed normally by your small intestine.
• Ultrasound. In standard (external) ultrasound, a wand-like device (transducer) is placed on your body. It emits inaudible sound waves that are reflected to the transducer and then translated into a moving image by a computer. Endoscopic ultrasound may provide images of your pancreas and bile and pancreatic ducts that are superior to those produced by standard ultrasound. In endoscopic ultrasound, your doctor uses a thin, flexible tube with a light (endoscope) to thread a small ultrasound device through your stomach. The device then generates a detailed image on a computer screen.
• X-ray of bile and pancreatic ducts. In a procedure called endoscopic retrograde cholangiopancreatography, your doctor gently threads an endoscope down your throat and through your stomach to the opening of the bile and pancreatic ducts in your duodenum. A dye passed through a thin, flexible tube (catheter) inside the endoscope allows for X-ray images of the ducts.
• Pancreatic function test. If you've lost weight or your doctor suspects a malabsorption problem, you may have a pancreatic function test. Several tests exist, but all measure the ability of your pancreas to secrete enzymes or other substances necessary for digestion.

You may need additional tests if your doctor is concerned about the possibility of other diseases, such as pancreatic cancer. Chronic pancreatitis puts you at a slightly higher risk of pancreatic cancer.

Complications

Severe cases of acute pancreatitis may lead to a number of complications:

• Infection. A damaged pancreas may become infected with bacteria that spread from the small intestine into the pancreas. Signs of infection include fever, an elevated white blood cell count and, in severe cases, organ failure. A fluid sample from your pancreas may be tested for bacterial infection. Pancreatic infections can be fatal without intensive treatment, including drainage or surgery to remove the infected tissue. Sometimes multiple operations are necessary.
• Pseudocysts. These are collections of pancreatic fluid and sometimes tissue debris that form within your pancreas or in an obstructed duct. If the cyst is small, no special care may be necessary, but large, infected or bleeding pseudocysts require immediate treatment.
• Abscess. This is a collection of pus in or near your pancreas that may develop after the onset of acute pancreatitis. Treatment involves drainage of the abscess by catheter or surgery.
• Respiratory failure. Chemical changes in your body can affect your lung function, causing the level of oxygen in your blood to fall to dangerously low levels.
• Shock. This life-threatening complication usually occurs when your blood pressure is so low your organs can't carry out their normal functions. Severe shock can cause death within minutes if left untreated.

The complications common to acute pancreatitis can also occur in the chronic form of the disease. In addition, chronic pancreatitis can lead to:

• Bleeding. Ongoing inflammation and damage to the blood vessels surrounding the pancreas can cause potentially fatal bleeding.
• Malnutrition and weight loss. Lack of digestive enzymes prevents your body from absorbing nutrients from food. The result is often unintended weight loss and malnutrition.
• Diabetes. Damage to insulin-producing cells can lead to diabetes, a disease that affects the way your body uses blood sugar.
• Drug addiction. Because medical treatments for severe pancreatic pain aren't always effective, people with pancreatitis may become addicted to pain medications.
• Pancreatic cancer. Long-term inflammation of the pancreas increases your risk of pancreatic cancer, one of the most serious of all malignancies.

Treatments and drugs

Acute pancreatitis
Severe acute pancreatitis usually requires a hospital stay. If you have complications, you may be admitted to the intensive care unit. Treatment goals include controlling the pain, allowing the pancreas to rest and restoring a normal balance of pancreatic juices.

Because the pancreas goes into action whenever you eat, you won't be able to eat or drink for a few days. Instead, you'll receive fluids and nutrition through a vein (intravenously). Your doctor may also feed you through a tube that's been passed into your stomach and intestine so that it goes past the pancreas. Placing the tube in the bowel beyond the pancreas ensures that the pancreas is not stimulated, yet you can still receive the nutrition you need.

Longer term treatment includes therapy for alcohol abuse, chemical dependency or smoking if these factors play a role in your pancreatitis. A team approach involving a chemical dependency counselor and a psychologist trained in cognitive therapy may be the most helpful.

When gallstones block the pancreatic duct, your doctor may recommend a procedure to remove the stones. You may eventually need surgery to remove your gallbladder if gallstones continue to pose problems.

Mild cases of acute pancreatitis generally improve in a week or less. Moderate to severe cases take longer.

Chronic pancreatitis
The main goals of treatment for chronic pancreatitis are to help stop alcohol and drug abuse, control pain and improve malabsorption problems.

• Therapy for alcohol dependency. This may be the most important step in treating alcohol-related pancreatitis. In the early stages of the disease, simply stopping drinking may relieve even severe pain. As pancreatitis progresses, continuing to use alcohol greatly increases the risk of complications and death — people who don't stop drinking have a significantly higher chance of dying of pancreatitis.
• Pain relief. Unlike acute pancreatitis, in which the pain often disappears within a few days to weeks, chronic pancreatitis pain can linger. However, conventional pain relievers can be ineffective and pose a real risk of addiction. Using potent pancreatic enzymes to treat pain has proved effective for some people. Enzyme therapy works by increasing the levels of enzymes in the duodenum, which in turn decreases the secretion of enzymes by the pancreas. This is thought to reduce secretion pressure — and hence, pain — within the pancreas. For severe pain that can't be controlled, treatment options include surgery to remove damaged tissue or procedures to block pain signals or deaden the nerves transmitting the pain.
• Enzyme therapy for malabsorption. Enzyme supplements such as pancrelipase (Pancrease, Viokase) can help treat malabsorption problems. By replacing missing enzymes, these tablets help restore normal digestion and improve steatorrhea, leading to weight gain and enhanced well-being. These supplements are generally taken before and during meals and snacks.
• Dietary changes. Your doctor may recommend eating smaller meals and limiting fats, which will help reduce your need for as many digestive enzymes.

Treatment for diabetes
Chronic pancreatitis can cause diabetes in some people. Treatment usually involves maintaining a healthy diet and getting regular exercise. Some people also need insulin injections, although insulin must be used cautiously because of the risk of low blood sugar (hypoglycemia). Your doctor will talk with you about how to manage diabetes, recognize symptoms of high and low blood sugar, and prevent complications.

Prevention

Although pancreatitis isn't always preventable, you can take steps to reduce your risk:

• Avoid excessive alcohol use. Overuse of alcohol is the leading cause of chronic pancreatitis and a contributing factor in many acute attacks.
• Stop smoking. Tobacco use increases your risk of pancreatitis, especially if you also drink alcohol.
• Limit fat. Eating a high-fat diet can raise your blood-fat levels and increase your risk of gallstones — both risk factors for pancreatitis. A healthy diet emphasizes fresh fruits and vegetables, whole grains, and lean protein, and limits fats, especially saturated fats such as butter.

Lifestyle and home remedies

Chronic pancreatitis may leave you with lifelong signs and symptoms, such as pain and malabsorption of certain nutrients. However, most people with acute pancreatitis recover completely. But even if you experience no lingering symptoms, it's important to take steps to keep your pancreas as healthy as possible:

• Avoid alcohol. If you can't voluntarily stop drinking alcohol, get treatment for alcoholism. Abstaining from alcohol may or may not reduce your pain, but it will reduce your risk of dying of your disease.
• Eat smaller meals. The more you eat during a meal, the greater the amount of digestive juices your pancreas must produce. Instead of large meals, eat smaller, more frequent meals.
• Limit fat in your diet. Limiting fat will help reduce loose and oily stools that result from a lack of pancreatic enzymes. Discuss with your doctor or a dietitian how much fat to eat each day because some fat is essential.
• Follow a diet high in carbohydrates. Carbohydrates give you energy to help fight fatigue. They're present in foods made from starches (complex carbohydrates) or sugars (simple carbohydrates). Try to get most of your daily calories from complex carbohydrates found in grains, vegetables and legumes. If you have diabetes, a dietitian can help you plan an appropriate diet.
• Drink plenty of liquids. If you have chronic pancreatitis, be sure to drink enough liquids so that you don't become dehydrated. Dehydration may aggravate your pain by further irritating your pancreas.
• Find safe ways to control pain. Talk with your doctor about options for controlling your pain, including the benefits and risks of prescription and over-the-counter pain relievers and the use of digestive enzymes.

Coping and support

By avoiding alcohol, eating well and working closely with your doctor to find appropriate medications, you have a better chance of managing your condition and living a more active, productive lifestyle.

As is true with other chronic diseases, living with pancreatitis can cause emotional ups and downs. Here are tips for dealing with those swings:

• Maintain normal daily activities as best you can.
• Stay connected with friends and family.
• Continue to pursue hobbies that you enjoy and are able to do.
• Consider joining a support group, especially one for people with chronic pain.

Keep in mind that your physical health can impact directly on your mental health. Denial, anger and frustration are common with chronic illnesses. At times, you may need more tools to deal with your emotions. Professionals such as therapists or behavioral psychologists may be able to help you put things in perspective. They can also teach coping skills, including relaxation techniques, that may help you.

In addition, having a chronic illness may increase your risk of depression. This isn't a failure to cope but may indicate a disruption in your body's neurochemistry that can be helped with appropriate medical treatment. Talk with your family, friends and doctor if you're feeling depressed.