Acute pancreatitis

Definition

Acute pancreatitis is sudden swelling and inflammation of the pancreas.

Causes, incidence, and risk factors

The pancreas is an organ located behind the stomach that produces chemicals called enzymes, as well as the hormones insulin and glucagon. Most of the time, the enzymes are only active after they reach the small intestine, where they are needed to digest food.

When these enzymes somehow become active inside the pancreas, they eat (and digest) the tissue of the pancreas. This causes swelling, bleeding (hemorrhage), and damage to the pancreas and its blood vessels.

Acute pancreatitis affects men more often than women. Certain diseases, surgeries, and habits make you more likely to develop this condition.

The condition is most often caused by alcoholism and alcohol abuse (70% of cases in the United States). Genetics may be a factor in some cases. Sometimes the cause is not known, however.

Other conditions that have been linked to pancreatitis are:

• Autoimmune problems (when the immune system attacks the body)
• Blockage of the pancreatic duct or common bile duct, the tubes that drain enzymes from the pancreas
• Damage to the ducts or pancreas during surgery
• High blood levels of a fat called triglycerides (hypertriglyceridemia)
• Injury to the pancreas from an accident

Other causes include:

• Complications of cystic fibrosis
• Hemolytic uremic syndrome
• Hyperparathyroidism
• Kawasaki disease
• Reye syndrome
• Use of certain medications (especially estrogens, corticosteroids, thiazide diuretics, and azathioprine)
• Viral infections, including mumps, coxsackie B, mycoplasma pneumonia, and campylobacter

Symptoms

The main symptom of pancreatitis is abdominal pain felt in the upper left side or middle of the abdomen.

The pain:

• May be worse within minutes after eating or drinking at first, especially if foods have a high fat content
• Becomes constant and more severe, lasting for several days
• May be worse when lying flat on the back
• May spread (radiate) to the back or below the left shoulder blade

People with acute pancreatitis often look ill and have a fever, nausea, vomiting, and sweating.

Other symptoms that may occur with this disease include:

• Clay-colored stools
• Gaseous abdominal fullness
• Hiccups
• Indigestion
• Mild yellowing of the skin and whites of the eyes (jaundice)
• Skin rash or sore (lesion)
• Swollen abdomen

Signs and tests

The doctor will perform a physical exam, which may show that you have:

• Abdominal tenderness or lump (mass)
• Fever
• Low blood pressure
• Rapid heart rate
• Rapid breathing (respiratory) rate

Laboratory tests will be done. Tests that show the release of pancreatic enzymes include:

• Increased blood amylase level
• Increased serum blood lipase level
• Increase urine amylase level

Other blood tests that can help diagnose pancreatitis or its complications include:

• Complete blood count (CBC)
• Comprehensive metabolic panel

Imaging tests that can show inflammation of the pancreas include:

• Abdominal CT scan
• Abdominal MRI
• Abdominal ultrasound

Treatment

Treatment often requires a stay in the hospital and may involve:

• Pain medicines
• Fluids given through a vein (IV)
• Stopping food or fluid by mouth to limit the activity of the pancreas

Occasionally a tube will be inserted through the nose or mouth to remove the contents of the stomach (nasogastric suctioning). This may be done if vomiting or severe pain do not improve, or if a paralyzed bowel (paralytic ileus) develops. The tube will stay in for 1 - 2 days to 1 - 2 weeks.

Treating the condition that caused the problem can prevent repeated attacks.

In some cases, therapy is needed to:

• Drain fluid that has collected in or around the pancreas
• Remove gallstones
• Relieve blockages of the pancreatic duct

In the most severe cases, surgery is needed to remove dead or infected pancreatic tissue.

Avoid smoking, alcoholic drinks, and fatty foods after the attack has improved.

Expectations (prognosis)

Most cases go away in a week. However, some cases develop into a life-threatening illness.

The death rate is high with:

• Hemorrhagic pancreatitis
• Liver, heart, or kidney impairment
• Necrotizing pancreatitis

Pancreatitis can return. The likelihood of it returning depends on the cause, and how successfully it can be treated.

Complications

• Acute kidney failure
• Acute respiratory distress syndrome (ARDS)
• Buildup of fluid in the abdomen (ascites)
• Cysts or abscesses in the pancreas
• Heart failure
• Low blood pressure

Repeat episodes of acute pancreatitis can lead to chronic pancreatitis.

Calling your health care provider

Call your health care provider if:

• You have intense, constant abdominal pain
• You develop other symptoms of acute pancreatitis

Prevention

You may lower your risk of new or repeat episodes of pancreatitis by taking steps to prevent the medical conditions that can lead to the disease:

• Avoid aspirin when treating a fever in children, especially if they may have a viral illness, to reduce the risk of Reye syndrome.
• Do NOT drink too much alcohol.
• Make sure children receive vaccines to protect them against mumps and other childhood illnesses (see: Immunizations - general overview).

References

Banks PA, Freeman ML; Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis. Am J Gastroenterol. 2006;101:2379-2400.

Frossard JL, Steer ML, Pastor CM. Acute pancreatitis. Lancet. 2008;371:143-152.

Owyang C. Pancreatitis. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 147.