Pancreatitis

The pancreas is a gland located in the upper abdomen behind the stomach and just in front of the spine. The pancreas manufactures and secretes powerful digestive enzymes that help to digest fats, proteins and carbohydrates. These enzymes are secreted through a duct (tube) that enters into the upper portion of the small intestine (duodenum) to mix with food as it travels through the small intestine. The pancreas also makes hormones, such as insulin and glucagon that control blood sugar. These hormones are released directly into the bloodstream.

Pancreatitis occurs when there is "inflammation" of the pancreas. This occurs when there is an insult to the pancreas causing inflammation and damage to the gland. There are two main forms of pancreatitis - acute and chronic. The acute form comes on suddenly and is felt as abdominal pain usually in the upper middle portion of the abdomen, often radiating straight through to the back. Chronic pancreatitis occurs when there is persistent or frequent and intermittent injury to the pancreas causing ongoing damage and symptoms.

What are the Symptoms of Pancreatitis?

Acute pancreatitis usually begins with pain in the upper middle abdomen and often can radiate to the back. The pain may last several hours, but often can last several days. The pain can be mild to severe. It is usually constant and the person generally loses their appetite and may experience nausea or vomiting. A mild case of pancreatitis may last briefly and require little medical intervention. On the other hand, pancreatitis can be severe and life-threatening when it is associated with involvement of other organs, such as heart, lungs, or kidneys. After repeated bouts of pancreatitis in a patient with chronic pancreatitis, the gland can lose the ability to manufacture digestive enzymes, insulin and glucagon. This can lead to malabsorption (the inability to properly digest food) and diabetes. The main symptoms of malabsorption are diarrhea, large bulky stools and weight loss. Diabetes may cause weight loss, excess thirst and urination, and fatigue.

What Causes Pancreatitis?

The most common causes of pancreatitis are alcohol abuse and gallstones. If a person drinks alcohol (beer, wine, or hard liquor) on a regular basis, pancreatitis can result. Unfortunately, there are often no warning signs prior to the first attack of pancreatitis. Alcohol is by far the most common cause of chronic recurrent pancreatitis. Gallstones are formed in the gallbladder and can travel out of the gallbladder into the common bile duct which connects the liver to the small intestine. The pancreatic duct joins the common bile duct at the opening into the small intestine. It is through this area that both bile and pancreatic juices flow into the small intestine for digestion. If a stone becomes lodged in the lower bile duct, the pancreatic duct is also obstructed and pancreatitis can result. If a person has had their gallbladder taken out previously, stones can form in the bile duct over time and cause pancreatitis. Other causes of pancreatitis include certain drugs (diuretics, antibiotics, Imuran, anti-HIV drugs), trauma, surgery, testing (ERCP), congenital abnormalities of the pancreas or intestine, or infections. In 15-20% of cases the cause of pancreatitis is not known.

How is Pancreatitis Treated?

The treatment a patient receives depends on the level of severity of the attack of pancreatitis. Mild pancreatitis is generally treated with supportive care, such as I.V. fluids and medicines to control pain and nausea. More severe pancreatitis can result in a prolonged hospitalization particularly if damage to lung, heart or kidneys is encountered. Further treatment depends upon the underlying cause of pancreatitis. If alcohol is the cause, alcohol abstention is critical. If gallstones are the cause, additional testing such as ERCP and/or surgery would be recommended. In chronic pancreatitis, alcohol abstention is mandatory and a low fat diet can be helpful. Pancreatic enzyme supplements (capsules) can be given to help rest the pancreas and reduce symptoms. If a patient with chronic pancreatitis has developed malabsorption or diabetes, pancreatic enzyme supplements and/or Insulin are used. Referral to a specialized pain center can assist with administration of chronic pain medication. Surgery is rarely needed to drain or remove the pancreas.

Testing

Blood work is performed to look for elevated blood levels of pancreatic enzymes (amylase and lipase). Imaging of the pancreas, liver and gallbladder can be done with ultrasonography and/or CT scanning. If gallstones or anatomic variation are suspected as a possible cause of pancreatitis, ERCP is usually performed. At the time of ERCP, stones within the common bile duct can usually be removed. If the gallbladder contains stones, surgery to remove the gallbladder is usually recommended.