Acute pancreatitis

Definition

Acute pancreatitis is sudden swelling and inflammation of the pancreas.

Causes

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

When these enzymes become active inside the pancreas, they digest the tissue of the pancreas. This causes swelling, bleeding (hemorrhage), and damage to the organ and its blood vessels. This condition is called acute pancreatitis.

Acute pancreatitis affects men more often than women. Certain diseases, surgeries, and habits make you more likely to develop this condition. The two most common causes of pancreatitis in the United States are heavy alcohol use and gallstones.

Alcohol use is responsible for up to 70% of cases in the United States. Acute pancreatitis typically requires 5 to 8 drinks per day for 5 or more years. Gallstones are the next most common cause. The condition develops when the gallstones travel out of the gallbladder into the bile ducts, where they block the opening that drains the common bile duct and pancreatic duct (ampulla). Genetics may be a factor in some cases. Sometimes, the cause is not known.

Other conditions that have been linked to pancreatitis are:

Autoimmune problems (when the immune system attacks the body)
Damage to the ducts or pancreas during surgery
High blood levels of a fat called triglycerides (hypertriglyceridemia) usually above 1000 mg/dL
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, sulfonamides, thiazides and azathioprine)
Viral infections, including mumps, coxsackie B, mycoplasma pneumonia, and campylobacter
Injury to the pancreas after a procedure such as an ERCP (endoscopic retrograde cholangiopancreatography) or EUS (endoscopic ultrasound) with FNA (fine needle aspirate)

Symptoms

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

Exams and Tests

The doctor will do a physical exam, which may show:

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

Lab tests that show the release of pancreatic enzymes will be done. These include:

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

Imaging tests that can show inflammation of the pancreas include:

Treatment

Treatment often requires a stay in the hospital. It may involve:

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

A tube may be inserted through the nose or mouth to remove the contents of the stomach (nasogastric suctioning). This may be done if vomiting and 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 damaged, dead or infected pancreatic tissue.

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

Outlook (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

Possible Complications

Pancreatitis can return. The chances of it returning depend on the cause, and how well it can be treated. Complications of acute pancreatitis may include:

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.

When to Contact a Medical Professional

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.
Treat medical conditions that contribute to hypertriglyceridemia.

References

Forsmark CE. Pancreatitis. In: Goldman L, Shafer AI, eds. Goldman's Cecil Medicine. 24th ed. Philadelphia, PA: Elsevier Saunders; 2011:chap 146.

Tenner S, Baillie J, DeWitt J, et al. American College of Gastroenterology Guideline: Management of Acute Pancreatitis. Am J Gastroenterol. 2013; 108:1400-1415.

Tenner S, Steinbert WM. Acute pancreatitis. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger & Fordtran's Gastrointestinal and Liver Disease. 9th ed. Philadelphia, PA: Elsevier Saunders; 2010:chap 58.