Introduction

Photo of a man reading a newspaper (PantherMedia / Elizabeth Beeler-Atkinson) Acute pancreatitis is an inflammation of the pancreas that typically causes very sudden and very severe stomach ache. The most common causes are gallstones and excessive alcohol consumption.

Acute pancreatitis can have serious complications, so it is typically treated in the hospital. Most of the time it passes without any serious problems developing in about one to two weeks. But in more severe cases of pancreatitis, treating the complications may take up to several months. Complications of pancreatitis can be fatal.

Symptoms

Acute pancreatitis almost always causes severe upper abdominal pain. The pain can spread to your back and is usually accompanied by nausea and vomiting. Fever, circulation problems and a bloated stomach are other common symptoms.

The pain is usually sudden and so severe that most people go straight to a doctor. They will usually be referred to the hospital the same day.

An inflamed gallbladder, a heart attack or a gastric perforation from an ulcer can also cause similar symptoms.

Causes and risk factors

Gallstones are the most common cause of acute pancreatitis. The pancreatic duct joins with the common bile duct before it enters the duodenum, a section of the small intestine. There is also a small ring of muscle called the Sphincter of Oddi surrounding this opening that acts to open and close it. If gallstones form and enter the common bile duct, they may end up blocking this opening. This means that the bile and pancreatic juices cannot flow through to the duodenum and build up. Experts believe that it is this blockage that causes the pancreas to become inflamed. Gallstones can form when cholesterol and other substances in the bile clump together. 

Illustration: Gallstones blocking the ampulla of Vater - as described in the informationGallstones blocking the ampulla of Vater


Excessive consumption of alcohol is the second most common cause of pancreatitis. It is still not known exactly how alcohol causes pancreatitis, but the link has been observed in many studies.

Other factors that can increase the likelihood of pancreatitis include constrictions in the bile duct or in the bile duct sphincter, and high levels of specific lipids (triglycerides) or calcium in the bloodstream. Acute pancreatitis is sometimes also caused by certain medications or a viral infection. Surgery performed close to the bile ducts or the gallbladder can also cause pancreatitis, but usually only in very rare cases.

No clear cause is found in as many as 10 out of 100 cases of pancreatitis.

Prevalence

In Germany about 54,000 people are treated at a hospital for acute pancreatitis every year. That corresponds to roughly 60 to 70 out of every 100,000 people. Most people who develop pancreatitis are over the age of 45 and it is more common in men than women.

Outlook

The outlook for pancreatitis can vary quite a bit depending on how severe the inflammation is and how badly the tissue has been damaged. About 80% of people who receive treatment for acute pancreatitis recover in about one to two weeks. More serious complications occur in about 20% of the cases. If that happens it can take weeks or even months to recover from pancreatitis. Overall about 3% of people who develop acute pancreatitis die of the complications, but if parts of the pancreas die off this figure increases to around 20%.

Effects

Pseudocysts are a common complication of acute pancreatitis. “Pseudocysts” are small blisters filled with pancreatic fluids that develop inside or on the pancreas. They usually form within a few weeks and often remain small and go undetected, but they sometimes cause problems like indigestion or bloating. Larger pseudocysts are also at greater risk of tearing open and bleeding or causing an infection.

One of the more serious complications of pancreatitis is called necrotizing infectious pancreatitis. This happens if a part of the pancreas dies (“necrotizes”) and becomes infected with bacteria. This complication usually starts in the second or third week after pancreatitis has developed and is very dangerous because it can provoke an inflammatory response referred to as SIRS (systemic inflammatory response syndrome). If this happens the inflammation can spread from the pancreas to the entire body. The first warning signs are a fever or low body temperature, a drop in blood pressure and accelerated heart or breathing rates. SIRS can cause organ failure depending on severity.

Diagnosis

Your doctor will also feel your abdomen and ask about various risk factors for pancreatitis such as alcohol consumption, medication use and possible signs of gallstones such as cramp-like upper abdominal pain (biliary colic). Blood is usually taken and the doctor will likely also do an ultrasound scan. Anyone thought to have pancreatitis will be referred to a hospital.

Lab tests can be used to tell how high the levels of amylase and lipase are in the blood. These are enzymes produced by the pancreas to break down sugar and fats. Very high levels of amylase or lipase are a sign of pancreatitis. Other blood tests may also be used to detect a possible blockage of bile.

An ultrasound scan of the belly is usually enough to tell whether gallstones are the cause. And if an infection has changed the tissue of the pancreas it can usually be seen in ultrasound too.

Sometimes more testing is needed. Magnetic resonance imaging (MRI) can be used to create a picture of the bile ducts and any gallstones. Another option is to use an endoscope to look for gallstones in the bile duct. The endoscope passes into the duodenum through the esophagus (endoscopic ultrasound).

A computed tomography (CT) scan can be used to detect complications such as necrotizing tissue and to get an idea about how the inflammation is developing. Endoscopic retrograde cholangiography (ERC) may also be needed for a diagnosis if the pancreatitis is caused by a blocked bile duct or related to an inflammation of the bile duct. This also involves moving an endoscope passed through the esophagus down to the bile duct opening in the duodenum. Contrast medium is injected into the duct to make any stones that are there show up in the x-ray image. These stones can also be removed during the examination by the endoscope. An ERC exam also involves radiation exposure, and may cause various complications.

Treatment

No treatment is available for dealing with the root cause of pancreatitis. But there are a number of options for reducing strain on the pancreas and relieving symptoms. Because fluid levels can drop due to acute pancreatitis, the first step is to prevent dehydration by using infusion therapy. A hollow needle inserted in an arm vein is used to release a solution into the bloodstream. Medication is used to provide relief from pain, nausea and vomiting. Stronger painkillers such as opioids are sometimes needed, and they may make you feel drowsy or light-headed.

Solid foods are avoided until the pain recedes and appetite returns to give the pancreas a chance to recuperate. In mild cases of pancreatitis it is sometimes possible to return to eating solid foods after just a few days. If the symptoms last longer, artificial feeding may be necessary to supply your body with enough nutrients.

If the pancreatitis is caused by gallstones, the stones may need to be removed using endoscopic retrograde cholangiography. After treatment the gallbladder is surgically removed to prevent further episodes.

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