How is acute pancreatitis treated?

Photo of woman on a drip (Jupiterimages / Photos.com / Thinkstock)

Acute pancreatitis usually clears up within one to two weeks. Solid foods are generally avoided for a while in order to reduce the strain on the pancreas. Supportive measures like an infusion (IV drip) to provide fluids and painkillers can help to relieve symptoms and prevent complications.

The main signs of acute pancreatitis are sudden and severe pain in the upper abdomen, nausea and vomiting. It is usually caused by gallstones blocking the opening of the pancreas or by drinking too much alcohol.

In 80% of people with acute pancreatitis, the inflammation either clears up completely or improves a lot within one to two weeks. But it sometimes leads to serious complications, so it’s usually treated in a hospital.

What is the most important first step in treating pancreatitis?

Acute pancreatitis causes the body to lose a lot of fluids quickly, which leads to a loss of important minerals too. Nausea and vomiting also make it difficult to get enough fluids. Dehydration can cause complications such as low blood pressure or even circulatory failure. To prevent this from happening, the patient is put on a drip that supplies them with fluids and electrolytes.

Relieving the pain

Acute pancreatitis is usually very painful. There are a number of medications to relieve the pain. Strong painkillers (opioids) are often needed. Painkillers are also usually given through a drip or catheter (epidural).

Sometimes it’s possible to adjust the dose of the painkiller on your own. This is called “patient-controlled analgesia” or PCA. You use a pump to control how much of the medicine is delivered. There are checks in place to prevent overdosing.

In the past, opioids such as morphine were used cautiously because it was feared that they would make it even harder for the digestive juices to flow out of the pancreas. But research has not found this to be true. There are currently no known reasons for not treating acute pancreatitis pain with opioids.

Weaker painkillers like acetaminophen (paracetamol) or an NSAID like ibuprofen can be used once the pain starts to subside.

When can you start eating again?

Patients are no longer advised to stop eating completely. Research has shown that many people can start eating a little again as soon as their symptoms improve and they feel hungry. This is even true for people who have a higher risk of complications.

It is often possible to start eating solid foods after one to two days, but doctors recommend starting off with food that can be easily digested and is low in fat. Still, if someone feels nauseous, needs to vomit or has complications such as bowel obstruction, it's best for them to wait before eating solid foods again.

When is it necessary to use a feeding tube?

If it's not possible to start eating again within a few days, a feeding tube can be used to supply important nutrients such as proteins, carbohydrates, fats, vitamins and minerals in a specially prepared liquid food. Feeding tubes are inserted through the nose and gently pushed down through the food pipe to the stomach or small intestine.

In rare cases, parenteral nutrition may also be necessary. It delivers nutrients directly into the bloodstream using a drip. This may be done if, for instance, someone can't eat at all because digestion causes immediate pain. Whenever possible, a feeding tube is used instead of a drip. This is because many studies have shown that giving parenteral nutrition through a drip is associated with more infections and complications, and even with more deaths.

Can antibiotics or other medications prevent complications?

Acute pancreatitis can lead to infections. These can affect the pancreas itself or other organs, such as the lungs or the bile ducts. The infections are treated with antibiotics.

It would be better to prevent them in the first place, though. Antibiotics were often used as a preventive measure in the past, particularly if some of the pancreas tissue had died (necrotizing pancreatitis). This was done to keep the dead tissue from becoming infected and causing a condition called infected pancreatic necrosis. But studies have not clearly shown that taking antibiotics as a precaution can prevent complications. Because the use of antibiotics also leads to side effects and increases the likelihood of antimicrobial resistance, experts no longer recommend routinely using antibiotics as a precaution.

Several studies looked into whether the use of prebiotics or probiotics can prevent complications or influence how severe a case of pancreatitis becomes. These substances are believed to promote the growth of harmless lactic acid bacteria, lowering the risk of infections. But research hasn't found this to be true.

How are gallstones treated?

If acute pancreatitis is caused by gallstones, the stones can be removed using endoscopic retrograde cholangiography (ERC). This involves gently pushing an endoscope through your food pipe, your stomach, and the first part of the small intestine, to the opening of the bile duct. A contrast medium is then injected into the bile duct to make any stones that are there show up in an x-ray image. With the help of a small basket-like wire instrument at the end of the endoscope, these stones can also be removed during the procedure.

If the pancreatitis was caused by gallstones, the gallbladder is usually removed at a later time. This lowers the risk of more gallstones forming and the pancreas becoming inflamed again. About 20 out of 100 people who don’t have their gallbladder removed have another pancreas inflammation within a few months. If there are no complications, the gallbladder can be removed within a few days of hospitalization. The sooner it is removed, the earlier you can leave the hospital. According to research, there are no drawbacks to removing the gallbladder early on in uncomplicated cases of pancreatitis. In severe cases or if there are complications, it's better to wait until the patient has had time to recover. Otherwise the risk of complications during the procedure is too high.

Severe cases of pancreatitis

In about 15 to 20 out of 100 cases, acute pancreatitis leads to complications affecting the pancreas or other organs. Pseudocysts (fluid-filled cyst-like blisters in the pancreas) are a common complication. If they are small and don’t cause any symptoms, they don’t need to be treated. Larger pseudocysts may rip open and bleed or become infected and form an abscess. To stop this from happening, the cyst can be punctured and drained from the outside using a hollow needle. In some cases, surgery is needed.

If it’s not infected, dead tissue doesn’t always need to be treated. Infected dead tissue has to be treated with antibiotics, though. It may also be necessary to remove the dead tissue. Various procedures are used, depending on what part of the pancreas is affected. If the dead tissue isn’t causing any acute problems, it’s best to wait for about four weeks before removing it so that the patient can recover from the illness first. By then the dead tissue will also have hardened, making it easier to tell it apart from healthy tissue and remove it.

Very severe cases of pancreatitis can lead to an inflammation throughout the entire body, known as systemic inflammatory response syndrome (SIRS). SIRS can cause single or multiple organ failure and has to be treated in an intensive care unit. There, doctors and nurses try to keep the organs functioning until the inflammation has passed.

What happens after recovery?

If a specific cause of acute pancreatitis was found, such as gallstones or a (rare) metabolic disorder, that cause is treated. Otherwise, no other treatments are needed following a case of uncomplicated acute pancreatitis. If the pancreatitis was alcohol-related, people are advised to drink a lot less alcohol afterwards. Some experts recommend not drinking any alcohol at all for 6 to 12 months after each episode of pancreatitis. But there has been no research into whether avoiding alcohol can help prevent new cases of pancreatitis if the cause isn’t alcohol-related.

People who had a severe case of acute pancreatitis with complications may need further treatment after leaving the hospital. Extreme weight loss is common during acute pancreatitis. It can sometimes take several weeks for your appetite to return and to put the weight back on. Advice from a nutritionist can help during this time. In some people, the pancreas doesn’t produce enough digestive juices (for a while) after the pancreatitis has cleared up. If that happens, artificial pancreatic enzymes can be taken with meals to help the body absorb food fats. People who have had acute pancreatitis are also more likely to develop diabetes, which then needs to be treated.