acute pancreatitis
http://www.uptodate.com Santhi Swaroop Vege, MD
PANCREATITIS OVERVIEW — Acute pancreatitis refers to inflammation of the pancreas, causing sudden and severe abdominal pain. The pancreas is an organ that lies in the back of the mid-abdomen (figure 1). It produces digestive juices and certain hormones, including insulin. Pancreatitis usually develops as a result of gallstones or moderate to heavy alcohol consumption over a period of years.
Most attacks of acute pancreatitis do not lead to complications, and most people recover uneventfully with medical care. However, a small proportion of people have a more serious illness that requires intensive medical care. In all cases, it is essential to determine the underlying cause of acute pancreatitis and, if possible, to treat this condition to prevent a recurrence.
PANCREATITIS CAUSES — There are many possible underlying causes of acute pancreatitis, but 60 to 75 percent of all cases are caused by gallstones or alcohol abuse.
Gallstone pancreatitis — Because the gallbladder and pancreas share a drainage duct, gallstones that lodge in this duct can prevent the normal flow of pancreatic enzymes and trigger acute pancreatitis.
Alcoholic pancreatitis — Alcohol is a common cause of acute pancreatitis. Alcoholic pancreatitis is more common in individuals who have a long history of alcohol abuse.
Drug-induced pancreatitis — A number of drugs used to treat medical conditions can trigger acute pancreatitis.
Post-ERCP — Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that is done to evaluate the gallbladder or pancreas. Acute pancreatitis develops in about 3 to 5 percent of people who undergo ERCP. Most cases of ERCP-induced pancreatitis are mild.
Hereditary conditions — Acute pancreatitis can be caused by hereditary conditions, such as familial hypertriglyceridemia (high blood triglyceride levels) and hereditary pancreatitis. These conditions usually occur in children and young adults.
Unexplained — No underlying cause can be identified in about 20 percent of people with acute pancreatitis. This condition is called idiopathic pancreatitis. Only a small proportion of this group will experience additional attacks over time.
PANCREATITIS SYMPTOMS — Acute pancreatitis frequently presents with sudden, constant pain in the upper part of the abdomen, although other medical conditions can also cause this type of pain. The pain may wrap around your upper body and involve the back in a band-like pattern. The pain typically lasts days and is often relieved by leaning forward. Some people have only slight abdominal tenderness and in 5 to 10 percent of people, there is no pain at all.
In people with gallstone pancreatitis, gallbladder pain may occur before pancreatic pain. Gallbladder pain (referred to as biliary colic) occurs in the right upper abdomen, extending to the back and right shoulder. The pain gradually increases in intensity, is constant, and may be accompanied by nausea and vomiting. Gallbladder pain often follows a meal.
In people with alcoholic pancreatitis, the symptoms of acute pancreatitis often occur one to three days after an alcohol binge or after stopping drinking. Pain is accompanied by nausea and vomiting in most people. In severe cases, the initial symptom may be shock or coma.
PANCREATITIS DIAGNOSIS — Diagnosing acute pancreatitis can be difficult because the signs and symptoms of pancreatitis are similar to other medical conditions. The diagnosis is usually based upon a medical history, physical examination, and the results of diagnostic tests. Two of the following three are required to make a diagnosis: (1) typical abdominal pain; (2) threefold or more elevation of pancreatic enzyme values in the blood; and (3) inflammation of the gland on computed tomography (CT) scan or magnetic resonance imaging (MRI) scan. The number and type of tests is tailored to the severity of acute pancreatitis and the most likely underlying causes.
Once a diagnosis of acute pancreatitis is made, additional tests are needed to determine the underlying cause. This ensures that the correct treatment is given to prevent pancreatitis from recurring.
Imaging tests — Imaging tests provide information about the structure of the pancreas, the ducts that drain the pancreas and gallbladder, and the tissues surrounding the pancreas. Imaging tests may include an x-ray of the abdomen, chest, CT scan or MRI of the abdomen.
Endoscopic retrograde cholangiopancreatography (ERCP) — ERCP is a procedure that can be used to remove stones from the bile duct if your pancreatitis is due to gallstones or other problems with the bile or pancreatic ducts. In addition, ERCP can be used to treat some causes of pancreatitis.
PANCREATITIS TREATMENT — The goals of treatment of acute pancreatitis are to alleviate pancreatic inflammation and to correct the underlying cause. Treatment usually requires hospitalization for at least a few days.
Mild pancreatitis — Mild pancreatitis usually resolves with simple supportive care, which entails monitoring, drugs to control pain, and intravenous fluids. You may not be allowed to eat anything during the first few days if you have nausea or vomiting.
Moderate to severe pancreatitis — Moderate to severe pancreatitis requires more extensive monitoring and supportive care. This is because severe pancreatitis can lead to potentially life-threatening complications, including damage of the heart, lung, and kidneys. People with pancreatitis of this severity may be closely monitored in an intensive care unit.
During this time you may be given one or more of the following treatments:
●Intravenous fluids are given to help prevent dehydration.
●Many patients with moderate to severe pancreatitis may not be able to eat in the early course of their illness. Instead, you may be fed through a tube placed through the nose or mouth into the small intestine.
If you cannot tolerate tube feeding or cannot get enough nutrients with tube feeding, you may be given nutrition through an intravenous line placed in the upper chest. You can resume eating gradually once your pain resolves and bowel function returns to normal.
●About 30 percent of people with severe acute pancreatitis develop an infection in the damaged pancreatic tissue. Antibiotics can prevent infections and control infections that are already present.
●Acute pancreatitis is sometimes complicated by extensive damage and/or infection to the pancreatic tissue. In these cases, the damaged and/orinfected tissue may be removed in a procedure referred to as a necrosectomy. Necrosectomy can be done as a minimally invasive procedure.
Gallstone pancreatitis treatment — In people who have gallstone pancreatitis, the treatment of pancreatitis is usually coupled with the treatment of gallstones. This may include a procedure to relieve the blockage caused by the gallstone(s).
Gallstone pancreatitis recurs in 30 to 50 percent of people after an initial attack of pancreatitis. Surgical removal of the gallbladder (cholecystectomy) is often recommended during the same admission in mild cases to prevent a recurrence.
In people who are elderly and who have serious medical problems, it may not be safe to remove the gallbladder. In this case, endoscopic retrograde cholangiopancreatography can be done to enlarge the bile duct opening. This would allow stones from the gallbladder to pass, helping to prevent a recurrence of acute pancreatitis.
The following organizations also provide reliable health information.
●American Gastroenterological Association
(http://www.gastro.org/info_for_patients/2014/5/20/understanding-pancreatitis)
PANCREATITIS OVERVIEW — Acute pancreatitis refers to inflammation of the pancreas, causing sudden and severe abdominal pain. The pancreas is an organ that lies in the back of the mid-abdomen (figure 1). It produces digestive juices and certain hormones, including insulin. Pancreatitis usually develops as a result of gallstones or moderate to heavy alcohol consumption over a period of years.
Most attacks of acute pancreatitis do not lead to complications, and most people recover uneventfully with medical care. However, a small proportion of people have a more serious illness that requires intensive medical care. In all cases, it is essential to determine the underlying cause of acute pancreatitis and, if possible, to treat this condition to prevent a recurrence.
PANCREATITIS CAUSES — There are many possible underlying causes of acute pancreatitis, but 60 to 75 percent of all cases are caused by gallstones or alcohol abuse.
Gallstone pancreatitis — Because the gallbladder and pancreas share a drainage duct, gallstones that lodge in this duct can prevent the normal flow of pancreatic enzymes and trigger acute pancreatitis.
Alcoholic pancreatitis — Alcohol is a common cause of acute pancreatitis. Alcoholic pancreatitis is more common in individuals who have a long history of alcohol abuse.
Drug-induced pancreatitis — A number of drugs used to treat medical conditions can trigger acute pancreatitis.
Post-ERCP — Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that is done to evaluate the gallbladder or pancreas. Acute pancreatitis develops in about 3 to 5 percent of people who undergo ERCP. Most cases of ERCP-induced pancreatitis are mild.
Hereditary conditions — Acute pancreatitis can be caused by hereditary conditions, such as familial hypertriglyceridemia (high blood triglyceride levels) and hereditary pancreatitis. These conditions usually occur in children and young adults.
Unexplained — No underlying cause can be identified in about 20 percent of people with acute pancreatitis. This condition is called idiopathic pancreatitis. Only a small proportion of this group will experience additional attacks over time.
PANCREATITIS SYMPTOMS — Acute pancreatitis frequently presents with sudden, constant pain in the upper part of the abdomen, although other medical conditions can also cause this type of pain. The pain may wrap around your upper body and involve the back in a band-like pattern. The pain typically lasts days and is often relieved by leaning forward. Some people have only slight abdominal tenderness and in 5 to 10 percent of people, there is no pain at all.
In people with gallstone pancreatitis, gallbladder pain may occur before pancreatic pain. Gallbladder pain (referred to as biliary colic) occurs in the right upper abdomen, extending to the back and right shoulder. The pain gradually increases in intensity, is constant, and may be accompanied by nausea and vomiting. Gallbladder pain often follows a meal.
In people with alcoholic pancreatitis, the symptoms of acute pancreatitis often occur one to three days after an alcohol binge or after stopping drinking. Pain is accompanied by nausea and vomiting in most people. In severe cases, the initial symptom may be shock or coma.
PANCREATITIS DIAGNOSIS — Diagnosing acute pancreatitis can be difficult because the signs and symptoms of pancreatitis are similar to other medical conditions. The diagnosis is usually based upon a medical history, physical examination, and the results of diagnostic tests. Two of the following three are required to make a diagnosis: (1) typical abdominal pain; (2) threefold or more elevation of pancreatic enzyme values in the blood; and (3) inflammation of the gland on computed tomography (CT) scan or magnetic resonance imaging (MRI) scan. The number and type of tests is tailored to the severity of acute pancreatitis and the most likely underlying causes.
Once a diagnosis of acute pancreatitis is made, additional tests are needed to determine the underlying cause. This ensures that the correct treatment is given to prevent pancreatitis from recurring.
Imaging tests — Imaging tests provide information about the structure of the pancreas, the ducts that drain the pancreas and gallbladder, and the tissues surrounding the pancreas. Imaging tests may include an x-ray of the abdomen, chest, CT scan or MRI of the abdomen.
Endoscopic retrograde cholangiopancreatography (ERCP) — ERCP is a procedure that can be used to remove stones from the bile duct if your pancreatitis is due to gallstones or other problems with the bile or pancreatic ducts. In addition, ERCP can be used to treat some causes of pancreatitis.
PANCREATITIS TREATMENT — The goals of treatment of acute pancreatitis are to alleviate pancreatic inflammation and to correct the underlying cause. Treatment usually requires hospitalization for at least a few days.
Mild pancreatitis — Mild pancreatitis usually resolves with simple supportive care, which entails monitoring, drugs to control pain, and intravenous fluids. You may not be allowed to eat anything during the first few days if you have nausea or vomiting.
Moderate to severe pancreatitis — Moderate to severe pancreatitis requires more extensive monitoring and supportive care. This is because severe pancreatitis can lead to potentially life-threatening complications, including damage of the heart, lung, and kidneys. People with pancreatitis of this severity may be closely monitored in an intensive care unit.
During this time you may be given one or more of the following treatments:
●Intravenous fluids are given to help prevent dehydration.
●Many patients with moderate to severe pancreatitis may not be able to eat in the early course of their illness. Instead, you may be fed through a tube placed through the nose or mouth into the small intestine.
If you cannot tolerate tube feeding or cannot get enough nutrients with tube feeding, you may be given nutrition through an intravenous line placed in the upper chest. You can resume eating gradually once your pain resolves and bowel function returns to normal.
●About 30 percent of people with severe acute pancreatitis develop an infection in the damaged pancreatic tissue. Antibiotics can prevent infections and control infections that are already present.
●Acute pancreatitis is sometimes complicated by extensive damage and/or infection to the pancreatic tissue. In these cases, the damaged and/orinfected tissue may be removed in a procedure referred to as a necrosectomy. Necrosectomy can be done as a minimally invasive procedure.
Gallstone pancreatitis treatment — In people who have gallstone pancreatitis, the treatment of pancreatitis is usually coupled with the treatment of gallstones. This may include a procedure to relieve the blockage caused by the gallstone(s).
Gallstone pancreatitis recurs in 30 to 50 percent of people after an initial attack of pancreatitis. Surgical removal of the gallbladder (cholecystectomy) is often recommended during the same admission in mild cases to prevent a recurrence.
In people who are elderly and who have serious medical problems, it may not be safe to remove the gallbladder. In this case, endoscopic retrograde cholangiopancreatography can be done to enlarge the bile duct opening. This would allow stones from the gallbladder to pass, helping to prevent a recurrence of acute pancreatitis.
The following organizations also provide reliable health information.
●American Gastroenterological Association
(http://www.gastro.org/info_for_patients/2014/5/20/understanding-pancreatitis)