Acute Pancreatitis

Acute pancreatitis is inflammation of the pancreas that appears suddenly and last for days. The inflammation releases pancreatic enzymes that cause digestion and inflammation of the pancreas and surrounding organs.

What is the pancreas?

The pancreas is an organ in the upper abdomen lying behind the stomach and is attached to the back wall of the abdomen. It produces enzymes that pass into the pancreas duct which empties, together with the bile duct, into the duodenum (the first part of the small intestine just after the stomach). The pancreas enzymes are needed to digest food. The pancreas also has special group of cells that make important hormones such as the insulin. These hormones are passed into the blood stream to control the blood sugar level.

What is pancreatitis?

Pancreatitis is the inflammation of the pancreas. There are two types:

1. Acute pancreatitis: the inflammation occurs suddenly and last for days. It tends to disappear completely often without leaving a permanent damage.
2. Chronic pancreatitis: the inflammation is persistent but less intense. It causes scarring and damage to the pancreas. Click here to read more about chronic pancreatitis

How common is acute pancreatitis?

In Australia, about 5 in 100,000 people develop acute pancreatitis each year. The rate is increasing due to the increase in alcohol consumption.

What are the causes of acute pancreatitis? 

1. Gallstones: are the most common cause in Australia. Gallstones form in the gallbladder and sometimes a stone passes into the bile duct and out into the duodenum. In some people a gallstone can get stuck and injure the pancreas resulting in pancreatitis. Click here ot read  more about gallstones.
2. Alcohol: is the second most common cause of pancreatitis. Unfortunately, as the consumption of alcohol is on the rise, so is the incidence of pancreatitis. Some people seem to be develop pancreatitis even with small amount of alcohol.
   Gallstones and alcohol account for 8 out of 10 cases of acute pancreatitis. Other causes include:
3. Viral infections e.g. mumps, HIV, hepatitis and Coxackie B viruses.
4. Drugs :e.g. thiazides, valporate, azathioprine and steroids
5. High blood fat (triglyceride)
6. Renal failure (uraemia)
7. High blood calcium level
8. Hereditary pancreatitis
9. Tumours of the pancreas
10. Abnormal structure of the pancreas e.g. pancreas divisum and annular pancreas
11. Injury or surgery near the pancreas
12. Autoimmune: this is when the immune system attacks the pancreas
13. Unknown cause: One in 10 patients have no obvious cause for pancreatitis. Recent research suggest that many of these patients have tiny gallstones (microlithiasis) in their bile. These are too small to be picked up by scans. These patients will benefit from cholecystectomy (surgical removal of the gallbladder) to prevent further attacks.

What are the symptoms of acute pancreatitis?

1. Upper abdominal pain. The pain quickly become severe and spread all over the abdomen and the back.
2. Nausea and vomiting
3. Abdominal distension
4. Dehydration
5. If pancreatitis becomes severe other organs become involved (heart, lungs and kidneys) resulting in other symptoms.

In most cases the inflammation is mild and settles within a week. However, 1 in 5 patients have a severe attack. The inflammation results in part of the pancreas to die and the inflammation spread to other organs (lungs, kidneys and heart). This is serious and can result in death.

What are the tests for acute pancreatitis?

When pancreatitis is suspected the patient will be admitted to the hospital and undergo several tests to confirm the diagnosis and exclude other conditions. Blood tests show elevated amylase and lipase levels. These are enzymes produced by the pancreas. Ultrasound scan is done to check for gallstones. CT scan is sometimes done to exclude other conditions such as perforated ulcer or to check if part of the pancreas has died indicating a severe attack. If a stone is suspected in the bile duct then MRCP may be done to check for that.

How is acute pancreatitis treated?

The treatment depends or the severity of the attack.

Mild Cases

• Conservative treatment in the ward
• Pain relief
• IV fluids and a period of fasting
• A nasogastric tube if severe vomiting
• Urine catheter to monitor urine output
• When the attack settles oral intake is resumed. If gallstones are the cause then cholecystectomy prior to discharge to avoid further attacks.

Severe Cases

• Admission to ICU (intensive care unit)
• Intravenous antibiotics are often given
• Feeding via a tube passed from nose into intestine as soon as possible.
• Early ERCP if gallstones are stuck in the bile duct.
• Surgery is only required if there is necrotic pancreas gets infected.

 What are the local complications of acute pancreatitis?

1. Pancreas necrosis. Part of the pancreas dies because of the severe inflammation
2. Infected pancreas necrosis. This is almost always fatal if not treated with surgery.
3. Acute fluid collections. This is fluid collecting around the pancreas as a result of severe inflammation. This tends to settle spontaneously.
4. Pancreas abscess. This is pus collection near the pancreas presenting few months after a severe attack.
5. Pseudocyst formation. This is a fluid collection near the pancreas containing pancreas juice. It arises 4-6 weeks after the attack. It can ruptures or cause bleeding and often require surgery.
6. Pancreas ascites. This is when the pancreas duct breaks down causing of release of pancreas juices into the abdominal cavity.

What is the outlook (prognosis) for acute pancreatitis?

Mild cases settles quickly and a full recovery is expected. Severe attacks occur in about 1 in 5 patients. Despite intensive treatment up to one fourth of these patients die.

How to prevent acute pancreatitis from happening again?

• It is very important to treat the cause of pancreatitis to prevent further attacks.
• Patients with gallstones should have their gallbladder removed (cholecystectomy). Click here to read more about lapaorscopic cholecystectomy. 
• Patients with alcohol related attacks should stop drinking alcohol all together. There is no safe amount of alcohol.
• Medical causes such as high calcium or triglycerides should be treated.
• Patients with drug related attacks should have the responsible drug stopped or changed.
• Patients with suspected microlithiasis (small gallstones) may benefit from cholecystectomy as well.