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Pancreatitis

  • Pancreas
  • Acute pancreatitis

Definition

Pancreatitis is a serious and potentially life threatening inflammation of the pancreas. It is classified as acute or chronic. Chronic pancreatitis is not reversible and is the end result of repeated episodes of acute pancreatitis.

What is going on in the body?

The pancreas is a leaf-shaped gland that is located behind the stomach and peritoneal cavity. Its duct is connected to the duodenum, and it secretes strong digestive enzymes into the duodenum during meals. It also secretes the hormones insulin and glucagon into the bloodstream. In addition, it secretes fluids like sodium bicarbonate into the duodenum, neutralizing acid coming from the stomach.
In pancreatitis, the pancreatic duct gets blocked, the flow of pancreatic juices is "backed-up," and the powerful enzymes are activated locally in the pancreas. These "juices" accumulate in the pancreas. They begin to digest the cells of the pancreas, and cause severe inflammation.
If the injury is repeated a number of times, the pancreas is damaged and is then unable to provide the digestive enzymes and hormones needed for the rest of the body to absorb nutrients and to function normally (a loss of insulin can lead to diabetes).

Risks

What are the causes and risks of the disease?

Causes of pancreatitis include:
  • gallstones
  • biliary tract disease, or disorders of the tubes draining bile from the gallbladder
  • peptic ulcers
  • alcoholism
  • medications such as glucocorticoids, furosemide, and azathioprine
  • complications from infections, such as mumps
  • high blood levels of triglycerides
  • damage to the pancreas from surgery or trauma
  • cancer of the pancreas
In severe cases of pancreatitis, blood pressure may fall, causing shock. Pancreatitis can be life-threatening.

Prevention

What can be done to prevent the disease?

Prevention of pancreatitis depends on the cause. For example, strict avoidance of alcohol will help prevent pancreatitis caused by alcohol-mediated injury to the pancreas. Surgical removal of the gall bladder is indicated if pancreatitis was a result of gallstones.
If pancreatitis appears to be the result of a specific medication (a thiazide, for example), the drug should not be taken again. If pancreatitis occurs because of an elevated calcium level, efforts should be made to lower calcium (removal of the parathyroid gland if it is responsible, for example). If triglycerides have caused pancreatitis, the fat level in the blood has to be lowered with medications.

Diagnosed

How is the disease diagnosed?

A thorough history (patient's family and medication history are very important) and physical examination are the first steps in diagnosis of pancreatitis. Blood tests may show an elevated white blood count, as well as elevated amylase and lipase levels (2 enzymes released into the bloodstream by the inflamed pancreas), kidney function tests, oxygen levels, an enzyme named "LDH" and glucose levels.
Other tests used to diagnose pancreatitis, or to determine what caused it, include:
  • abdominal CT Scan (the imaging test of choice).
  • ultrasound (especially to see gallstones in the gal bladder)
  • ERCP (a test by a specialist that can directly visualize the ducts that may be blocked by a gallstone causing pancreatitis and may permit gallstone reoval as an emergency without surgery).
  • Lipid profile or triglyceride levels

Long Term Effects

What are the long-term effects of the disease?

Repeated episodes of acute pancreatitis leads to chronic pancreatitis. Chronic pancreatitis can lead to poor absorption of nutrients (especially fats) because of pancreatic destruction. Diabetes may occur later from chronic pancreatitis due to the destruction of the cells in the pancreas that produce insulin
Weight loss and diarrhea are common in chronic pancreatitis and are caused by poor absorption of nutrients. Severe bleeding, or a secondary infection in the pancreas may occur and either can be life threatening.

Other Risks

What are the risks to others?

Pancreatitis is not contagious (unless it is a result of mumps which is unusual, and mumps, not pancreatitis, may be contagious) and poses no risk to others.

Treatments

What are the treatments for the disease?

Usually a person with pancreatitis is hospitalized. Supportive treatment is the goal (especially fluids and possibly antibiotics). No drugs stop the basic inflammatory process in pancreatitis.
The person is not allowed to eat or drink anything, because food and drink would stimulate the pancreas to produce more enzymes. Fluids and nutrients are given through an intravenous line, which is a thin tube inserted into a vein. It may also be used for intensive nutrition in serious or prolonged cases of pancreatitis. A stomach tube (called an "NG <or nasogastric> tube") is inserted through the nose into the stomach to remove fluids and air.
Oxygen is given. Narcotics such as meperidine are used to control the pain. Antibiotics may be given to treat infections that occur in dying pancreatic tissue.
ERCP may be used to diagnose and possibly remove gallstones that block the duct from the pancreas. CT Scan may be used to guide needle drainage of large fluid collections if they are result of dead pancreatic tissue and especially if they are infected.
Surgery in the first few days of pancreatitis should be avoided if at all possible because it is a associated with a death rate of 65%. Surgery may also be indicated when there is heavy bleeding, or gallstones that cannot be removed by ERCP.
If pancreatitis is the result of elevated triglycerides, fats may be removed from the blood stream emergently by a process called "plasmapheresis."

Side Effects

What are the side effects of the treatments?

There may be side effects with any medication. Antibiotics may cause stomach upset, diarrhea from a bacteria called C. difficile, or an allergic reaction. Narcotics may cause an allergic reaction, or can depress bleeding. Possible side effects of surgery include bleeding, infection, and reactions to anesthesia, and is high risk early in the course of pancreatitis.

After Treatment

What happens after treatment for the disease?

If the pancreatitis is due to alcoholism, the prognosis is better if the person avoids alcohol. But if the person drinks, a recurrence of pancreatitis is likely. Pancreatitis from other causes can have varying outcomes, depending on the cause.

Monitor

How is the disease monitored?

Pancreatitis is monitored by the health care provider. In hospitalized patients, pancreatitis can cause kidney or lung failure. Blood tests may be done to check both kidney (including the presence of excess acid in the blood) and lung function (oxygen levels). White blood count is monitored because of potential infections during acute pancreatitis. The hematocrit (or concentration of red cells) is monitored. Amylase and lipase levels may help identify recurrences of acute pancreatitis.
Any new or worsening symptoms, especially abdominal pain, should be immediately reported to the health care provider. Symptoms of chronic pancreatitis&mdash;like diarrhea from poor nutrient absorption&mdash;should also be reported.

Sources

Current Medical Diagnosis and Treatment, Tierney, 2000

The Merck Manual of Medical Information, 1997

Professional Guide to Diseases, 1998

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