Pancreatitis is an inflammation of the pancreas, a gland with mixed secretion (exocrine and endocrine) and a major importance in the correct functioning of the body. It is located before the spine, after the stomach and comes into contact with the spleen (at the left side) and the duodenum ( at the right side).
Being a mixed gland, it secretes:
- Very powerful digestive enzymes ( with an exocrine component represented by acini). The pancreatic juice is drained through the excretory channels in the duodenum, where it participates to the chemical digestion of all food principles: carbohydrates, proteins and lipids by sucrase, protease, lipase. These enzymes are secreted in an inactive form, their activation being done only in the duodenal lumen.
- Hormones such as insulin and glucagon (with an endocrine component, consisting of the so-called islands of Langerhans, representing about 2% of the total mass of the pancreas). The pancreatic hormones are responsible for regulating glycemia and for the way in which the body regulates its energy reserves. They are secreted into the bloodstream, the blood flow being 10 times higher for the endocrine pancreas compared with the exocrine pancreas and from here they reach target tissues and organs, exerting specific effects. The inflammation of the glandular parenchyma, a phenomenon specific to pancreatitis, is triggered by factors that lead to the intrapancreatic activation of enzymes, before being eliminated in the duodenum, which will destroy the tissue, the process being actually that of pancreas autodigestion. There are two main types of pancreatitis: acute and chronic, each one having its specific causes, evolution, treatment and prognosis.
It is a sudden inflammation of the pancreas (acute attack in a short time). It is a relatively common disease, representing approximately 10% of the causes of hospitalization in an emergency department (of all abdominal surgical emergencies). The main etiological factors are represented by the excessive and constant consumption of alcohol and biliary lithiasis. Other causes include certain medications, infections, pancreatic traumas, metabolic disorders such as diabetes, dyslipidemia, hypertension, atherosclerosis and surgical or endoscopic interventions located peripancreatically. In approximately 10-15% of patients, the cause remains unknown.
The severity of acute pancreatitis varies from mild (felt by the patient as an abdominal discomfort) to severe (life threatening). Despite the severity of the disease, over 80% of the patients recover totally after being properly and timely treated. In very severe cases, acute pancreatitis can lead to the development of some intraparenchymal haemorrhages, with large ischemic necroses, bacterial superinfections and finally, the formation of pancreatic cysts. These situations are serious and because of the fact that they can cause the installation can cause multiple organ failure through the blood dissemination of pancreatic enzymes and toxins in the bloodstream. From here the toxins are circulating throughout the body and can affect any tissue and organ, especially the vital ones.
Chronic pancreatitis usually occurs after an episode of acute pancreatitis and it is the expression of the evolute of the pancreatic inflammatory process. In over 70% of cases, chronic pancreatitis is caused by the prolonged alcohol consumption (chronic alcoholism). Less common causes are represented by metabolic disorders. A very small percentage of the patients have hereditary chronic pancreatitis. Chronic pancreatitis is characterized by a progressive inflammatory process and repair by fibrosis. The first affected is the exocrine compartment, then the inflammation expands on the endocrine one as well, leading to global pancreatic insufficiency. Chronic pancreatitis is not a common disease, compared with the acute form.
The symptoms of chronic pancreatitis are varied and quite often it is asymptomatic or paucisymptomatic for years. The clinical picture may be precipitated by a worsening, which will lead to the sudden onset of the abdominal pain and of the functional changes of the pancreas (with the impairment of both components) which will manifest through maldigestion and impaired glycemia.
Acute pancreatitis is characterized by symptoms with sudden, intense and violent onset. The main complaints are:
- Severe abdominal pain localized in the upper half of the abdomen and extended to the back and the left shoulder; it is characterized as a severe pain and classically it is resistant to common analgesics. It worsens at food (especially high-fat products).
- Abdominal sensitivity to palpation, abdominal wall edema, swollen abdomen, muscular defense in the epigastrium and the adjacent areas
- (alimentary, bilious, mixed) Nausea, vomiting
- Diarrhea and stopped intestinal transit
- Malaise – tachycardic patient, with fever, shaking with cold sweats until the appearance of the shock and the general hemodynamic instability.
Severe acute pancreatitis has signs of multiple organ failure, impaired breathing and kidney and brain function.
Chronic pancreatitis – its symptoms closely resemble that of acute pancreatitis (especially at the moment of the attack). The pain is constant, has the same location and irradiation and in the case of some patients, it can seriously affect the quality of their lives. Other symptoms: significant weight loss, affecting the absorption of food principles ( as a result of exocrine pancreatic insufficiency, which in time becomes unable to secrete enzymes necessary for a proper digestion of food, as a result of extensive fibrosis that characterizes chronic pancreatitis). Patients have steatorrhoea (diarrhea caused by the malabsorption of lipids, which has a rancid, fetid smell) and eating disorders, especially when they consume foods rich in proteins and lipids. In time, patients may develop diabetes (by holding the endocrine component in the pathological process).
Most cases of acute pancreatitis are biliary lithiasis and the excessive consumption of alcohol. Other causes which are less common: consumption of various drugs, lipid metabolism disorders (particularly triglycerides), infections, surgery or abdominal traumas. 10-15% of the cases of pancreatitis still remain without an identifiable cause and are considered idiopathic. Chronic pancreatitis has as a main cause the chronic alcohol intake (in 70% of cases – the affected patients consume as an average 15 grams of alcohol / day for 6-12 years) which affects directly and irreversibly the parenchyma, leading to necrosis and subsequent fibroses of the pancreatic tissue. Chronic pancreatitis can also be caused by metabolic imbalances, hereditary causes or causes associated with the abuse of nonsteroidal anti-inflammatory drugs, autoimmune pancreatitis or secondary to the dysfunction of the Oddi sphincter. In children, the most common cause is cystic fibrosis (mucoviscidosis – an inherited disease affecting the exocrine glands of the liver, pancreas, having also severe lung determinations and causing multiple organ failure).
The causes of acute pancreatitis are:
- Drugs: sulfonamides, azathioprine, steroids, NSAIDs, furosemide, thiazide diuretics. Acute pancreatitis may also occur in autoimmune diseases such as polyarteritis nodosa, systemic lupus erythematosus.
- Viral infections with paramyxoviruses, cytomegaloviruses, Epstein Barr.
- Endoscopic maneuvers: ERCP (Endoscopic retrograde cholangiopancreatography).
Less common causes: fat necrosis, pancreatic head carcinomas, blocking the duct with ascaris, infections caused by the varicella zoster virus.
Pancreatitis can occur in any individual, apparently healthy, but it is most common in adults (compared to young and old people) and men ( which is actually explained by risk factors). There are several favouring factors which associate a higher risk of developing pancreatitis in certain population categories:
- Biliary, pathological causes: biliary lithiasis, biliary microlithiasis (sand)
- Diet: chronic and excessive alcohol consumption, excessive consumption of fat
- Metabolic causes: metabolic syndrome.
Acute pancreatitis can be the first manifestation event in the case of biliary lithiasis. The two diseases are associated because the excretion duct of the gall bladder joins the pancreatic excretory duct and opens into the duodenum through a common orifice. Thus, a calculus migrated from the gall bladder which blocks the duodenal ampulla, will block the pancreatic duct. The pancreatic juice, but also a part of the bile will go retrogradelly through the Wirsung channel (the main pancreatic duct) within the pancreatic parenchyma, where they will activate enzymes that triggers autodigestion. Enzyme activation process is self-sustaining, and the key is to transform trypsinogen into trypsin. The pancreatic lipases and amylases will then be activated, reactions occurring in a chain. The process is not localized, and can expand locally, causing important peripancreatic distructions, local bleeding and the accumulation of intraperitoneal fluid. The risk factors for chronic pancreatitis are mainly: the attacks of acute pancreatitis and prolonged consumption of alcohol. People with chronic pancreatitis are usually men, aged between 30 and 45 years.
The diagnosis of acute pancreatitis is clinically suspected when a healthy person or a person who presents important risk factors (chronic alcoholism, history of gallstones) develops violent symptoms which are suggestive of this disease: severe abdominal pain which does not improve with analgesics, malaise.
To confirm the diagnosis, the doctor will perform a series of special investigations, including:
- complete blood count (CBC), to determine the hematocrit and the hemoglobin
- Tests for kidney or liver function
- Serum calcium level
- Determination of blood gases
- Determining the level of amylase and lipase. These tests, amylase and lipase, are specific investigations in order to diagnose acute pancreatitis (they are usually increased):
- Serum amylase increases in 2-12 hours after the onset of symptoms and returns to normal within 72 hours
- Serum lipase begins to increase at 4 hours after the onset and normalizes in 7-14 days. However, in 10% of cases, serum amylase may remain high in the cases of acute pancreatitis, chronic pancreatitis and hypertriglyceridemia. The report amylase / lipase is an indicator of the etyology: if lipase is 2-3 times higher than amylase, pancreatitis is caused by the acute alcohol ingestion.
Other investigations are:
- Abdominal x-ray – to rule out perforation: in the case of acute pancreatitis, a typical aspect called sentinel loop appears in the abdominal radiography, or radiopaque gallstones can be seen in 10% of the patients
- Abdominal CT – experts do not recommend its performance within 48 hours because the result can be unclear.
The accurate diagnosis of chronic pancreatitis includes:
- The determination of serum amylases and lipases: they are not increased in the case of advanced chronic pancreatitis but they may be useful markers to find a pancreatic inflammation
- The determination of the level of triglycerides.
The imaging investigations include abdominal ultrasound, radiography, nuclear imaging, computed tomography. The mosst efficient in terms of diagnosing chronic pancreatitis is ERCP (endoscopic retrograde cholangiopancreatography). It is practised also in the case of acute pancreatitis, but only 48-72 hours after the onset.
In order to diagnose acute pancreatitis, ultrasound is the preferred method, being noninvasive and providing complex data about the free fluid in the abdomen, the appearance of the pancreas and the peripancreatic tissue and the presence of gallstones in the gall bladder. Other tests useful for diagnosing chronic pancreatitis are the determination of bilirubin and alkaline phosphatase (they are usually increased), the determination of the rheumatoid factor, antinuclear antibodies (in the case of autoimmune etiologies). In the advanced stages of the disease, when diabetes and malabsorption are present, the analysis of blood, urine and stool will confirm the disease. In these situations, the oral glucose tolerance test is also made in order to evaluate the state of the endocrine pancreas. The endoscopic ultrasound and the pancreatic biopsy are used to extract a small sample of tissue in order to analyse it and give a diagnosis, establish the pathological type and stage of the process.
In an emergency, the doctor can also resort to laparoscopy in order to confirm diagnosis and to quickly view the lesions, the complications and the extent of the disease. However, such exploration is considered by many specialists as dangerous and can cause infections which can be hardly treated and controlled.
Keep in mind!
The diagnosis of acute pancreatitis can be considered when a patient with severe abdominal pain has the amylase level at least 3 times higher than normal.
The treatment of acute pancreatitis
The therapeutic measures taken for patients with acute pancreatitis are supportive, medical and include also specialized surgical treatment.
In the case of supportive measures, the suppression of food and administration of analgesics are practised. It is not recommended to administer morphine or its derivatives because they cause spasm on the sphincter of Oddi and can only make the pain worse. Antispasmodics and oxygen mask are sometimes administered. The patient will be immobilized in a lying down position and immediately transported to the hospital. During this time the patient will receive intravenous fluids in order to prevent dehydration. About 20% of patients develop severe acute pancreatitis and need hospitalization in an intensive care unit. Here, the patient can be closely monitored because the severe forms of pancreatitis include a life-threatening major risk of damaging the liver, the lungs, the heart and the kidneys.
The medical treatment is applied in uncomplicated cases and consists of the suppression of the effect of the pancreatic enzymes by administering anti-enzymes, sedating pain, preventing infections (by taking antibiotics and reducing inflammation – with corticosteroid treatment).
The acute pancreatitis attack lasts a few days if there are no complications and it is treated correctly by complete medical and supportive measures. However, patients with acute pancreatitis should be admitted to hospital and observed in a surgical department because the condition may get easily complicated. The complications of acute pancreatitis are generally intestinal occlusions, organ perforations, generalized peritonitis (in early stages) or complications of the peripancreatic necrosis (suppurations, abscesses and even septicemia).
The severe cases with extensive pancreatic necrosis, infectious complications, will be treated surgically, because the removal of the devitalized tissue is very important to promote rapid healing.
Complicated acute pancreatitis (especially when it is of an obstructive, erosive and infectious nature) is surgically treated. Also, acute pancreatitis with gallstones should be resolved surgically (with an immediate removal of the calculus). Generally, after the removal of the calculi, the inflammatory process decreases in intensity and gradually goes out completely, the pancreas coming back to the previous state.
The surgical intervention can be achieved through the conventional or laparoscopic method – minimally invasive technique. Within this process, several small incisions (5-10 millimeters) are done in the abdominal wall through which the working instruments and the laparoscope are inserted, a tube equipped with a video camera that transmits images from the abdominal cavity. It is connected to a monitor and in this way the surgeon can use the instrument with a very high precision. The advantages of this technique are represented by the small incisions, minor scars, less intense pain, lower infection risk and rapid recovery.
Keep in mind!
Surgery is recommended for those patients with an infected pancreatic necrosis and complications. Another therapeutic approach is represented by the endoscopic retrograde cholangiopancreatography (ERCP), but this must be done only in the first 24-72 hours after the admission in the hospital. ERCP reduces mortality and morbidity, and its indications are:
- The patient’s clinical deterioration or no improvement of symptoms under medical supportive treatment in 24 hours
- Detection of calculi on the common bile-duct or intrahepatic / extrahepatic ducts dilated at CT.
The disadvantages of ERCP are the major risk of haemorrhage after the intervention and the fact that this technique itself is able to precipitate the onset of pancreatitis or to infect an already started pancreatitis which was sterile.
The treatment of chronic pancreatitis
Chronic pancreatitis is more difficult and more complicated to treat. The first therapeutic measures consist of relieving pain by administering analgesics and improving the metabolic and nutritional status of the patient (these problems are a direct consequence of the functional impairment of the exocrine and endocrine pancreas). The patients will receive enzymes to supplant normal secretion and insulin if necessary (if the disease is so intense and evolved and insulin and glucagon can not be synthesized and secreted anymore – endocrine function of the gland being therefore abolished as well). Then, the patient will receive such enzymes all his life in order to stimulate the function and the absorption of essential nutrients. Pancreatic enzyme replacement also treats malabsorption and steatorrhea. A low-fat diet may have protective effects. Surgery can relieve abdominal pain, can restore the correct drainage of pancreatic secretions (in the cases of chronic pancreatitis through a lithiasic blockage) and may reduce the frequency of attacks. The most common indication for surgery is the pain and the slowing of the functional deterioration. Also, chronic pancreatitis requires surgery if such complications appear: biliary or duodenal obstructions, pancreatic cysts and pseudocysts, gastrointestinal bleeding. The operations generally consist of pancreatic resection or drainage procedures.
The patients with chronic pancreatitis are advised to avoid alcohol and follow the medical recommendations concerning the dietary modifications that they have to do. The medical treatment should be administered correctly in order to avoid recurrence of complications due to malabsorption and reduce the frequency of relapses.
Because most cases of pancreatitis are caused by alcohol abuse, reducing it seems to have protective effects. Also, dietary changes, by reducing foods high in fat can be useful, as well as the recommendations concerning the removal of risk factors: obesity, hypertriglyceridemia, hypertension and the adequate control of diabetes.
The prognosis of pancreatitis generally depends on the severity of the disease, the intensity of symptoms and the presence of complications (when going to the emergency room or in the further evolution).