What is pancreatitis?

Causes and Symptoms

Linked to the small intestines by the pancreatic duct, the
pancreas contributes enzymes necessary to digestion. When the pancreas is damaged or its duct is blocked, the enzymes may begin to digest the pancreatic tissue itself, a process called autodigestion. Inflammation ensues, resulting in acute pancreatitis. Although there may be complications, most cases are self-correcting once the damaging agent is eliminated, and the pancreatitis does not recur. With continuing damage to the pancreas, however, the disease may become self-perpetuating and either break out periodically in attacks that mimic the acute form or cause few symptoms until much of the pancreas has been destroyed, a chronic form of pancreatitis that is difficult to treat. Either form can be fatal. Acute pancreatitis causes death in less than 5 percent of cases and generally does so because of complications, such as extensive tissue destruction and hemorrhage or infection. Complications from chronic pancreatitis can be fatal in as many as 50 percent of cases.

Although a variety of damaging agents are known to lead to pancreatitis, in as much as 15 percent of cases no clear cause is detectable; doctors call these cases idiopathic pancreatitis. Of detectable causes,
alcoholism and biliary tract disease account for about 80 percent of both acute and chronic cases in the United States and Europe (the percentages vary widely in other parts of the world). Alcohol is the most common toxic agent causing pancreatitis, although susceptibility varies and only a minority of heavy drinkers develop acute pancreatitis; however, a long history of steady drinking is by far the most common cause of chronic pancreatitis. Gallstones in the common bile duct, or any other stricture or obstruction that backs up bile into the pancreatic duct, can trigger acute pancreatitis. Because surgeons can correct this problem by removing the obstruction, it seldom leads to chronic pancreatitis. Other, rarer causes include traumatic injury (especially the damage done by the steering wheel or seat belt during an automobile accident), damage incurred during abdominal surgery or endoscopic procedures in the small intestine, reactions to some medicines, viral infections, very high levels of fats in the blood (hyperlipidemia), structural abnormalities in the pancreas, or hereditary disease.

Despite the variety in causes, patients present a fairly limited set of symptoms, at least during an acute episode. Usually (but not always), they initially complain of steady pain in the upper abdomen that in severe cases seems to bore into them and radiate to the back. They may also have an enlarged abdomen, run a fever, experience nausea, and vomit. The physician is likely to find the abdomen distended, while the patient feels tenderness when it is touched. In severe cases, the patient may develop signs of shock, unstoppable hiccuping, jaundice, discoloration around the navel, fluid buildup in the peritoneal cavity, and impaired bowel function. While abdominal pain is a prominent feature of chronic pancreatitis as well, the most common associated symptoms are diarrhea, fatty stool, weight loss from poor digestion, and the development of diabetes mellitus.

Because none of these symptoms belongs exclusively to pancreatitis, physicians must conduct tests to establish the diagnosis; however, no single test is conclusive. Only by carefully showing that other possible diseases, such as pancreatic cancer, are not responsible for the symptoms can doctors be sure that pancreatitis is the culprit. Blood tests that detect elevated levels of amylase and lipase (pancreatic digestive enzymes) support the diagnosis. X-rays, ultrasonography, computed tomography (CT) scanning, and endoscopic inspection of the pancreas and common bile duct can identify both causes and complications of pancreatitis.

Treatment and Therapy

The treatment for pancreatitis depends on its cause. If the problem is abuse of alcohol or other drugs, physicians usually let an attack of acute pancreatitis run its course while the patient abstains from the offending substance. Nevertheless, even mild attacks frequently require hospitalization, because painkillers and intravenous hydration therapy are needed. If gallstones are thought to be the problem, plans are made to remove them by surgery. Patients with severe acute pancreatitis are sent to the hospital’s intensive care unit, since they urgently need supportive treatment to stay alive. There, doctors insert a tube through the patient’s nose and into the stomach to suck out excess gastric fluids and relieve pressure on the pancreas. They may give antibiotics if there is evidence of infection. Extra oxygen or mechanical assistance may be needed to support breathing. Occasionally, surgery may be called for even in pancreatitis not caused by gallstones, in order to cut away dead, infected tissue or drain fluid accumulations known as pseudocysts. Following an attack and treatment, a patient may require intravenous nourishment for weeks before the pancreas is ready to resume its full function.

Continued alcohol abuse will generally spur recurrent bouts of pancreatitis. Sometimes, however, the alcohol (or, rarely, slowly developing biliary tract disease) causes more subtle, gradual impairment of pancreatic function with few symptoms; in fact, some patients do not go to the doctor until the damage has become extensive and permanently disabling. Others have intense, continual upper abdominal pain that painkillers cannot reduce easily. (In fact, drug addiction from high dosages of painkillers often becomes a problem.) The doctor’s first step is to stop the patient’s alcohol intake. If gallstones or other obstructions are present, clearing the bile duct with surgery or an endoscopic procedure will decrease pain. Sometimes, high doses of pancreatic enzymes may be helpful in relieving pain.

In cases of uncontrollable pain, however, surgery may be needed to block the sympathetic nerves or even to remove all or part of the pancreas. If pancreatic function is sufficiently impaired by this procedure, or by the progress of the disease, chronic pancreatitis patients will digest food poorly and may require enzyme supplements to avoid continued weight loss. Since insulin is made in the pancreas, such patients may also develop diabetes. All chronic pancreatitis patients will need professional advice about appropriate diet and lifestyle changes.

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