The pancreas is a flat gland located behind the stomach. It has two main functions: producing digestive enzymes and secreting hormones, such as insulin and glucagon, to regulate blood sugar levels. The pancreas releases digestive enzymes into the duodenum when it detects fats and proteins within the foods we consume. Specialized cells in the pancreas (islets) secrete glucagon and insulin into the bloodstream. Glucagon causes the liver to release glucose into the blood and insulin causes cells to take up glucose from the blood.
Pancreatitis is a term that means inflammation of the pancreas. The two main types of pancreatitis are acute and chronic. Acute does not refer to disease severity; rather it means there is an abrupt onset of symptoms. Chronic means smouldering, long-standing disease that continues even after resolving the original trigger. It is a long-term condition characterized by scarring and irreversible destruction of pancreatic tissue. The main symptoms are pain, weight loss, and manifestations related to the loss of functional pancreatic tissue such as diabetes or malabsorption.
On this page, we review acute and chronic pancreatitis separately, as there are distinct differences.
The main symptoms of acute pancreatitis are nausea accompanied by pain in the upper abdomen or back. Symptoms of acute pancreatitis come on suddenly and can vary in severity from mild to life threatening. Mild cases typically resolve over the course of a week or so. Severe cases may include major complications such as infection, hemorrhage, failure of other organ systems such as lungs or kidneys, or fluid collections in the abdomen. Such fluid collections, called pseudocysts, often resolve spontaneously.
Large cysts that persist for more than 6 weeks usually need draining to prevent further problems such as infection or hemorrhage. In most cases of acute pancreatitis, the patient recovers completely.
The most common cause of acute pancreatitis in adults is gallstones. The gallbladder is a small sac-like organ located below the liver. Its primary function is to store and concentrate bile, an important digestive fluid made by the liver. When fat enters the upper portion of the small intestine (duodenum), bile flows from the liver through bile ducts to the duodenum. When the small intestine is empty, bile flows back into the gallbladder for storage. Bile consists of water, cholesterol, fats, bile salts (also called bile acids), and a yellow pigment product known as bilirubin.
Gallstones (cholelithiasis) are the most common gallbladder disorder, and affect about one-fifth of men and one-third of women at some point throughout life. Stones form when cholesterol and other elements of the bile are abnormally concentrated or they are in disproportion. Three types of gallstones exist:
- Pigment stones, comprised primarily of bilirubin, are more common in some populations and parts of the world than in others and occur most frequently among persons who have types of anemia characterized by rapid destruction of red blood cells (autoimmune hemolytic anemia).
- Mixed stones, the most widespread type of stone, develop from crystalline particles of cholesterol mixed with other bile substances. Sometimes people refer to mixed stones as cholesterol stones, since they are comprised mostly of cholesterol.
- The third type of stone, comprised of pure cholesterol, is rare.
Alcohol abuse is the second most common cause of acute pancreatitis and, unlike gallstones, this can also lead to chronic pancreatitis. Some patients may have more than one attack of pancreatitis but usually recover fully after each one.
Less common causes include viral infection (mumps, coxsackie B), trauma, manipulation of the pancreas at the time of surgery, elevated blood triglyceride levels, congenital structural abnormalities of the pancreas or intestine, and some medications (e.g., estrogen, azathioprine, corticosteroids, thiazide diuretics, tetracycline).
Endoscopic retrograde cholangiopancreatography (ERCP) is a medical procedure used to diagnose and treat conditions of the bile ducts. During this procedure, a physician passes a scope through the mouth to examine the liver, gallbladder, bile ducts, and pancreas. Unfortunately, the procedure itself may sometimes lead to acute pancreatitis.
In about 15% of acute pancreatitis cases, the cause is unknown (idiopathic pancreatitis).
Damage to the pancreas may occur during auto-digestion, when digestive enzymes normally secreted into the small intestine for food digestion activate inappropriately within the pancreas and begin attacking that organ. There may be bleeding into the gland causing swelling, serious tissue damage, infection, and cysts. When the disease is more serious, enzymes and toxins may enter the bloodstream and significantly injure other organs, such as the heart, lungs, and kidneys. Intense, painful symptoms may last for 48 hours. About 20% of cases are severe.
On physical examination, the abdomen is tender. During acute attacks, blood tests reveal high levels of the digestive enzyme amylase. A CT (computed axial tomography) scan or ultrasound of the abdomen may show evidence of swelling or damage to the pancreas, or fluid collections around the pancreas.
Patients with acute pancreatitis often have significant pain and vomiting, and generally require admission to hospital for supportive care with intravenous fluids, electrolytes, and analgesics. Fasting is the best approach to prevent further stimulation and irritation of the pancreas. During this time, the doctor will monitor tests to determine the cause of the pancreatitis and to treat any complications that arise.
In most cases, symptoms subside after 4-7 days, at which point patients resume oral food intake and leave the hospital. Patients with very severe pancreatitis may require treatment in an intensive care unit, and may even need urgent surgery to deal with complications such as a pancreatic abscess. If the pancreatitis is due to gallstones, then a surgeon may remove the gallbladder once the pancreatitis has subsided, to prevent future recurrences.
Outlook - Acute Pancreatitis
In most cases there is little one can do in terms of prevention; however, to avert some types of acute pancreatitis, you should avoid excess alcohol, and if you have diabetes or hyperlipidemia, then it’s important to follow the prescribed treatment plan for your condition.
The primary ongoing symptom of chronic pancreatitis is pain localized to the upper abdomen that often radiates to the back. Episodes of pain last from hours to days, and may eventually become continuous. Eating may worsen the pain. Patients who develop pancreatic insufficiency may develop loose, foul-smelling stools and lose weight. Chronic pancreatitis patients may undergo numerous
disturbances to their lifestyle and health, including hospitalization, unemployment, disrupted social life, weight loss, depression (sometimes to the point of suicide) and narcotic dependency (if using narcotics for pain).
Alcohol abuse is the cause of about 75% of all cases of chronic pancreatitis. Less common causes include hereditary pancreatitis or pancreatic duct obstruction. However, in a significant proportion of cases of chronic pancreatitis, physicians are unable to identify a cause. A key feature of chronic pancreatitis is that there is always irreversible scarring of the duct and of the functioning glandular tissue in the pancreas. Ultimately, this damage results in an inability to digest food properly, due to a lack of pancreatic enzymes (pancreatic insufficiency). This also affects insulin production, potentially leading to diabetes.
Typically, there is a previous history of pancreatitis before a diagnosis of chronic pancreatitis. There may be signs of malnutrition and weight loss. An abdominal CT scan or ultrasound may reveal inflammation and/or calcification of the pancreas. Amylase levels may be increased, but this test is less reliable with chronic pancreatitis than with acute pancreatitis. A number of specialized tests are available to assess pancreatic function and enzyme secretion.
Treatment of the various symptoms and complications of chronic pancreatitis addresses the two main issues of pain and pancreatic insufficiency.
If there is a clearly identified cause of the chronic pancreatitis, then correcting it is the first step. Patients with a history of excess alcohol use must completely stop consuming it. Unfortunately, this may not lead to resolution of symptoms, but often slows further progression.
Some evidence exists supporting the use of high-dose pancreatic enzymes to help control pain attributed to chronic pancreatitis. By taking pancreatic enzymes, the level of hormonal stimulation of pancreatic enzyme secretion decreases, potentially leading to improved pain control.
Taking analgesics will help for pain relief as do narcotics. However, due to the chronic nature of the pain, patients taking narcotics continuously could develop dependency or addiction. Other strategies to control pain may include interventions such as nerve blocks or pancreatic duct drainage. Referral to a chronic pain clinic can also be helpful in identifying treatment options other than narcotics for pain control. In very rare cases of intractable pain not helped by these measures, the patient may require surgery.
Patients should follow a low fat diet supplemented with fat-soluble vitamins (A, D, E, & K) and calcium. Patients with pancreatic insufficiency should receive enzyme replacement therapy (Cotazym®, Creon®, Ultrase®). Not all these formulations are equally efficacious. Patients who develop diabetes from chronic pancreatitis will usually require insulin treatment.
Outlook - Chronic Pancreatitis
Complications that can arise from chronic pancreatitis include narcotic addiction, obstruction of the common bile duct, pancreatic insufficiency, and diabetes mellitus. As with other chronic illnesses, patients who have chronic pancreatitis may experience a sense of helplessness. Knowing more about pancreatitis may relieve this concern and give the patient some pro-active steps to take toward managing the disease. It is important to recognize that this disorder often requires a multidisciplinary management approach involving healthcare practitioners such as the family physician, gastroenterologist, surgeon, internist, psychiatrist, counsellor, dietitian, and pain specialist.