Pancreatitis

Pancreatitis, inflammation of the pancreas, occurs in acute and chronic forms. In pancreatitis, the enzymes normally excreted by the pancreas digest pancreatic tissue (auto-digestion). Acute pancreatitis can range from mild self limiting episodes of abdominal discomfort to severe systemic illness associated with fluid sequestration, metabolic disorder, hypotension, sepsis, and death. Life-threatening illness is associated with pancreatic hemorrhage or necrosis in about 10% of patients.

In 90% of patients with acute pancreatitis, the disease occurs as a mild, self-limiting illness and requires only simple supportive care. In the remaining 10% of patients, the disease can evolve into a severe form with significant complications, a lengthy duration, and a significant mortality rate.

Causes

Acute pancreatitis is usually caused by drinking too much alcohol or by gallstones . A gallstone can block the pancreatic duct, trapping digestive enzymes in the pancreas and causing pancreatitis.

Chronic pancreatitis occurs when digestive enzymes attack and destroy the pancreas and nearby tissues. Chronic pancratitis is usually caused by many years of alcohol abuse , excess iron in the blood, and other unknown factors. However, it may also be triggered by only one acute attack, especially if the pancreatic ducts are damaged.

Signs and symptoms

The following are the other most common symptoms of pancreatitis. However, each individual may experience symptoms differently. Symptoms may include:

• nausea
• vomiting
• fast pulse
• feeling ill
• fever
• swelling in the upper abdomen
• ascites (fluid accumulation in the abdominal cavity)
• dropping blood pressure
• severe abdominal pain in upper abdomen (with acute pancreatitis)

The symptoms of pancreatitis may resemble other conditions or medical problems. Always consult your physician for a diagnosis.

Diagnosis

To diagnose pancreatitis, your doctor will take your medical history and perform a complete medical examination. He or she will be particularly interested in how much alcohol you drink and if you have had symptoms of gallstones. Diagnostic tests include blood and urine studies for pancreatic enzymes and sugars, x-rays of the abdomen and chest, ultrasound exam of the pancreas and gallbladder, and computed tomography (CT) scan of the pancreas. In severe cases of chronic pancreatitis, your doctor may order an endoscopic retrograde cholangiopancreatography (ERCP). An ERCP is a way of looking at your pancreas through a slim flexible tube, called an endoscope, that is inserted into your mouth and down to the pancreas. An endoscope is fitted with a tiny fiber optic camera that gives the physician a detailed view of the pancreas. During the ERCP, the physician can remove a sample of tissue, a biopsy, from the pancreas. Your doctor may also want a stool sample to test for excess fats.

Treatment

The goal of therapy is to maintain circulation and fluid volume. Treatment measures must also relieve pain and decrease pancreatic secretions. In 90% of patients with acute pancreatitis, the disease occurs as a mild self-limiting illness and requires simple supportive care alone. In the remaining 10% of patients, the disease can evolve into a severe form of acute pancreatitis with significant complications, a lengthy duration of illness, and a significant mortality rate.

Emergency measures

Emergency treatment for shock (which is the most common cause of death in early-stage pancreatitis) consists of vigorous I.V. replacement of electrolytes and proteins.

Metabolic acidosis that develops secondary to hypovolemia and impaired cellular perfusion requires vigorous fluid volume replacement.

Drug treatment choices may include morphine sulfate for pain; diazepam for restlessness and agitation; and antibiotics for documented bacterial infections.

Specific metabolic complications, such as hypokalemia, hypocalcemia, hemorrhage, and coagulopathy, must be treated with appropriate replacement products, such as potassium chloride, I. V. calcium gluconate or chloride, red blood cells, and fresh frozen plasma. Hyperglycemia and glycosuria are man ifestations of altered carbohydrate metabolism. Treatment consists of careful titration of glucose and insulin to maintain a euglycemic state.

After the emergency

After the emergency phase, continuing I.V. therapy should provide adequate electrolytes and protein solutions. If the patient is unable to resume oral feedings, total parenteral nutrition may be necessary. Non-stimulating enteral feedings may be safer because of the decreased risk of infection and maintenance of normal physiology.

Surgery for acute pancreatitis is reserved for specific complications and to correct an anatomic problem. Surgery is usually required for patients with necrotizing pancreatitis to debride devitalized tissue and to provide external drainage. Debridement is often required on multiple occasions, usually at 24- to 48-hour intervals, until the necrotic tissue is replaced by a granulating wound.

Prevention

Although pancreatitis isn't always preventable, you can take steps to reduce your risk:

• Avoid excessive alcohol use. Overuse of alcohol is the leading cause of chronic pancreatitis and a contributing factor in many acute attacks.
• Stop smoking. Tobacco use increases your risk of pancreatitis, especially if you also drink alcohol.
• Limit fat. Eating a high-fat diet can raise your blood-fat levels and increase your risk of gallstones - both risk factors for pancreatitis. A healthy diet emphasizes fresh fruits and vegetables, whole grains, and lean protein, and limits fats, especially saturated fats such as butter.