- June 10, 2021
Pancreas is a gland located in the upper abdomen and is mainly involved in the digestion of food material and also helps to control the blood glucose levels. Acute pancreatitis, most commonly caused by gallbladder stone and alcohol needs specialized treatment. The common issues related to acute pancreatitis are discussed in detail.
What is Acute pancreatitis : Acute pancreatitis indicates sudden inflammation in the pancreas. The word ‘acute’ means sudden in onset, and ‘pancreatitis’ means inflammation in the pancreas. This differentiate it from other disease of pancreas ‘chronic pancreatitis’ most commonly caused by alcohol, and manifesting as either continuous pain abdomen or recurrent attacks of pain. The rapidity of onset of symptoms differentiate this condition from the chronic pancreatitis.
What causes acute pancreatitis : Gall bladder stone and alcohol are the most common causes of acute pancreatitis. Gall bladder stone related acute pancreatitis occur more commonly in middle aged women. Stone from the gall bladder may slip into the bile duct. The terminal part of bile duct and duct of pancreas opens together at the papilla. Downward movement of stone through the ampulla can cause transient obstruction at ampulla and can lead to acute pancreatitis. Alcoholic pancreatitis is more common in men. Usually consumption of more than 100gm of alcohol for more than 5 years is required to cause acute pancreatitis. Not all the individuals consuming alcohol will develop acute or chronic pancreatitis, as subtle changes in genetic information known as genetic polymorphism is required to cause the disease.
Raised calcium and triglyceride level can also lead to acute pancreatitis. Excessive vitamin D intake or raised parathyroid hormone can lead to hypercalcemia and acute pancreatitis. Vitamin D and Parathormone are essential to maintain adequate calcium level in blood. Trauma is a common cause in the children. Hitting of abdomen against the bench or car steering can lead to pancreatic injury and acute pancreatitis. Medicines are also a common cause of acute pancreatitis. Medicines for treatment of cancer and control of hypertension can lead to acute pancreatitis. In elderly individuals, tumor of pancreas and ampulla can lead to blockage of duct of pancreas and lead to acute pancreatitis. Virus infection such as mumps can also lead to acute pancreatitis. Worms such as ascaris can also enter the duct of pancreas and lead to acute pancreatitis.
What are the symptoms of Acute Pancreatitis Most common symptom is severe pain in upper abdomen, and pain often radiates to back bone also. Pain is often relieved by stooping forward or lying in prone position. Most of the patients also complain of vomiting, decrease passage of gas and constipation. Few patients also complain of breathing difficulty and decrease in urine output. In few patients with stone in bile duct or tumor of pancreas, jaundice may also occur.
How do we diagnose acute pancreatitis If acute pancreatitis is suspected, blood test such as amylase and lipase are ordered. These are the pancreatic enzymes and are elevated after an attack of acute pancreatitis. Ultrasonography and CT scan can show the swelling in pancreas gland. At the same time other blood test such as blood counts, haemoglobin, liver function test, kidney function test and blood gasses are also done, which help in the management of the disease.
Treatment of acute pancreatitis : The treatment of acute pancreatitis is primarily supportive care. Patients with acute pancreatitis should be hospitalized and managed by specialized team. Evaluation of the underlying cause and treatment are started simultaneously. Ultrasound examination, questioning regarding alcohol intake/trauma/fever, and blood test help us in reaching the correct diagnosis. Ultrasonography may miss the small stones in gall bladder, Endoscopic ultrasonography may be performed to detect small stones in gall bladder (microliths) if suspicion remains for the stone disease. Patients with respiratory compromise with falling oxygen saturation, renal failure and low blood pressure are best managed in ICU. Intravenous fluid, judicious use of antibiotics, pain killers, maintenance of adequate oxygen level and urine output are cornerstones for the management of acute pancreatitis.
What are complications acute pancreatitis : In first week of illness effect on other organs such as lungs, kidney and heart are main complications. During second week onwards, patient may develop complications of leakage of fluid from pancreas and the infection. Due to disruption of pancreatic duct, fluid may leak and collect in abdomen and around the pancreas. These fluid collections are known as pseudocyst or Walled off Pancreatic Necrosis or “WOPN”. This fluid may get infected, and may require drainage. Endoscopic ultrasound guided (EUS) drainage is the best way of draining the fluid collections. During EUS guided drainage, fluid is drained inside the stomach or upper part of intestine. If collections are not amenable to endoscopic drainage, tubes are placed through the percutaneous routes to drain the collections.
What are possible late complications of acute pancreatitis : Due to damage to the pancreas,
few patients may develop diabetes mellitus, as enough amount of insulin is not secreted. Few patients may develop diarrhoea, loosing fat in the stool due to insufficient secretions of enzymes required to digest the dietary fat. If underlying cause is not treated well, there is always a risk of another attack of acute pancreatitis.
How to prevent the recurrence of acute pancreatitis : Treatment of underlying cause is necessary to prevent the another episode of acute pancreatitis. Alcohol should be stopped, gall bladder should be removed in patients with pancreatitis due to biliary cause, offending drugs should be stopped, calcium and triglyceride level should be corrected and pancreatic tumor should be operated.
When should gall bladder surgery be performed after acute pancreatitis: If gall bladder stone is the cause of acute pancreatitis, and the attack is mild (no organ failure, no significant fluid collection) gall bladder surgery should be performed before discharge. Otherwise gall bladder surgery should be performed after treatment of the complications of acute pancreatitis.
Take home message: Acute pancreatitis is a complex disease requiring specialized care. With the proper management, most of the patients has favourable outcome.
Dr Vikas Singla
Director and Head, Gastroenterology
Canter for Gastroenterology Hepatology and Endoscopy
Max Superspeciality Hospital Saket New Delhi India