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What is Pancreatitis?
Pancreatitis literally means an inflamed or swollen pancreas. The pancreas is a gland situated behind the stomach and near the small intestine. It releases the hormones insulin and glucagon (hormone involved in carbohydrate metabolism) into the bloodstream which helps to use glucose for energy. The role of the pancreas is to secrete enzymes essential for digestion into the small intestine through a tube called the pancreatic duct. These enzymes help in the digestion of fats, proteins and carbohydrates in food. Normally, digestive enzymes become active only when they reach the small intestine to digest food. But if they become active inside the pancreas, they start digesting the pancreas itself causing inflammation and pain. This is called Pancreatitis.
Symptoms of Pancreatitis
Both acute and chronic Pancreatitis have some common symptoms but the severity will vary from person to person. The usual symptoms are:
01) Epigastric (upper abdomen) pain spreading towards the back
02) Pain worsens after eating
03) Swollen and tender abdomen
04) Nausea and vomiting
05) Fever and chills
06) Rapid pulse rate
08) Low blood pressure
09) Hemodynamic (blood circulation) instability, shock
10) Severe weight loss due to malabsorption
11) Pale, foul smelling and oily stools.
Also, in rare cases hemorrhagic discoloration of the flanks (Grey Turner sign) or of the umbilicus (Cullen sign) may occur. Pancreatic pseudocyst, diabetes mellitus or pancreatic cancer can occur as a complication.
Diagnosis of Pancreatitis
A) Acute Pancreatitis:
Blood investigations: After the physical examination and asking medical history, the doctor will order a blood test. Blood investigations would involve full blood count; renal function tests; liver function; serum calcium; serum amylase and lipase; and arterial blood gas investigations. The blood will show at least three times the normal presence of amylase and lipase, which are digestive enzymes formed in the pancreas. In general, serum lipase is considered a more sensitive and specific test than serum amylase in the diagnosis of Pancreatitis. The blood test would also show changes in the levels of glucose, calcium, magnesium, sodium, potassium bicarbonate.
Computerized axial tomography (CAT): The doctor may order an abdominal ultrasound to look for gallstones or look for inflammation or destruction of the pancreas. CAT scans are also useful in locating pseudocysts.
Balthazar scoring for grading acute Pancreatitis is as follows:
|CT Grade||Appearance on CT||CT Grade Points|
|Grade A||Normal CT||0 points|
|Grade B||Focal or diffuse enlargement of the pancreas||1 point|
|Grade C||Pancreatic abnormalities and peripancreatic inflammation||2 points|
|Grade D||Fluid collection in a single location||3 points|
|Grade E||Two or more fluid collections and / or gas bubbles in or adjacent to pancreas||4 points|
|No necrosis||0 points|
|0 to 30% necrosis||2 points|
|30 to 50% necrosis||4 points|
|Over 50% necrosis||6 points|
B) Chronic Pancreatitis: Here the focus is to check whether the pancreas is still making enough digestive enzymes.
A secretin simulation test is considered the most functional test to check if bi-carbonate production is impaired, which would indicate chronic Pancreatitis. Also, ultrasound imaging, endoscopy, retrograde cholangiopancreatography (ERCP), magnetic resonance imaging (MRI) and CAT scan techniques are used to look for chronic problems like calcification of the pancreas (tissue hardens from deposits of insoluble calcium salts). In more advanced stages of the disease, when diabetes and malabsorption occur, a doctor can use a number of blood, urine, and stool tests to help diagnose chronic Pancreatitis and to monitor its progression. Fecal elastase test (test to check concentration of the pancreatic elastase-1 enzyme) checks for pancreatic exocrine (secretion of hormones) dysfunction.
Causes of Pancreatitis
Some of the common causes are:
01) Idiopathic cause – unidentifiable genetic cause
04) Trauma to that part of the body
05) Use of steroids for other diseases
06) Virus infections like mumps
07) Autoimmune disease like systemic lupus erythematosus
08) Snake or scorpion bites
09) Other disorders like hypercalcemia, hyperlipidemia, hypertriglyceridemia or hypothermia (high levels of calcium, blood fats)
10) ERCP (a combination of endoscopy and fluoroscopy) undertaken
11) Use of sulfonamides, non-steroidal anti-inflammatory drugs (NSAIDs), diuretics, etc to cure other diseases
12) Carcinoma or other cancers
13) Ischemia (localized reduction of blood flow) after bypass surgery
14) Fatty necrosis
16) Congenital pancreatic divisum (two pancreatic ducts instead of one)
17) Cystic fibrosis
In up to 70 percent of adult patients, chronic Pancreatitis appears to be caused by alcoholism. This form is more common in men than in women and often develops between the ages of 30 and 40.
Types of Pancreatitis
Pancreatitis is usually categorized by the cause as the symptoms and the treatment would differ accordingly. The Balthazar scoring and necrosis scoring methods can help distinguish each case to identify severity of Pancreatitis.
A) Acute Pancreatitis:
This type of Pancreatitis pertains to sudden inflammation of the pancreas. It can be further categorized into mild and severe.
1) Mild-acute Pancreatitis: Mild cases can be successfully treated in the common ward by conservative measures like NPO (abstaining from any oral intake) and IV fluid re-hydration.
2) Severe-acute Pancreatitis: It can have severe complications and high mortality (20%) despite treatment. Severe Pancreatitis will need intensive care therapy or even surgery (often more than one intervention) to deal with complications. Necrosis will be followed by a systemic inflammatory response syndrome (SIRS) and will determine the immediate clinical course.
B) Chronic Pancreatitis:
This pertains to a persistent and long-standing inflammation of the pancreas that alters the gland’s normal structure and functions. It can be present in the form of acute inflammation in a previously injured pancreas or as chronic damage to the pancreas with persistent pain or malabsorption. The pain and damage would be present even if there is no steatorrhea (presence of excess fat in feces) or diabetes.
Treatment of Pancreatitis
A) Acute Pancreatitis:
Hospitalization: Acute Pancreatitis usually lasts only a few days if there aren’t any other complications like that of kidney or lungs. Treatment depends on the severity of the attack and hospitalization would be necessary merely so that fluids can be replaced intravenously (IV). In some severe cases of acute Pancreatitis, IV may be required for 3 to 6 weeks (parenteral nutrition).
Pain control: Pain killers like morphine and Demerol are administered to the patient. Due to lack of efficacy and risk of toxicity meperidine, which was widely used earlier, has been discontinued.
Bowel rest: As the pancreas is stimulated to secrete enzymes by the presence of food in the stomach, the treatment involves giving intravenous fluids to prevent dehydration but stopping oral intake of food. As there is no food in the stomach, the system allows the pancreas to rest. If intake of food in started too early, there are chances of a relapse. Approximately 75% of relapses tend to occur 2 days after oral re-feeding is resumed.
Nutritional support: Nowadays, instead of total parenteral nutrition (TPN), early post-pyloric enteral feeding (feeding tube) into the third portion of the duodenum is more commonly carried out. The advantage of enteral feeding is that it is free from the side effects like fungemia.
Medications: Controlled trials of imipenem 0.5 gram intravenously every eight hours for two weeks showed a reduction in pancreatic sepsis from 30% to 12%. Another randomized controlled trial with patients who had at least 50% pancreatic necrosis found a benefit from imipenem with a reduction in infected necrosis from 34% to 20%.
Surgery: The most common cause of death in acute Pancreatitis is secondary infection. Surgery is undertaken only in cases of infected pancreatic necrosis and other complications.
B) Chronic Pancreatitis:
Analgesics: Relieving pain is the first step in treating chronic Pancreatitis. Treatment is aimed at curing the underlying cause of Pancreatitis as well as relief from pain and malabsorption. The abdominal pain can be very severe and may require high doses of analgesics. Disability and mood problems have to be prevented with early diagnosis and treatment.
Surgery: Surgery becomes necessary in severe cases of chronic Pancreatitis where pain relievers don’t work and the underlying disease cannot be cured with medication alone. The surgery may involve draining an enlarged pancreatic duct or removing part of the pancreas. Surgery for Chronic Pancreatitis tends to be divided into two areas – re-sectional and drainage procedures.
Pancreatic Enzyme Supplementation: For malabsorption and steatorrhea intake of supplementary pancreatic enzymes is effective. This has worked most effectively in the cases of idiopathic chronic Pancreatitis where alcoholism is the cause.
Living with Pancreatitis
Acute Pancreatitis occurs suddenly and lasts for a short period of time and can be cured easily. In chronic Pancreatitis there is slow destruction of the pancreas. Like chronic, even acute can cause serious complications if untreated. In severe cases the quality of life of the patient is adversely affected due to symptoms like bleeding, breathing problems, hypoxia (cells/tissues receiving less oxygen), tissue damage, pseudocysts, accumulations of fluid and tissue debris, lung failure, increase in blood toxicity, kidney failure needing dialysis, etc.
Prevention of Pancreatitis
Some measures to prevent Pancreatitis are:
1) Low consumption of refined sugar and sweets
2) Eating smaller meals instead of large meals
3) Complete cessation of alcohol
4) Avoiding very fatty food
5) Doing some form of exercise like aerobics, yoga (Indian form of exercises), etc.