What Is Pancreatitis?
The severe upper abdominal pain brought on by inflammation of the pancreas typically catches people off-guard. This sudden pain—which may radiate to the back and be worse after eating—is a hallmark symptom of acute pancreatitis, along with nausea and vomiting. Acute pancreatitis is a commonly diagnosed gastrointestinal (GI) illness and the leading reason for GI-related hospitalization in the United States.
Acute pancreatitis not only causes pain but also can result in fever, shortness of breath, and kidney problems. Fortunately, most attacks of acute pancreatitis do not lead to these complications and are considered mild, and those who receive immediate medical care recover uneventfully within 48 hours. In its severe form, however—affecting 15 to 20 percent of patients—acute pancreatitis will develop into a complicated recovery, which may result in infection, respiratory failure, organ failure, or death.
Although acute pancreatitis is a common ailment, researchers have been giving it more attention lately because of a steady climb in its incidence over the past couple of decades. In 1998, slightly more than 100,000 people were hospitalized for acute pancreatitis. By 2002, the number had more than doubled to 210,000. In 2009, it had climbed to 274,119.
Finding the cause
There is no mystery about why the incidence of acute pancreatitis has increased; it follows a trajectory similar to that for obesity.
People who are obese are at triple the risk of developing acute pancreatitis. That’s because obesity is a major risk factor for gallstones, and gallstones account for 40 to 70 percent of acute pancreatitis cases, particularly in people over 60. This occurs when a gallstone, passing from the gallbladder into the bile duct, lodges temporarily in the sphincter of Oddi, a structure that allows bile and pancreatic secretions to ebb and flow. The digestive enzymes headed for the small intestine are then forced back to the pancreas, where they cause inflammation.
The stone may either pass on its own or it may require an endoscopic retrograde cholangiopancreatography (ERCP), a procedure that removes stones from the bile ducts. In both situations, doctors recommend the removal of the gallbladder to prevent recurrence of acute pancreatitis.
The second most common cause of acute pancreatitis is heavy, long-term alcohol consumption, which is responsible for 25 to 35 percent of all cases. Non-drinkers are not immune to pancreatitis, but alcohol definitely appears to raise the risk; the prevalence of pancreatitis is about four times higher in people with a history of alcoholism than in those without.
Alcohol-induced acute pancreatitis occurs hours to days after consuming alcohol. It is not entirely clear how drinking plays a role in acute pancreatitis; it’s possible that alcohol harms specific cells of the pancreas, causes obstruction in the small ducts of the pancreas, or affects the sphincter of Oddi. At this point there is no way to predict why some heavy drinkers are more vulnerable to developing acute pancreatitis than others.
The third leading cause of acute pancreatitis is high triglycerides. Typically, triglyceride levels higher than 1,000 mg/dL will put people at risk for developing acute pancreatitis. If this is the case, then lowering triglyceride levels is essential to prevent this from occurring.
The fourth most common cause of acute pancreatitis is smoking. Smoking has been shown to cause recurrent episodes of acute pancreatitis. In addition, long-term heavy smoking will increase the risk of developing fibrosis of the pancreas (chronic pancreatitis) and pancreatic cancer.
Acute pancreatitis can also be caused by hereditary pancreatitis as well as genetic mutations that have been linked to acute pancreatitis, such as carrying a mutated CFTR gene, which is the gene linked to cystic fibrosis. Certain conditions such as inflammatory bowel disease and lupus are associated with an increased risk for acute pancreatitis. Other risk factors include complications from ERCP, traumatic injury, and certain medications.
The American College of Gastroenterology’s most recent guidelines for managing acute pancreatitis recommend that doctors determine the underlying cause and, if possible, treat the condition to prevent a recurrence. About 20 to 30 percent of acute pancreatitis patients will have a recurrence, and repeated episodes of acute pancreatitis can progress to chronic pancreatitis. No underlying cause can be identified in about 20 percent of people with acute pancreatitis, but only a small proportion of this group will experience additional attacks over time.
First, head for the hospital
If you experience the symptoms of acute pancreatitis, it’s important to seek medical help immediately.
According to the current guidelines, a diagnosis is confirmed when patients meet two of the three following criteria: abdominal pain consistent with the disease, blood tests that show enzyme levels three times higher than normal, and/or abdominal imaging indicating acute pancreatitis.
Computed tomography (CT) scans are not considered necessary unless the diagnosis remains unclear or patients do not get better within 72 hours after being admitted to the hospital.
At the outset, it may be difficult for doctors to distinguish mild acute pancreatitis from severe acute pancreatitis, which is characterized by persistent organ failure. The first 12 to 24 hours of hospitalization are critical, because this is when the highest incidence of organ dysfunction occurs. Medical treatment of mild acute pancreatitis is relatively straightforward, but treatment of severe acute pancreatitis involves intensive care.
Recovering from pancreatitis
At this time, no medications have shown to be effective in managing acute pancreatitis, so physicians rely on a number of supportive and therapeutic interventions to help patients recover. The current guidelines recommend aggressive intravenous rehydration to replenish lost fluids and reduce the risk of serious complications. Painkillers and oxygen are also administered. Most people with moderate to severe pancreatitis will need a temporary feeding tube. Those with the mild form who are not experiencing nausea and vomiting can have solid food once their abdominal pain resolves.
Patients with infections outside the pancreas, such as urinary tract infections, cholangitis, or pneumonia, will need antibiotic treatment. Patients with acute cholangitis, an infection of the bile duct usually associated with gallstone obstruction, typically undergo ERCP, preferably within the first 24 hours of admission.
Some patients will require surgery: Surgical removal of the gallbladder (cholecystectomy) is recommended in patients with gallstone disease, and those with extensive infection or damage to the pancreatic tissue may need radiological, endoscopic, or very occasionally surgical procedures to remove dead tissue (necrosectomy).
Making healthy changes
Once an episode of acute pancreatitis is under way, there is no course but to seek immediate medical help. But considering that the majority of cases are associated with gallstone disease and alcoholism, there are steps people can take to mitigate their risk.
Many lifestyle factors associated with gallstone disease are modifiable, including diet. If you need to lose weight, talk to your doctor about a sensible plan of action, but take it slowly. While obesity itself is a risk factor for acute pancreatitis, so is attempting to lose weight rapidly. Large clinical trials have indicated that including the following in a balanced diet may reduce the risk of gallstone disease:
• fruits and vegetables, particularly cruciferous and green leafy vegetables, citrus fruits, and vitamin C–rich fruits and vegetables
• polyunsaturated and monounsaturated fats
• moderate amounts of coffee
As for alcohol-associated acute pancreatitis, if you struggle with drinking, talk to your doctor about the steps you will need to take to achieve and maintain abstinence from alcohol. Quitting smoking, too, is very important, and your doctor may be able to help.