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Gastroenterology
Acute Pancreatitis



Acute Pancreatitis
Pancreas

What is the pancreas?

Most of the food you eat would be as deadly as poison if it got directly into your bloodstream. Through the chemical wizardry of digestion your digestive tract disassembles virtually everything you eat into smaller components, ones that your body can use. One key element in that digestive process is the pancreas.

Most people have heard the word pancreas, but when asked, have no idea where this organ is located or what it really does. In fact, the pancreas is an elongated pear-shaped organ about 6 inches in length, somewhat wider on the right side and narrower on the left. Located deep within the body, it stretches across the upper abdomen, nestled behind the stomach and in front of the spine. To describe the pancreas, doctors divided it into three sections: the wider right end is called the head, the middle section the body and the narrow left end the tail

What does the pancreas do?

The pancreas is made up of two different types of tissue, each doing a different job - one helps digest the food and the other makes insulin to regulate blood sugar.

Acute pancreatitis

It is a testament to reliability that most adults do not know much about the pancreas. We don't simply because we don't have to. From the moment of birth, the pancreas is like a machine on autopilot - silently working in the background doing its job meal after meal, day after day. We may only have one pancreas, but it usually lasts a lifetime processing over 100,000 meals and rarely ever breaks down. One problem that can occur, however, is acute pancreatitis, a sudden inflammation of the pancreas which causes severe upper abdominal pain.

What causes acute pancreatitis?

The most common cause of acute pancreatitis is gallstones, especially in female patients who are more prone to gallstone disease. As mentioned above, the pancreatic duct and bile duct share a common drain into the duodenum, called the papilla. Sometimes, a gallstone will sneak out of the gallbladder and travel down the bile duct. If the stone is too big to pass, it will often become lodged at the papilla. Sometimes, there is no actual stone, but a large amount of debris from the gallbladder called "sludge" which blocks the drain. In either case, this blockage causes a backup of pressure into the pancreatic ducts. This backup unintentionally activates the digestive enzymes within the pancreas itself. This is a big problem since the pancreas then begins to digest itself which releases even more enzymes, starting a chain reaction of self-destruction. This is acute pancreatitis.

The second most common cause of acute pancreatitis is chronic alcohol abuse, most often seen in men.

Other less common conditions that may cause acute pancreatitis include hereditary pancreatitis, blunt force abdominal trauma (like a steering wheel), post-ERCP pancreatitis, high blood calcium from overactive parathyroind gland or kidney failure, and high blood fat (triglyceride) levels. Certain medications may occasionally cause pancreatitis. These may include DDI (dideoxycytosine), DDC (dideoxyinosine), (Imuran) azathioprine, (Purinethol) 6-mercaptopurine, tetracycline, Depakene (valproic acid), Tylenol (acetaminophen), and others. Pancreatitis is associated with certain connective-tissue disorders such as Lupus (SLE), polyarteritis nodosa, and sarcoidosis. Infectious causes including viruses such as mumps, rubella, cytomegalovirus (CMV), HIV-AIDS, and others. Some bacteria can cause pancreatitis such as Campylobacter and Legionella. In approximately 15% of cases, the cause of acute pancreatitis is unknown, so-called idiopathic acute pancreatitis.

What are the symptoms?

Patient with acute pancreatitis generally complain of the sudden onset of severe pain in the upper mid-abdomen. The pain is a constant and may radiate to the back. Some patients have symptoms of nausea, vomiting and fever. Often, the pain is temporarily relieved by sitting up and bending forward - a characteristic of pancreatic pain.

How does your doctor know?

Diagnosis is the first step in treatment. If your doctor suspects that you may have acute pancreatitis, he will generally order several blood tests to confirm the diagnosis:

Blood tests

When pancreatitis is suspected, the first test performed is usually a blood test that measures the level of amylase and lipase. These are the normal enzymes that aid in the digestion of food in the intestine. They are made in the pancreas, secreted into the pancreatic ducts, and transported through the ducts to the intestine. When there is inflammation of the pancreas or blockage of the pancreatic ducts, lipase and amylase seep out of the pancreas and into the bloodstream.

X-ray tests What is the treatment?

The treatment of pancreatitis may be conservative or aggressive depending upon the severity of inflammation and the development of complications. Since there is no currently proven medication for acute pancreatitis, treatment is mostly supportive. Most patients are hospitalized and given IV fluids. Since eating stimulates the pancreas, food is witheld for a few days to "rest" the pancreas.. Medications are given to control pain. The role of antibiotics is controversial. But, if infection is suspected, IV antibiotics are added. In prolonged cases, aggressive IV nutritional support is also necessary.

The risk of abdominal surgery is high in any seriously ill patient. Surgery is only performed as a last resort in acute pancreatitis. If there is suspicion of an uncontrolled abscess or severe necrosis (death) of pancreatic and surrounding tissue, a CT-guided fine-needle aspiration "tap" is often done. If dead tissue or active infection is found, surgery may be necessary to remove the dead tissue and drain the infection. If gallstones are found to be the cause of acute pancreatitis, it is best to have the gallbladder removed once the acute attack has resolved. Most patients are sent home and return to have the operation some time later. The operation to remove the gall bladder is called a cholecystectomy and, in most cases, can be done with minimally invasive laparoscopic "band-aid" surgery.

Complications

Acute pancreatitis is a serious disease. About 25% percent of patients with severe acute pancreatitis develop complications such as necrosis multiorgan failure (lungs, kidney, or heart), abscess, or pseudoscyst formation. Unfortunately, the serum amylase level and the lipase level are not specific enough measures of disease activity to predict these complications. Most complications of acute pancreatitis and deaths occur within two weeks of onset of pain.

Prognosis

Most patients (85%) recover fully from acute pancreatitis within a week or two and do not experience recurrence, if the cause is removed. Recurrences are common with continued alcohol abuse. However, in some cases, life-threatening complications develop such as necrosis, infection, liver, heart, or kidney impairment. The death rate is over high when these complications are present.

Chronic pancreatitis

Some patients do not recover fully and develop another complication of acute pancreatitis called chronic pancreatitis. The body has a great capacity to heal. But, sometimes acute pancreas is so severe that the pancreas is damaged beyond repair. This may occur after one severe attack of pancreatitis, but most often is seen after multiple acute episodes, often the result of continued alcohol abuse.

Symptoms of chronic pancreatitis include:

How can you prevent acute pancreatitis?

There are a few things that help. Prevention of acute pancreatitis is associated with prevention of the causative disorders. So, if you drink alcohol, control alcohol intake. If you have attacks of gallstone disease, consider elective surgery before you develop a case of "gallstone pancreatitis." Wear your seatbelt and use proper safety precautions to avoid abdominal trauma.

Summary

Acute pancreatitis is a variable ailment that may range from a mild to a life-threatening condition. Establishing an accurate diagnosis through laboratory testing and x-ray studies is important. Since there is no proven medical treatment, care is mostly supportive. Most cases of acute pancreatitis are mild the pancreas usually completely heals and the patient fully recovers. Patients with signs of severe disease should be hospitalized and closely monitored for signs of complications.


Text & Images Courtesy of Three Rivers Endoscopy Center
© Dr. Robert Fusco, Three Rivers Endoscopy Center, All Rights Reserved





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