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What is the pancreas?
The pancreas is a flat, fillet-shaped gland located behind the stomach. It has two main functions: producing digestive enzymes (such as amylase, carboxypeptidase, chymotrypsinogen, elastase, pancreatic lipase, and trypsinogen), and secreting hormones such as insulin and glucagon, which regulate blood sugar levels. The pancreas releases digestive enzymes into the duodenum when it detects fats and proteins. The islets of the pancreas secrete insulin and glucagon into the bloodstream. Insulin causes cells to take up glucose from the blood, and glucagon causes the liver to release glucose into the blood.
What is pancreatitis?
Pancreatitis is a term that means inflammation of the pancreas. The two main types of pancreatitis are acute and chronic. Acute does not refer to disease severity, it just means an abrupt onset of symptoms. Chronic means smouldering, long-standing disease that continues even after resolving the original trigger.
Chronic pancreatitis is a long-term condition characterized by scarring and irreversible destruction of pancreatic tissue. The main symptoms are pain, weight loss, and manifestations related to the loss of functional pancreatic tissue such as diabetes or malabsorption.
Acute Pancreatitis
What causes acute pancreatitis?
The most common cause of acute pancreatitis in adults is gallstones. Alcohol abuse is next, and unlike gallstones, this can also cause chronic pancreatitis. Some patients may have more than one attack of pancreatitis but usually recover fully after each one. Less common causes include viral infection (mumps, coxsackie B), trauma, manipulation of the pancreas at the time of surgery or ERCP, elevated blood triglyceride levels, congenital structural abnormalities of the pancreas or intestine, and some medications (e.g. estrogen, azathioprine, corticosteroids, thiazide diuretics, tetracycline). In about 15% of cases, the cause is unknown.
Damage to the pancreas may occur during auto-digestion, when digestive enzymes normally secreted into the small intestine for food digestion activate inappropriately within the pancreas and begin attacking that organ. There may be bleeding into the gland causing swelling, serious tissue damage, infection, and cysts. When the disease is more serious, enzymes and toxins may enter the bloodstream and significantly injure organs, such as the heart, lungs, and kidneys. Intense, painful symptoms may last for 48 hours. About 20% of cases are severe.
What are the symptoms of acute pancreatitis?
The main symptoms of acute pancreatitis are pain in the upper abdomen or back, and nausea. Acute pancreatitis comes on suddenly, and can vary in severity from mild to life threatening. Mild cases typically resolve over the course of a week or so. Severe cases may include major complications such as infection, hemorrhage, failure of other organ systems such as lungs or kidneys, or fluid collections in the abdomen. Such fluid collections, called pseudocysts, often resolve spontaneously.
Large cysts that persist for more than 6 weeks usually need draining to prevent further problems such as infection or hemorrhage. In most cases of acute pancreatitis, the patient recovers completely.
How is acute pancreatitis diagnosed?
On physical examination, the abdomen is tender. During acute attacks, blood tests reveal high levels of the digestive enzyme amylase. A CT scan or ultrasound of the abdomen may show evidence of swelling or damage to the pancreas, or fluid collections around the pancreas.
What is the treatment for acute pancreatitis?
Patients with acute pancreatitis often have significant pain and vomiting, and generally require admission to hospital for supportive care with intravenous fluids, electrolytes, and analgesics. Fasting is the best approach to prevent further stimulation and irritation of the pancreas. During this time, the doctor will monitor tests to determine the cause of the pancreatitis and to treat any complications that arise.
In most cases, symptoms subside after 4-7 days, patients resume oral intake, and leave the hospital. Patients with very severe pancreatitis may require treatment in an intensive care unit, and may even need urgent surgery to deal with complications such as a pancreatic abscess. If the pancreatitis is due to gallstones, then a surgeon may remove the gallbladder once the pancreatitis has subsided, to prevent future recurrences.
Can acute pancreatitis be prevented?
In most cases, the answer is no. However, to prevent some types of acute pancreatitis you should avoid excess alcohol, and if you have diabetes or hyperlipidemia, follow the prescribed treatment for your condition.
Chronic Pancreatitis
What causes chronic pancreatitis?
75% of all cases of chronic pancreatitis are caused by alcohol abuse. Less common causes include hereditary pancreatitis or pancreatic duct obstruction. However, in a significant proportion of cases of chronic pancreatitis, doctors are unable to identify a cause. A key feature of chronic pancreatitis is that there is always irreversible scarring of the duct and of the functioning glandular tissue in the pancreas. Ultimately, this damage results in an inability to digest food properly, due to a lack of pancreatic enzymes (pancreatic insufficiency). This also affects insulin production, potentially leading to diabetes.
What are the symptoms of chronic pancreatitis?
The primary ongoing symptom of chronic pancreatitis is pain localized to the upper abdomen that often radiates to the back. Episodes of pain last from hours to days, and may eventually become continuous. Eating may worsen the pain. Patients who develop pancreatic insufficiency may develop loose, foul-smelling stools and lose weight.
How is chronic pancreatitis diagnosed?
There is often a previous history of pancreatitis. There may be signs of malnutrition and weight loss. An abdominal CT scan or ultrasound may reveal inflammation and/or calcification of the pancreas. Amylase levels may be increased, but this test is less reliable with chronic pancreatitis than with acute pancreatitis. A number of specialized tests are available to assess pancreatic function and enzyme secretion.
What are the consequences of chronic pancreatitis?
Hospitalization
Unemployment
Disrupted social life
Weight loss
Depression, sometimes to the point of suicide
Narcotic dependency (if narcotics are required for pain)
How is chronic pancreatitis treated?
Treatment of the various symptoms and complications of chronic pancreatitis addresses the two main issues of pain and pancreatic insufficiency.
Pain:
If there is a clearly identified cause of the chronic pancreatitis, then correcting it is the first step. Patients with a history of excess alcohol use must stop alcohol completely. Unfortunately, this may not lead to resolution of symptoms, but often slows further progression.
Some evidence exists supporting the use of pancreatic enzymes to help control pain attributed to chronic pancreatitis. By taking pancreatic enzymes, the level of hormonal stimulation of pancreatic enzyme secretion decreases, potentially leading to improved pain control. As opposed to the enzyme formulations used for pancreatic insufficiency (see below), the enzyme formulations used to control pain are non-enteric coated (Viokase®, Cotazym®). This means they dissolve in the stomach leading to immediate enzyme release.
Taking analgesics will help for pain relief as do narcotics. However, due to the chronic nature of the pain, patients taking narcotics continuously could develop dependency or addiction. Other strategies to control pain may include interventions such as nerve blocks or pancreatic duct drainage. Referral to a chronic pain clinic can also be helpful in identifying treatment options other than narcotics for pain control. In very rare cases of intractable pain not helped by these measures, the patient may require surgery.
Pancreatic Insufficiency:
Patients should follow a low fat diet supplemented with fat-soluble vitamins (A, D, & K) and calcium. Patients with pancreatic insufficiency should receive enzyme replacement therapy (Cotazym®, Creon®, Ultrase®). Not all these formulations are equally efficacious. Patients who develop diabetes from chronic pancreatitis will usually require insulin treatment.
Are there any complications with chronic pancreatitis?
Complications that can arise from chronic pancreatitis include narcotic addiction, obstruction of the common bile duct, pancreatic insufficiency, and diabetes mellitus.
Summary
As with other chronic illnesses, patients with chronic pancreatitis may experience a sense of helplessness. Knowing more about pancreatitis may relieve this concern and give the patient some pro-active steps to take toward managing the disease. It is important to recognize that this disorder often requires a multidisciplinary management approach involving healthcare practitioners such as the family physician, gastroenterologist, surgeon, internist, psychiatrist, counsellor, dietitian, and pain specialist.
Quick Review of Pancreatitis
There are two primary types of pancreatitis: acute and chronic
Acute pancreatitis refers to a severe abrupt onset of the disease which resolves in a short period of time
Chronic means that the disease is long-standing with ongoing symptoms that do not resolve
The most common causes of adult pancreatitis are gallstones and alcohol abuse
Symptoms of pancreatitis include pain in the upper abdomen and back as well as nausea and vomiting, the chronic form of the disease may lead to weight loss
Treatment for acute pancreatitis addresses symptom management for pain and vomiting. Patients may be hospitalized for supportive care and the administration of intravenous fluids
Treatment for chronic pancreatitis involves pain management with analgesics and narcotics, administration of pancreatic enzymes, and diet modification
Complications of pancreatitis include infection, hemorrhage, pancreatic insufficiency, and diabetes mellitus
Are you taking prescription medication for any of the following stomach problems/symptoms:
Stomach pain or discomfort
Heartburn
Sour taste in mouth/acid regurgitation
Excessive burping/belching
Increased abdominal bloating
Nausea
Early satiety
If you answer yes to any one of the symptoms listed above then take this test to see if your current medication is adequately controlling your stomach symptoms.
The PASS Test
PPI* Acid Symptom Suppression Test
*PPI is short for proton pump inhibitor, a class of medication used to suppress the acid in your stomach. These include Losec®, Nexium®, Pantoloc®, Pariet™, and Prevacid®.
