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Pancreatitis

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Introduction

The pancreas is a long, flat gland that sits tucked behind the stomach in the upper abdomen in front of the backbone (Figure 1). The pancreas produces enzymes that help digestion and hormones (such as insulin) that help regulate the way your body processes sugar (glucose).

Pancreatitis happens when the enzymes do not work properly, irritating the cells of your pancreas and causing inflammation. Mild cases of pancreatitis may be treated with supportive care, such as intravenous (IV) fluids and pain medication, resulting in a short hospital stay. Severe cases require more intense treatment, longer hospitalization and possibly surgery.

There are two types of pancreatitis: acute and chronic

Acute Pancreatitis

There are two types of acute pancreatitis: mild and severe. Acute pancreatitis happens very suddenly and is usually mild. Mild pancreatitis lasts for about 5 to 10 days. Severe pancreatitis is usually caused when some part of the pancreas has died (necrosis). Severe pancreatitis is sometimes called necrotizing pancreatitis and requires a longer hospital stay than mild pancreatitis, often with a stay in the intensive care unit. Severe pancreatitis can also be life threatening.

Symptoms

Signs and symptoms of acute pancreatitis include:

• Severe upper abdominal pain that radiates to your back, shoulders or flank.

• Abdominal pain that may feel worse after eating and may become severe and constant.
• Nausea and vomiting.

• Tender abdomen.

• Yellowing of the skin.

• Fever.

• Shortness of breath.

Causes

Gallstones and large amounts of alcohol intake for a long period of time are the most common causes of acute pancreatitis.

Gallstones
Gallstones are hardened deposits of digestive fluid that form in your gallbladder, a pear-shaped organ that helps in the digestion of food by releasing digestive fluid (bile) into your small intestine (Figure 2). Gallstones can block the bile duct, which keeps enzymes made in the pancreas from traveling to the small intestine. These enzymes back up into the pancreas and cause inflammation. Gallstones can range in size from as small as a grain of sand to the size of a grape. A person may have one gallstone or many.

Other causes

Other causes of pancreatitis may include:

• Medications.

• Cigarette smoking.

• Cystic fibrosis.

• High calcium levels in the blood (hypercalcemia).

• High levels of parathyroid hormone in the blood (hyperparathyroidism).

• High triglyceride levels in the blood (hypertriglyceridemia).

• Infections with certain viruses.

• Injury to the pancreas (such as in a car accident).

• Pancreatic cancer.

• Pancreas or bile duct surgery.

Diagnosis

Diagnosing acute pancreatitis is usually based upon medical history, a physical exam and diagnostic tests, such as:

• Blood tests, which show high levels of pancreatic enzymes.

• Computed tomography (CT) scan or magnetic resonance imaging (MRI) of the stomach (abdomen).
• Abdominal ultrasound (sonogram) from outside the body or inside the body

(endoscopic).

• A procedure called an endoscopic retrograde cholangiopancreatography (ERCP) that uses a long tube with a camera on the end to take pictures of your pancreas and bile ducts. This helps your health care provider see if there are gallstones blocking the bile duct.

Your health care provider may order additional tests. These tests can help determine whether (or not) a mild case of acute pancreatitis might develop into severe acute pancreatitis (necrotizing pancreatitis). With this information, your health care provider may be able to provide early medical treatment to help improve your outcome.

Treatment

Mild acute pancreatitis

Mild acute pancreatitis is the most common type of acute pancreatitis. With mild acute pancreatitis, the pancreas swells and becomes enlarged but the pancreas tissues does not die.

Treatment usually includes a hospital stay of a few days. The length of a hospital stay differs with each person. Your length of hospital stay depends on your medical situation.

While hospitalized:

• You may not feel like eating due to nausea and pain. Your health care provider helps you decide when you can eat. Usually you begin by drinking clear liquids for the first 12 to 24 hours. If you take these liquids without problems, you can usually try low-fat foods.

• Fluids are given through a vein (intravenous, IV) in your arm to help keep your body hydrated and help give it the energy it needs to repair your pancreas.

• You are given medications to help control the pain and to help the pancreas heal.

Most people get better within 3 to 7 days and do not need further treatment other than trying to find the cause of pancreatitis so that it may be prevented from happening again.

Severe acute pancreatitis (necrotizing pancreatitis)

With necrotizing pancreatitis, the pancreatic tissue begins to die and blood enters the pancreas tissue (Figure 3). This condition is serious because it makes your pancreas more likely to be infected with bacteria. Death can happen if the infection is not treated right away.

With necrotizing pancreatitis, a person may be hospitalized for weeks and sometimes for months, although this is rare. During your hospital stay:

• You may not be able to drink or eat by mouth. If this happens, you may receive essential nutrients through a feeding tube placed through your nose and passes into your small intestine.

• Fluids are given through a vein (intravaneous,

IV) in your arm to help keep your body hydrated and help give it the energy it needs to repair your pancreas.

• You receive antibiotics through a vein in your arm to prevent or treat an infection.
• A measuring device placed on your finger checks the oxygen level in your blood. If there is not enough oxygen in your blood, you may be given extra oxygen through a small tube placed into your nostrils.

• The amount of urine you make (urine output) is checked to see if your kidneys are working properly.
• You are given medications to help control your pain and to help the pancreas heal.

Pancreatic infections can form with necrotizing pancreatitis. Pancreatic infections are serious and require intensive treatment. In some people, endoscopic, radiologic or surgical treatment may be required to drain fluid or remove infected tissue from the pancreas (Figure 4).
Pancreatic fluid collection

Your pancreas may develop other problems after you go home. Because of pancreatitis, your pancreas is more likely to develop fluid collections, which can become infected over time. Some of these infections may be serious and require further hospitalization and/or surgery.

Pseudocyst

A pancreatic pseudocyst is a collection of tissue, blood, fluid, and pancreatic enzymes.

This collection disrupts the normal function of the pancreas.

Pseudocyst

A pancreatic pseudocyst is a collection of tissue, blood, fluid, and pancreatic enzymes.

This collection disrupts the normal function of the pancreas.

Symptoms of a pseudocyst may include:

• Abdominal pain that does not go away.

• Abdominal bulging.

• Not being able to eat.

• Vomiting

• Jaundice

You will most likely need an endoscopic retrograde cholangiopancreatography (ERCP) or surgery to drain the cyst. If left untreated, a pseudocyst can rupture or develop an infection or abscess.

Contact your health care provider right away if you experience any of the symptoms associated with a pseudocyst.

Other fluid collection problems

Another problem happens when dead pancreatic tissue combined with fluid presses on organs like the small or large intestine or stomach. This pressure can block or make a hole in these organs. Also, pressure may be placed upon the bile duct and cause a yellow discoloring of the skin and the whites of the eyes (jaundice). The swelling from the fluid pressure may cause blood vessels to rupture, although this is rare. Endoscopy, radiology or surgery (open or laparoscopic) treatments may be necessary to drain fluid from your pancreas and to remove diseased or dead pancreas tissue.

Treating the cause

Once your pancreatitis is under control, your health care provider will want to determine what caused the pancreatitis attack. Treatment depends on the cause.

Examples of treatment include:

• Removing bile duct stones. A procedure called an endoscopic retrograde cholangiopancreatography (ERCP) uses a long tube with a camera on the end to take pictures of your pancreas and bile ducts. This helps your health care provider see whether (or not) there are stones blocking the bile duct. If so, the stones can be removed by using tools passed through the endoscope.

• Gallbladder surgery. If gallstones caused your pancreatitis (with or without bile duct blockage), your health care provider may recommend surgery to remove your gallbladder (cholecystectomy). If your attack is mild, surgery may be done before you go home. In severe cases, surgery may be done later in order to let inflammation go down.

• Treatment for excessive alcohol use. Drinking several drinks a day over many years can cause pancreatitis. If this is the cause of your pancreatitis, your health care provider may recommend you enter a treatment program to help you stop. Continuing to drink alcohol may worsen your pancreatitis and lead to serious complications including chronic pancreatitis.

Chronic Pancreatitis

Chronic pancreatitis is a long-term condition that does not heal or improve, gradually worsening as time goes on (Figure 5). It causes permanent damage and scarring of the pancreas.

Symptoms

Symptoms of chronic pancreatitis include:

• Upper abdominal pain.

• Indigestion.

• Losing weight without trying.

• Oily, smelly stools (steatorrhea).

• Symptoms of diabetes like excessive thirst, hunger and urination.
• Yellow eyes and skin (jaundice)

Causes

The most common cause of chronic pancreatitis is alcohol abuse. If alcohol
is the cause, not drinking any alcohol is necessary to avoid more damage. Your health care provider may refer you to a treatment program to help you stop drinking if you have trouble stopping on your own.

Other causes of chronic pancreatitis may include:

• Any case of necrotizing pancreatitis causing scarring of the pancreas duct.

• Heredity (genetic or familial pancreatitis).

• No cause found (idiopathic).

Diagnosis

A diagnosis of chronic pancreatitis is usually based upon medical history, a physical exam and diagnostic tests, such as:

• Blood tests.

• Stool tests.

• Pancreatic function tests by placing a tube into the small intestine to collect pancreas juices.

• Computed tomography (CT) scan.

• Abdominal ultrasound.

• Endoscopic ultrasound.

• Magnetic resonance imaging (MRI).

• ERCP (endoscopic retrograde cholangiopancreatography).

Your health care provider may order additional tests.

Treatment

The treatments listed on page 5 may also be used to treat chronic pancreatitis. However, if you have chronic pancreatitis, you may need the following additional treatments to manage your condition:

• Pain management. Chronic pancreatitis can cause persistent abdominal pain. Your health care provider may recommend medications to control your pain and may refer you to a pain specialist. Severe pain may be relieved with surgery to block nerves that send pain signals from the pancreas to the brain.
• Enzymes to improve digestion. Pancreatic enzyme supplements can help your body break down and process the nutrients in the foods you eat. Pancreatic enzymes are taken in tablet form with each meal.
• Changes to your diet. Your health care provider may refer you to a dietitian who can help you plan low-fat meals that are high in nutrients.

• Lifestyle changes. Your health care provider may also recommend that you do not smoke or drink alcoholic beverages.

• Endoscopic treatment. Endoscopy may be used to put tubes in a blocked pancreatic duct and to sometimes inject anesthetic medications into nerve tissues around the pancreas (celiac ganglion) to block pain-carrying nerves.
• Surgery. Surgery is used in cases that do not respond to other methods, either bypassing the obstructed pancreatic duct or even removal of the pancreas; however, removal of the entire pancreas is rarely needed. Removal of the pancreas can cause diabetes. Because of diabetes, insulin-producing cells are taken from the removed pancreas and injected into the liver where they secrete insulin and help control diabetes.

Possible complications

Complications that can happen because of chronic pancreatitis:

• Diabetes. Damage to insulin-producing cells in your pancreas can lead to diabetes, which affects the way your body uses blood sugar.
• Malnutrition. Both chronic and acute pancreatitis can cause your pancreas to produce fewer pancreatic enzymes. These enzymes are needed to break down and process nutrients from food. This loss of enzymes can lead to malnutrition and weight loss.
• Pancreatic cancer. Long-standing inflammation in your pancreas caused by chronic pancreatitis is a risk factor for developing pancreatic cancer.

If you have concerns or questions about the information in this booklet or about pancreatitis, talk to your health care provider.