Pancreatitis

Definition

Pancreatitis is an inflammation of the pancreas, an organ that is important in digestion. Pancreatitis can be acute, beginning suddenly, usually with the patient recovering fully; or chronic, progressing slowly with permanent injury to the pancreas.

Description

The pancreas is located in the midline of the back of the abdomen, closely associated with the liver, stomach, and duodenum, the first part of the small intestine. The pancreas is considered a gland. A gland is an organ whose primary function is to produce chemicals that pass either into the main blood circulation (called an endocrine function), or pass into another organ (called an exocrine function). The pancreas is unusual because it has both endocrine and exocrine functions. Its endocrine function produces three hormones. Two of these hormones, insulin and glucagon, are central to the processing of sugars in the diet (carbohydrate metabolism or breakdown). The third hormone produced by the endocrine cells of the pancreas affects gastrointestinal functioning. This hormone is called vasoactive intestinal polypeptide (VIP). The pancreas's exocrine function produces a variety of digestive enzymes (trypsin, chymotrypsin , lipase, and amylase, among others). These enzymes are passed into the duodenum through a channel called the pancreatic duct. In the duodenum, the enzymes begin the process of breaking down a variety of food components, including, proteins, fats, and starches.

Acute pancreatitis occurs when the pancreas suddenly becomes inflamed but improves. Patients usually recover fully from the disease, and in almost 90% of cases, the symptoms disappear within about a week after treatment. The pancreas returns to its normal structure and functioning after healing from the illness. After an attack of acute pancreatitis, the tissue and cells of the pancreas typically return to normal. With chronic pancreatitis, damage to the pancreas occurs slowly over time. Symptoms may be persistent or sporadic, but the condition does not disappear and the pancreas is permanently impaired. Pancreatic tissue is damaged, and the tissue and cells function poorly.

Causes & symptoms

There are a number of causes of acute pancreatitis. The most common, however, are gallbladder disease and alcoholism . These two diseases are responsible for more than 80% of all hospitalizations for acute pancreatitis. Other factors in the development of pancreatitis include:

• certain drugs
• infections
• structural problems of the pancreatic duct and bile ducts (channels leading from the gallbladder to the duodenum)
• injury to the abdomen resulting in injury to the pancreas (including injuries occurring during surgery)
• abnormally high levels of circulating fats in the bloodstream
• malfunction of the parathyroid gland, with high blood levels of calcium
• complications from kidney transplants
• a hereditary tendency toward pancreatitis (recent advances in gene mapping have led to the discovery that a mutation in the gene responsible for cystic fibrosis is associated with a greatly increased risk of pancreatitis)

Pancreatitis caused by drugs accounts for about 5% of all cases. Some drugs that are definitely related to pancreatitis include:

• azathioprine, 6–mercaptopurine (Imuran)
• dideoxyinosine (Videx)
• estrogens (birth control pills)
• furosemide (Lasix)
• pentamidine (NebuPent)
• sulfonamides (Urobak, Azulfidine)
• tetracycline
• thiazide diuretics (Diuril, Enduron)
• valproic acid (Depakote)

Some drugs that are probably related to pancreatitis include:

• acetaminophen (Tylenol)
• angiotensin–converting enzyme (ACE) inhibitors (Capoten, Vasotec)
• erythromycin
• methyldopa (Aldomet)
• metronidazole (Flagyl, Protostat)
• nitrofurantoin (Furadantin, Furan)
• nonsteroidal anti–inflammatory drugs (NSAIDs) (Aleve, Naprosyn, Motrin)
• salicylates (aspirin)

All of these causes of pancreatitis seem to have a similar mechanism in common. Under normal circumstances, many of the extremely potent enzymes produced by the pancreas are not active until they enter the duodenum, in which contact with certain other chemicals allows them to function. In pancreatitis, these enzymes become prematurely activated and actually begin their digestive functions within the pancreas. The pancreas, in essence, begins to digest itself. This process is known as autodigestion. A cycle of inflammation begins, including swelling and loss of function. Digestion of the blood vessels in the pancreas results in bleeding. Other active pancreatic chemicals cause the blood vessels to become leaky, and fluid begins to leak out of the normal circulation into the abdominal cavity. The activated enzymes also gain access to the bloodstream through the eroded blood vessels, and begin circulating throughout the body.

Pain is a major symptom of pancreatitis. The pain is usually quite intense and steady, located in the upper right hand corner of the abdomen, and often described as "piercing" or "boring." This pain is also often felt all the way through to the patient's back. The patient's breathing may become quite shallow because deeper breathing tends to cause more pain. Patients usually find some relief of pain by sitting up and bending forward; this postural relief is characteristic of pancreatic pain. Nausea and vomiting , and abdominal swelling are all common, as well. A patient will often have a slight fever , with an increased heart rate and low blood pressure.

Classic signs of shock may appear in more severely ill patients. Shock is a very serious syndrome that occurs when the volume (quantity) of fluid in the blood is very low. In shock, a patient's arms and legs become extremely cold, the blood pressure drops dangerously low, the heart rate is quite fast, and the patient may begin to experience changes in mental status.

In very severe cases of pancreatitis (called necrotizing pancreatitis) the pancreatic tissue begins to die and bleeding increases. Due to the bleeding into the abdomen, two distinctive signs may be noted in patients with necrotizing pancreatitis. Turner's sign is a reddish purple or greenish brown color in the flank area (the area between the ribs and the hip bone). Cullen's sign is the appearance of a bluish color around the navel.

Some of the complications of pancreatitis are due to shock. When shock occurs, all of the body's major organs are deprived of blood and the oxygen it carries, resulting in damage. Kidney, respiratory, and heart failure are serious risks of shock. The pancreatic enzymes that have begun circulating throughout the body (as well as various poisons created by the abnormal digestion of the pancreas by those enzymes) have severe effects on the major body systems. Any number of complications can occur, including damage to the heart, lungs, kidneys, lining of the gastrointestinal tract, liver, eyes, bones, and skin. As the pancreatic enzymes work on blood vessels surrounding the pancreas, and even blood vessels located at a distance, the risk of blood clots increases. These blood clots complicate the situation by blocking blood flow in the vessels. When blood flow is blocked, the supply of oxygen is decreased to various organs and the organ can be damaged.

The pancreas may develop additional problems, even after the pancreatitis decreases. When the entire organ becomes swollen and suffers extensive cell death (pancreatic necrosis), the pancreas becomes extremely susceptible to serious infection. A local collection of pus (called a pancreatic abscess ) may develop several weeks after the illness subsides, and may result in increased fever and a return of pain. Another late complication of pancreatitis, occurring several weeks after the illness begins, is called a pancreatic pseudocyst. This occurs when dead pancreatic tissue, blood, white blood cells, enzymes, and fluid that has leaked from the circulatory system accumulates. In an attempt to enclose and organize this abnormal accumulation, a kind of wall forms from the dead tissue and the growing scar tissue in the area. Pseudocysts cause additional abdominal pain by putting pressure on and displacing pancreatic tissue, resulting in more pancreatic damage. Pseudocysts also press on other nearby structures in the gastrointestinal tract, causing more disruption of function. Pseudocysts are life-threatening when they become infected (abscess) and rupture. Simple rupture of a pseudocyst causes death 14% of the time. Rupture complicated by bleeding causes death 60% of the time.

As the pancreatic tissue is increasingly destroyed in chronic pancreatitis, many digestive functions become disturbed. The quantity of hormones and enzymes normally produced by the pancreas begins to seriously decrease. Decreases in the production of enzymes result in the inability to appropriately digest food. Fat digestion, in particular, is impaired. A patient's stools become greasy as fats are passed out of the body. The inability to digest and use proteins results in smaller muscles (wasting) and weakness. The inability to digest and use the nutrients in food leads to malnutrition and a generally weakened condition. As the disease progresses, permanent injury to the pancreas can lead to diabetes.

Diagnosis

Diagnosis of pancreatitis can be made very early in the disease by noting high levels of pancreatic enzymes circulating in the blood (amylase and lipase). Later in the disease, and in chronic pancreatitis, these enzyme levels will no longer be elevated. Because of this fact, and because increased amylase and lipase can also occur in other diseases, the discovery of such elevations are helpful but not mandatory in the diagnosis of pancreatitis. Other abnormalities in the blood may also point to pancreatitis, including increased white blood cells (occurring with inflammation and/or infection), changes due to dehydration from fluid loss, and abnormalities in the blood concentration of calcium, magnesium, sodium, potassium , bicarbonate, and sugars.

X rays or ultrasound examination of the abdomen may reveal gallstones , perhaps responsible for blocking the pancreatic duct. The gastrointestinal tract will show signs of inactivity (ileus) due to the presence of pancreatitis. Chest x rays may reveal abnormalities due to air trapping from shallow breathing, or due to lung complications from the circulating pancreatic enzyme irritants. Computed tomography scans (CT scans) of the abdomen may reveal the inflammation and fluid accumulation of pancreatitis, and may also be useful when complications like an abscess or a pseudocyst are suspected.

In the case of chronic pancreatitis, a number of blood tests will reveal the loss of pancreatic function that occurs over time. Blood sugar (glucose) levels will rise, eventually reaching the levels present in diabetes. The levels of various pancreatic enzymes will fall, as the organ is increasingly destroyed and replaced by nonfunctioning scar tissue. Calcification of the pancreas can also be seen on x rays. Endoscopic retrograde cholangiopancreatography (ERCP) may be used to diagnose chronic pancreatitis in severe cases. In this procedure, the doctor uses a medical instrument fitted with a fiber-optic camera to inspect the pancreas. A magnified image of the area is shown on a television screen viewed by the doctor. Many endoscopes also allow the doctor to retrieve a small sample (biopsy) of pancreatic tissue to examine under a microscope. A contrast product may also be used for radiographic examination of the area.

Treatment

Pancreatitis is a serious condition that requires medical diagnosis and treatment. Alternative therapies should be used only to complement conventional treatment.

Nutritional therapy

Before taking nutritional supplements, patients should consult their doctors to make sure these supplements do not interfere with their overall treatment program. The following nutritional changes are recommended to help support pancreatic function and relieve pancreatitis symptoms:

• Follow a diabetic diet and avoid alcohol consumption.
• Limit intake of hydrogenated/saturated fats, sugar, and highly processed foods.
• Increase intake of yellow and orange fruits and dark-green vegetables, which are good sources of betacarotene, whole foods, vitamin C , and other antioxidants.
• Take high-potency multivitamin/mineral supplements.
• Use chromium (300 mcg daily) supplements to help control blood sugar level and enhance insulin effectiveness.
• Take lipotrophic agents (which increase bile flow to and from the liver), such as vitamin B₆, vitamin B₁₂, folic acid , choline, betaine, and methionine.
• Take pancreatic enzymes at mealtime.

Other therapies

Other alternative treatments such as acupuncture or relaxation techniques can help patients cope with painful symptoms associated with pancreatitis. Reduce stress by meditation, yoga, t'ai chi , or other relaxation techniques. Stress can stimulate pancreatitis attacks.

Allopathic treatment

Treatment of acute pancreatitis involves quickly and sufficiently replacing lost fluids by giving the patient new fluids through a needle inserted in a vein (intravenous or IV fluids). Pain is treated with a variety of medications. In order to decrease pancreatic function (and decrease the discharge of more potentially harmful enzymes into the bloodstream), the patient is not allowed to eat. A thin, flexible tube (nasogastric tube) may be inserted through the patient's nose and down into his or her stomach. Oxygen may need to be administered by nasal prongs or by a mask.

Complications, such as infections that often occur in cases of necrotizing pancreatitis, abscesses, and pseudocysts, will require antibiotics administered intravenously. Severe necrotizing pancreatitis may require surgery to remove part of the dying pancreas. A pancreatic abscess can be drained by a needle inserted through the abdomen and into the collection of pus (percutaneous needle aspiration) or surgically removed, if necessary. Pancreatic pseudocysts may shrink on their own (in 25–40% of cases) or may continue to expand, requiring needle aspiration or surgery. When diagnostic exams reveal the presence of gallstones, surgery may be necessary for their removal.

Because chronic pancreatitis often includes repeated flares of acute pancreatitis, the same kinds of basic treatment are necessary. Patients receive IV replacement fluids, receive pain medication, and are monitored for complications. Treatment of chronic pancreatitis caused by alcohol consumption requires that the patient stop drinking alcohol entirely. As chronic pancreatitis continues and insulin levels drop, a patient may require insulin injections in order to be able to process sugars in his or her diet. Pancreatic enzymes can be replaced with oral medicines, and patients sometimes have to take as many as eight pills with each meal. Drugs can be used to reduce the pain, but when narcotics are used for pain relief, there is danger of the patient becoming addicted.

Expected results

A number of systems have been developed to help determine the prognosis of an individual with pancreatitis. A very basic evaluation of a patient will allow some prediction to be made based on the presence of dying pancreatic tissue (necrosis) and bleeding. When necrosis and bleeding are present, as many as 50% of patients may die.

More elaborate systems have been created to help determine the prognosis of patients with pancreatitis. Ranson's signs, the most commonly used system, identifies 11 different signs that can be used to determine the severity of the disease. The first five categories are evaluated when the patient is admitted to the hospital:

• age over 55 years
• blood sugar level over 200 mg/Dl
• serum lactic dehydrogenase over 350 IU/L (increased with increased breakdown of blood, as would occur with internal bleeding, and with heart or liver damage)
• AST over 250μ (a measure of liver function, as well as a gauge of damage to the heart, muscle, brain, and kidney)
• white blood count over 16,000 MUL

The next six of Ranson's signs are reviewed 48 hours after admission to the hospital. These are:

• greater than 10% decrease in hematocrit (a measure of red blood cell volume)
• increase in BUN (blood urea nitrogen, an indicator of kidney function) greater than 5 mg/dL
• blood calcium less than 8 mg/dL
• PaO₂ (a measure of oxygen in the blood) less than 60 mm Hg
• base deficit greater than 4 mEg/L (a measure of change in the normal acidity of the blood)
• fluid sequestration greater than 6 L (an estimation of the quantity of fluid that has leaked out of the blood circulation and into other body spaces).

Once a doctor determines how many of Ranson's signs are present and gives the patient a score, the doctor can better predict the risk of death. The more signs present, the greater the chance of death. A patient with less than three positive Ranson's signs has a less than 5% chance of dying. A patient with three to four positive Ranson's signs has a 15–20% chance of dying.

The results of a CT scan can also be used to predict the severity of pancreatitis. Slight swelling of the pancreas indicates mild illness. Significant swelling, especially with evidence of destruction of the pancreas and/or fluid buildup in the abdominal cavity, indicates more severe illness. With severe illness, there is a worse prognosis.

Surgical treatment of pancreatitis is frequently followed by complications because of the leakage of pancreatic enzymes from the remaining portion of the organ. A team of French surgeons has reported that treating patients with somatostatin-14, a hormone that inhibits pancreatic secretion as well as pancreatic blood flow, appears to be effective in lowering the rate of complications from pancreatic surgery. In spite of recent advances in surgical technique, however, the mortality rate following surgery for pancreatitis is still 3%–10%.

Prevention

Alcoholism is essentially the only preventable cause of pancreatitis. Patients with chronic pancreatitis must stop drinking alcohol entirely. The drugs that cause or may cause pancreatitis should also be avoided.

Resources

BOOKS

Greenberger, Norton J., Phillip P. Toskes, and Kurt J. Isselbacher. "Acute and Chronic Pancreatitis." In Harrison's Principles of Internal Medicine, edited by Anthony S. Fauci, et al. New York: McGraw–Hill, 1998.

"Pancreatitis." In Reader's Digest Guide to Medical Cures & Treatments. Canada: The Reader's Digest Association, Inc., 1997.

"Pancreatitis." In Alternative Medicine: The Definitive Guide. Tiburon, CA: Future Medicine Publishing, Inc., 1999.

PERIODICALS

Amann, Stephen, et al. "Pancreatitis: Diagnostic and Therapeutic Interventions." Patient Care 31, no. 11 (June 15, 1997): 200+.

Goulliat, C., J. F. Gigot. "Pancreatic Surgical Complications—The Case for Prophylaxis." Gut 49 (December 2001): 32–39.

Le Marechal, C., O. Raguenes, I. Quere, et al. "Screening of Pancreatic Secretory Trypsin Inhibitor (PSTI) Mutations in Chronic Pancreatitis by DHPLC." American Journal of Human Genetics 69 (October 2001): 623.

Meissner, Judith E. "Caring for Patients with Pancreatitis." Nursing 27, no. 10 (October 1997): 50+.

"Mutations in the PSTI Gene Associated with Pancreatitis." Gene Therapy Weekly (December 27, 2001): 19.

Schlapman, Nancy. "Spotting Acute Pancreatitis." RN 64 (November 2001): 54.

ORGANIZATION

National Digestive Diseases Information Clearinghouse. 2 Information Way, Bethesda, MD 20892-3570. <http://www.niddk.nih.gov>.

Mai Tran

Rebecca J. Frey, PhD

Pancreatitis

Definition

Pancreatitis is an inflammation of the pancreas, an organ that is important in digestion. Pancreatitis can be acute (beginning suddenly, usually with the patient recovering fully) or chronic (progressing slowly with continued, permanent injury to the pancreas).

Description

Thepancreasislocated in the midline of the back of the abdomen, closely associated with the liver, stomach, and duodenum (the first part of the small intestine). The pancreas is considered a gland. A gland is an organ whose primary function is to produce chemicals that pass either into the main blood circulation (called an endocrine function), or pass into another organ (called an exocrine function). The pancreas is unusual because it has both endocrine and exocrine functions. Its endocrine function produces three hormones. Two of these hormones, insulin and glucagon, are central to the processing of sugars in the diet (carbohydrate metabolism or breakdown). The third hormone produced by the endocrine cells of the pancreas affects gastrointestinal functioning. This hormone is called vasoactive intestinal polypeptide (VIP). The pancreas's exocrine function produces a variety of digestive enzymes (trypsin, chymotrypsin, lipase, and amylase, among others). These enzymes are passed into the duodenum through a channel called the pancreatic duct. In the duodenum, the enzymes begin the process of breaking down a variety of food components, including, proteins, fats, and starches.

Acute pancreatitis occurs when the pancreas suddenly becomes inflamed but improves. Patients recover fully from the disease, and in almost 90% of cases the symptoms disappear within about a week after treatment. The pancreas returns to its normal architecture and functioning after healing from the illness. After an attack of acute pancreatitis, tissue and cells of the pancreas return to normal. With chronic pancreatitis, damage to the pancreas occurs slowly over time. Symptoms may be persistent or sporadic, but the condition does not disappear and the pancreas is permanently impaired. Pancreatic tissue is damaged, and the tissue and cells function poorly.

Causes and symptoms

There are a number of causes of acute pancreatitis. The most common, however, are gallbladder disease and alcoholism. These two diseases are responsible for more than 80% of all hospitalizations for acute pancreatitis. Other factors in the development of pancreatitis include:

• certain drugs
• infections
• structural problems of the pancreatic duct and bile ducts (channels leading from the gallbladder to the duodenum)
• injury to the abdomen resulting in injury to the pancreas (including injuries occurring during surgery)
• abnormally high levels of circulating fats in the bloodstream
• malfunction of the parathyroid gland, with high blood levels of calcium
• complications from kidney transplants
• a hereditary tendency toward pancreatitis.

Pancreatitis caused by drugs accounts for about 5% of all cases. Some drugs that are definitely related to pancreatitis include:

• Azathioprine, 6-mercaptopurine (Imuran)
• Dideoxyinosine (Videx)
• Estrogens (birth control pills)
• Furosemide (Lasix)
• Pentamidine (NebuPent)
• Sulfonamides (Urobak, Azulfidine)
• Tetracycline

• Thiazide diuretics (Diuril, Enduron)
• Valproic acid (Depakote).

Some drugs that are probably related to pancreatitis include:

• Acetaminophen (Tylenol)
• Angiotensin-converting enzyme (ACE) inhibitors (Capoten, Vasotec)
• Erythromycin
• Methyldopa (Aldomet)
• Metronidazole (Flagyl, Protostat)
• Nitrofurantoin (Furadantin, Furan)
• Nonsteroidal anti-inflammatory drugs (NSAIDs) (Aleve, Naprosyn, Motrin)
• Salicylates (aspirin).

All of these causes of pancreatitis seem to have a similar mechanism in common. Under normal circumstances, many of the extremely potent enzymes produced by the pancreas are not active until they are passed into the duodenum, where contact with certain other chemicals allow them to function. In pancreatitis, something allows these enzymes to become prematurely activated, so that they actually begin their digestive functions within the pancreas. The pancreas, in essence, begins digesting itself. A cycle of inflammation begins, including swelling and loss of function. Digestion of the blood vessels in the pancreas results in bleeding. Other active pancreatic chemicals cause blood vessels to become leaky, and fluid begins leaking out of the normal circulation into the abdominal cavity. The activated enzymes also gain access to the bloodstream through leaky, eroded blood vessels, and begin circulating throughout the body.

Pain is a major symptom in pancreatitis. The pain is usually quite intense and steady, located in the upper right hand corner of the abdomen, and often described as "boring." This pain is also often felt all the way through to the patient's back. The patient's breathing may become quite shallow because deeper breathing tends to cause more pain. Relief of pain by sitting up and bending forward is characteristic of pancreatic pain. Nausea and vomiting, and abdominal swelling are all common as well. A patient will often have a slight fever, with an increased heart rate and low blood pressure.

Classic signs of shock may appear in more severely ill patients. Shock is a very serious syndrome that occurs when the volume (quantity) of fluid in the blood is very low. In shock, a patient's arms and legs become extremely cold, the blood pressure drops dangerously low, the heart rate is quite fast, and the patient may begin to experience changes in mental status.

In very severe cases of pancreatitis (called necrotizing pancreatitis), the pancreatic tissue begins to die, and bleeding increases. Due to the bleeding into the abdomen, two distinctive signs may be noted in patients with necrotizing pancreatitis. Turner's sign is a reddish-purple or greenish-brown color to the flank area (the area between the ribs and the hip bone). Cullen's sign is a bluish color around the navel.

Some of the complications of pancreatitis are due to shock. When shock occurs, all of the body's major organs are deprived of blood (and, therefore, oxygen), resulting in damage. Kidney, respiratory, and heart failure are serious risks of shock. The pancreatic enzymes that have begun circulating throughout the body (as well as various poisons created by the abnormal digestion of the pancreas by those enzymes) have severe effects on the major body systems. Any number of complications can occur, including damage to the heart, lungs, kidneys, lining of the gastrointestinal tract, liver, eyes, bones, and skin. As the pancreatic enzymes work on blood vessels surrounding the pancreas, and even blood vessels located at a distance, the risk of blood clots increases. These blood clots complicate the situation by blocking blood flow in the vessels. When blood flow is blocked, the supply of oxygen is decreased to various organs and the organ can be damaged.

The pancreas may develop additional problems, even after the pancreatitis decreases. When the entire organ becomes swollen and suffers extensive cell death (pancreatic necrosis), the pancreas becomes extremely susceptible to serious infection. A local collection of pus (called a pancreatic abscess ) may develop several weeks after the illness subsides, and may result in increased fever and a return of pain. Another late complication of pancreatitis, occurring several weeks after the illness begins, is called a pancreatic pseudocyst. This occurs when dead pancreatic tissue, blood, white blood cells, enzymes, and fluid leaked from the circulatory system accumulate. In an attempt to enclose and organize this abnormal accumulation, a kind of wall forms from the dead tissue and the growing scar tissue in the area. Pseudocysts cause additional abdominal pain by putting pressure on and displacing pancreatic tissue (resulting in more pancreatic damage). Pseudocysts also press on other nearby structures in the gastrointestinal tract, causing more disruption of function. Pseudocysts are life-threatening when they become infected (abscess) and when they rupture. Simple rupture of a pseudocyst causes death 14% of the time. Rupture complicated by bleeding causes death 60% of the time.

As the pancreatic tissue is increasingly destroyed in chronic pancreatitis, many digestive functions become disturbed. The quantity of hormones and enzymes normally produced by the pancreas begins to seriously decrease. Decreases in the production of enzymes result in the inability to appropriately digest food. Fat digestion, in particular, is impaired. A patient's stools become greasy as fats are passed out of the body. The inability to digest and use proteins results in smaller muscles (wasting) and weakness. The inability to digest and use the nutrients in food leads to malnutrition, and a generally weakened condition. As the disease progresses, permanent injury to the pancreas can lead to diabetes.

Diagnosis

Diagnosis of pancreatitis can be made very early in the disease by noting high levels of pancreatic enzymes circulating in the blood (amylase and lipase). Later in the disease, and in chronic pancreatitis, these enzyme levels will no longer be elevated. Because of this fact, and because increased amylase and lipase can also occur in other diseases, the discovery of such elevations are helpful but not mandatory in the diagnosis of pancreatitis. Other abnormalities in the blood may also point to pancreatitis, including increased white blood cells (occurring with inflammation and/or infection), changes due to dehydration from fluid loss, and abnormalities in the blood concentration of calcium, magnesium, sodium, potassium, bicarbonate, and sugars.

X rays or ultrasound examination of the abdomen may reveal gallstones, perhaps responsible for blocking the pancreatic duct. The gastrointestinal tract will show signs of inactivity (ileus ) due to the presence of pancreatitis. Chest x rays may reveal abnormalities due to air trapping from shallow breathing, or due to lung complications from the circulating pancreatic enzyme irritants. Computed tomography scans (CT scans) of the abdomen may reveal the inflammation and fluid accumulation of pancreatitis, and may also be useful when complications like an abscess or a pseudocyst are suspected.

In the case of chronic pancreatitis, a number of blood tests will reveal the loss of pancreatic function that occurs over time. Blood sugar (glucose) levels will rise, eventually reaching the levels present in diabetes. The levels of various pancreatic enzymes will fall, as the organ is increasingly destroyed and replaced by non-functioning scar tissue. Calcification of the pancreas can also be seen on x rays. Endoscopic retrograde cholangiopancreatography (ERCP) may be used to diagnose chronic pancreatitis in severe cases. In this procedure, the doctor uses a medical instrument fitted with a fiber-optic camera to inspect the pancreas. A magnified image of the area is shown on a television screen viewed by the doctor. Many endoscopes also allow the doctor to retrieve a small sample (biopsy) of pancreatic tissue to examine under a microscope. A contrast product may also be used for radiographic examination of the area.

Treatment

Treatment of pancreatitis involves quickly and sufficiently replacing lost fluids by giving the patient new fluids through a needle inserted in a vein (intravenous or IV fluids). These IV solutions need to contain appropriate amounts of salts, sugars, and sometimes even proteins, in order to correct the patient's disturbances in blood chemistry. Pain is treated with a variety of medications. In order to decrease pancreatic function (and decrease the discharge of more potentially harmful enzymes into the bloodstream), the patient is not allowed to eat. A thin, flexible tube (nasogastric tube) may be inserted through the patient's nose and down into his or her stomach. The nasogastric tube can empty the stomach of fluid and air, which may accumulate due to the inactivity of the gastrointestinal tract. Oxygen may need to be administered by nasal prongs or by a mask.

The patient will need careful monitoring in order to identify complications that may develop. Infections (often occurring in cases of necrotizing pancreatitis, abscesses, and pseudocysts) will require antibiotics through the IV. Severe necrotizing pancreatitis may require surgery to remove part of the dying pancreas. A pancreatic abscess can be drained by a needle inserted through the abdomen and into the collection of pus (percutaneous needle aspiration). If this is not sufficient, an abscess may also require surgical removal. Pancreatic pseudocysts may shrink on their own (in 25-40% of cases) or may continue to expand, requiring needle aspiration or surgery. When diagnostic exams reveal the presence of gallstones, surgery may be necessary for their removal. When a patient is extremely ill from pancreatitis, however, such surgery may need to be delayed until any infection is treated, and the patient's condition stabilizes.

Because chronic pancreatitis often includes repeated flares of acute pancreatitis, the same kinds of basic treatment are necessary. Patients cannot take solids or fluids by mouth. They receive IV replacement fluids, receive pain medication, and are monitored for complications. Treatment of chronic pancreatitis caused by alcohol consumption requires that the patient stop drinking alcohol entirely. As chronic pancreatitis continues and insulin levels drop, a patient may require insulin injections in order to be able to process sugars in his or her diet. Pancreatic enzymes can be replaced with oral medicines, and patients sometimes have to take as many as eight pills with each meal. As the pancreas is progressively destroyed, some patients stop feeling the abdominal pain that was initially so severe. Others continue to have constant abdominal pain, and may even require a surgical procedure for relief. Drugs can be used to reduce the pain, but when narcotics are used for pain relief there is danger of the patient becoming addicted.

Prognosis

A number of systems have been developed to help determine the prognosis of an individual with pancreatitis. A very basic evaluation of a patient will allow some prediction to be made based on the presence of dying pancreatic tissue (necrosis) and bleeding. When necrosis and bleeding are present, as many as 50% of patients may die.

More elaborate systems have been created to help determine the prognosis of patients with pancreatitis. The most commonly used system identifies 11 different signs (Ranson's signs) that can be used to determine the severity of the disease. The first five categories are evaluated when the patient is admitted to the hospital:

• age over 55 years
• blood sugar level over 200 mg/Dl
• serum lactic dehydrogenase over 350 IU/L (increased with increased breakdown of blood, as would occur with internal bleeding, and with heart or liver damage)
• AST over 250 mu (a measure of liver function, as well as a gauge of damage to the heart, muscle, brain, and kidney)
• white blood count over 16,000 u L

The next six of Ranson's signs are reviewed 48 hours after admission to the hospital. These are:

• greater than 10% decrease in hematocrit (a measure of red blood cell volume)
• increase in BUN greater than 5 mg/dL (blood urea nitrogen, an indicator of kidney function)
• blood calcium less than 8 mg/dL
• PaO₂ less than 60 mm Hg (a measure of oxygen in the blood)
• base deficit greater than 4 mEg/L (a measure of change in the normal acidity of the blood)
• fluid sequestration greater than 6 L (an estimation of the quantity of fluid that has leaked out of the blood circulation and into other body spaces)

KEY TERMS

Abscess— A pocket of infection; pus.

Acute— Of short and sharp course. Illnesses that are acute appear quickly and can be serious or life-threatening. The illness ends and the patient usually recovers fully.

Chronic— Of long duration and slow progression. Illnesses that are chronic develop slowly over time, and do not end. Symptoms may be continual or intermittent, but the patient usually has the condition for life.

Diabetes— A disease characterized by an inability to process sugars in the diet, due to a decrease in or total absence of insulin production. May require injections of insulin before meals to aid in the metabolism of sugars.

Duodenum— The first section of the small intestine that receives partly digested material from the stomach.

Endocrine— A system of organs that produces chemicals that go into the bloodstream to reach other organs whose functioning they affect.

Enzyme— A chemical that speeds up or makes a particular chemical reaction more efficient. In the digestive system, enzymes are involved in breaking down large food molecules into smaller molecules that can be processed and utilized by the body.

Exocrine— A system of organs that produces chemicals that go through a duct (or tube) to reach other organs whose functioning they affect.

Gland— Collections of tissue that produce chemicals needed for chemical reactions elsewhere in the body.

Hormone— A chemical produced in one part of the body that travels to another part of the body in order to exert an effect.

Once a doctor determines how many of Ranson's signs are present and gives the patient a score, the doctor can better predict the risk of death. The more signs present, the greater the chance of fatal complications. A patient with less than three positive Ranson's signs has a 95% survival rate. A patient with three to four positive Ranson's signs has a 80-85% survival rate.

The results of a CT scan can also be used to predict the severity of pancreatitis. Slight swelling of the pancreas indicates mild illness. Significant swelling, especially with evidence of destruction of the pancreas and/or fluid build-up in the abdominal cavity, indicates more severe illness. With severe illness, there is a worse prognosis.

Prevention

Alcoholism is essentially the only preventable cause of pancreatitis. Patients with chronic pancreatitis must stop drinking alcohol entirely. The drugs that cause or may cause pancreatitis should also be avoided.

Resources

ORGANIZATIONS

National Digestive Diseases Information Clearinghouse. 2 Information Way, Bethesda, MD 20892-3570. (800) 891-5389. 〈http://www.niddk.nih.gov/health/digest/nddic.htm〉.

Pancreatitis

Definition

Pancreatitis is an inflammation of the pancreas, an organ that is important in digestion. In pancreatitis, normal digestive enzymes act abnormally to break down the pancreas itself.

Description

The pancreas is a complex organ with many critical functions for normal digestion and regulation of blood sugar. When inflamed, as in pancreatitis, several potent enzymes are inappropriately activated within the organ itself. In acute pancreatitis, inflammation is sudden and causes symptoms. In almost 90% of acute cases, the symptoms disappear within one week after treatment, and the pancreas returns to its normal function. With chronic pancreatitis, damage to the pancreas occurs over longer periods of time. Symptoms may be persistent or sporadic, as the pancreas is slowly but permanently impaired. More than 90% of pancreatic tissue will be destroyed before serious symptoms begin. Late signs of chronic pancreatitis include diabetes mellitus and malabsorption syndromes in which nutrients are poorly absorbed from the digestive tract.

Causes and symptoms

There are a number of causes of acute pancreatitis, the most common of which are gallstones and alcoholism. These two diseases are responsible for more than 80% of all hospitalizations for acute pancreatitis. Gallstones may obstruct normal drainage from the pancreas into the small intestine, resulting in a backup of normal pancreatic secretions and inflammation of the pancreas until the obstruction is relieved.

The mechanism by which alcohol inflames the pancreas is not well understood. It is thought that alcohol causes proteins to collect in the pancreas and results in obstruction and calcification of the organ.

Other factors in the development of acute pancreatitis include:

• certain drugs, including estrogens, sulfonamides, and diuretics
• interferon and ribavirin therapy for chronic hepatitis C infection
• infections
• structural problems of the pancreatic duct and common bile duct
• injury to the abdomen
• abnormally high levels of circulating fats in the bloodstream
• high blood levels of calcium
• complications from kidney failure or transplant
• a hereditary tendency toward pancreatitis
• various forms of vasculitis (inflamed blood vessels )

In pancreatitis, enzymes become prematurely activated so that they actually begin their digestive functions within the pancreas. The pancreas, in essence, begins digesting itself. Digestion of the blood vessels in the pancreas results in bleeding. Other active pancreatic chemicals cause blood vessels to become leaky, and fluid begins seeping into the abdominal cavity. The activated enzymes also gain access to the bloodstream through leaky, eroded blood vessels, and begin circulating throughout the body.

Pain is a major symptom in acute pancreatitis, and it is usually quite intense and steady, located in the upper abdomen, and radiating to the patient's back. Nausea, vomiting, and abdominal swelling are also common symptoms. A patient will often have a slight fever, with an increased heart rate and low blood pressure.

Patients with acute pancreatitis are at risk of complications related to shock, a serious syndrome that occurs when the blood pressure is too low to get adequate circulation to critical organs. Without adequate blood pressure, organs are deprived of oxygen, nutrients, and waste removal and may not function well. Kidney, respiratory, and heart failure are serious possible outcomes of shock.

Even if shock does not occur, circulating pancreatic enzymes and related toxins can cause damage to the heart, lungs, kidneys, lining of the gastrointestinal tract, liver, eyes, bones, and skin. As the pancreatic enzymes affect blood vessels, the risk of blood clots increases. When blood flow is blocked by clotting, the supply of oxygen is further decreased to various organs and additional damage done.

Other serious complications of acute pancreatitis include pancreatic necrosis, abcess, and pseudocyst formation. Pancreatic necrosis occurs when a significant portion of the pancreas is permanently damaged during an acute attack. Pancreatic necrosis has an increased risk of death and an increased chance of pancreatic infection. A pancreatic abscess is a local collection of pus that may develop several weeks after the illness subsides. Another late complication of pancreatitis, occurring several weeks after the illness begins, is called a pancreatic pseudocyst, which occurs when dead pancreatic tissue, blood, white blood cells, enzymes, and fluid leaked from the circulatory system accumulate. Pseudocysts cause recurrent abdominal pain and also press on other nearby structures in the gastrointestinal tract, causing disruption of function. Pseudocysts are life threatening when they become infected (abscess) and rupture. Simple rupture of a pseudocyst causes death 14% of the time, but rupture complicated by bleeding causes death 60% of the time.

In severe cases of pancreatitis, called necrotizing pancreatitis, the pancreatic tissue begins to die, and bleeding increases. Due to the bleeding into the abdomen, two distinctive signs may be noted in patients with necrotizing pancreatitis. Turner's sign is a red-dish-purple or greenish-brown color to the area between the ribs and the hip (flank). Cullen's sign is a bluish color around the navel.

Alcohol abuse is the cause of tissue damage in 80% of cases of chronic pancreatitis. Tissue damage occurs more slowly, and many digestive functions become disturbed. The quantity of hormones and enzymes normally produced by the pancreas begins to decrease, resulting in the inability to appropriately digest food. Fat digestion, in particular, is impaired. A patient's stools become greasy as fats are passed out of the body. The inability to digest and use proteins results in smaller muscles (wasting) and weakness. The inability to digest and use the nutrients in food leads to malnutrition, vitamin deficiencies, and a generally weakened condition. As the disease progresses, permanent injury to the pancreas can lead to diabetes.

Diagnosis

Diagnosis of pancreatitis, whether acute or chronic, is not simple. History and physical exam are very important, as well as imaging studies and laboratory tests. Levels of amylase and lipase that are three times above the upper limit of normal are predictive of acute pancreatitis. Other abnormalities in the blood may also point to pancreatitis, including increased white blood cells, changes due to dehydration from fluid loss, and abnormalities in the blood concentration of calcium, magnesium, sodium, potassium, bicarbonate, and glucose.

X rays or ultrasound examination of the abdomen may reveal gallstones, possibly responsible for blocking the pancreatic duct. The gastrointestinal tract will show signs of inactivity (ileus) due to the presence of pancreatitis. Chest x rays may reveal abnormalities due to shallow breathing or due to lung complications from the circulating pancreatic enzyme irritants. Computed tomography (CT) scans of the abdomen may reveal the inflammation and fluid accumulation of pancreatitis.

In the case of chronic pancreatitis, lipase and amylase levels will no longer be elevated. However, blood tests will reveal the loss of pancreatic function that occurs over time. Blood sugar (glucose) levels will rise, eventually reaching the levels consistent with diabetes. The levels of various pancreatic enzymes will fall, as the organ is increasingly destroyed and replaced by non-functioning scar tissue. Calcification of the pancreas can also be seen on x rays. Endoscopic retrograde cholangiopancreatography (ERCP) may be used to diagnose chronic pancreatitis in unclear cases. In this procedure, the physician uses a medical instrument fitted with a fiber-optic camera to inspect the pancreas.

Recent developments in understanding of genetics and the role of genetics in susceptibility to pancreatitis may soon lead to use of genetic testing for early diagnosis and prognosis of pancreatitis. The testing can detect abnormalities in trypsin and trypsin inhibitor genes and cystic fibrosis genes.

Treatment

Treatment of acute pancreatitis involves replacing lost fluids intravenously (in a vein). These intravenous (IV) solutions need to contain appropriate amounts of salts, sugars, and sometimes even proteins, in order to correct the patient's disturbances in blood chemistry. Pain is treated with a variety of medications, chiefly meperidine. To decrease pancreatic function, the patient is not allowed to eat. A thin, flexible tube (nasogastric tube) may be inserted through the patient's nose and down into the stomach. The nasogastric tube can empty the stomach of fluid and air that may accumulate due to the inactivity of the gastrointestinal tract.

The patient will need careful monitoring to identify complications that may develop. Infections will require antibiotics through the IV. Severe necrotizing pancreatitis may require surgery to remove part of the dying pancreas, especially if infection has begun. A pancreatic abscess can be drained by a needle inserted through the abdomen and into the collection of pus (percutaneous needle aspiration). An abscess may also require surgical removal. In 25-40% of cases, pancreatic pseudocysts may shrink on their own or continue to expand, requiring needle aspiration or surgery. Surgery may be necessary for the removal of gallstones.

Because chronic pancreatitis often includes repeated flares of acute pancreatitis, the same kinds of basic treatment are necessary. Treatment of chronic pancreatitis caused by alcohol consumption requires that the patient stop drinking alcohol entirely. A low-protein and low-fat diet is prescribed. As chronic pancreatitis continues and insulin levels drop, a patient may require insulin injections to be able to process sugars in the diet. Pancreatic enzymes can be replaced with oral medications. As the pancreas is progressively destroyed, some patients stop feeling the abdominal pain that was initially so severe. Others continue to have constant abdominal pain, and may require a surgical procedure for relief.

Prognosis

When necrosis and bleeding are present, as many as 50% of patients with pancreatitis may die. Overall, the mortality rate for patients with mild acute pancreatitis is less than 1%. Those with sever pancreatitis have a mortality rate as high as 25%.

Ranson's criteria can help determine the severity of the disease. The first five categories are evaluated when the patient is admitted to the hospital, including:

• age over 55 years
• blood sugar level over 200 mg/dl
• serum lactic dehydrogenase over 350 IU/L
• AST over 250 μ (a measure of liver function, as well as a gauge of damage to the heart, muscle, brain, and kidney)
• white blood count over 16,000 μL

The following six of Ranson's criteria are reviewed 48 hours after the patient's admission to the hospital, including:

• greater than 10% decrease in hematocrit (a measure of red blood cell volume)
• increase in BUN (blood urea nitrogen, an indicator of kidney function) greater than 5 mg/dL
• blood calcium less than 8 mg/dL
• PaO₂ (a measure of oxygen in the blood) less than 60 mm Hg
• base deficit greater than 4 mEg/L (a measure of change in the normal acidity of the blood)
• fluid sequestration greater than 6 L, or 13 pt (an estimation of the quantity of fluid that has leaked out of the blood circulation and into other body spaces)

Once it is determined how many of Ranson's signs are present in the patient, the physician can better predict the risk of death. A patient with less than three positive Ranson's signs has less than a 5% chance of dying. A patient with three to four positive Ranson's signs has a 15-20% chance of death.

The results of a CT scan can also be used to predict the severity of pancreatitis. Slight swelling of the pancreas indicates mild illness. Significant swelling, especially with evidence of destruction of the pancreas and/or fluid build-up in the abdominal cavity, indicates more severe illness and a worse prognosis.

Health care team roles

The physician will make a full physical examination of the patient to determine which tests are necessary. Radiologic technologists will perform imaging studies and clinical laboratory technicians will perform the laboratory tests. Nurses have an active supportive role throughout the patient's illness.

Prevention

Alcoholism is essentially the only preventable cause of pancreatitis. Patients with chronic pancreatitis must stop drinking alcohol entirely. The drugs that may cause pancreatitis should also be avoided when possible.

KEY TERMS

Abscess— A pocket of infection; pus.

Acute— Of short and sharp course; illnesses that appear quickly and can be serious or life-threatening.

Chronic— Of long duration and slow progression; illnesses that develop slowly over time, and do not end.

Diabetes— A disease characterized by an inability to regulate blood sugar levels in the blood.

Endocrine— A system of organs that produces chemicals that go into the bloodstream to affect the function of other organs from a distance.

Enzyme— A chemical that speeds up or makes a particular chemical reaction more efficient.

Exocrine— A system of organs that produces chemicals that go through a duct (or tube) to affect the functioning of other organs.

Gland— A collection of tissue that produces chemicals needed for use outside of the gland itself.

Hormone— A chemical produced in one part of the body that travels to another part of the body in order to exert an effect.

Resources

BOOKS

Izenberg, Neil, ed. Human Disease and Conditions. Charles Scribner's Sons, 2000: 643-644.

Toskes, Phillip P., and Norton J. Greenberger. "Disorders of the Pancreas." In Harrison's Principles of Internal Medicine, edited by E. Braunwald, et al. McGraw-Hill, 2001: 1788-1803.

PERIODICALS

Bates, Betty. "Pancreatitis Difficult Etiology Becoming Easier to Pinpoint." Family Practice News (March 15, 2005): 72.

"Ciombination Therapy for Chronic Hepatitis C May Cause Pancreatitis." Science Letter (Sept. 21, 2004): 23.

"Genetic Testing May Play Key Role in Management of Pancreatitis." Genomics & Genetics Weekly (Dec. 24, 2004): 179.

"Managing Acute and Chronic Pancreatitis." The Practitioner (Oct. 12, 2005): 672.

Munos, Abilio, and David A. Katerndahl. "Diagnosis and Management of Acute Pancreatitis." American Family Physician 62 (July 2000): 164-73.

ORGANIZATIONS

National Digestive Diseases Information Clearinghouse. 2 Information Way, Bethesda, MD 20892-3570.

OTHER

National Institute of Diabetes and Digestive and Kidney Diseases. 〈http://www.niddk.nih.gov/health/digest/pubs/pancreas/pancreas.htm〉.

The National Pancreas Foundation. 〈http://www.pancreasfoundation.org/diseases.html〉.

Pancreatitis

Definition

Pancreatitis is an inflammation of the pancreas , an organ that is important in digestion. In pancreatitis, normal digestive enzymes act abnormally to break down the pancreas itself.

Description

The pancreas is a complex organ with many critical functions for normal digestion and regulation of blood sugar. When inflamed, as in pancreatitis, several potent enzymes are inappropriately activated within the organ itself. In acute pancreatitis, inflammation is sudden and causes symptoms. In almost 90% of acute cases, the symptoms disappear within one week after treatment, and the pancreas returns to its normal function. With chronic pancreatitis, damage to the pancreas occurs over longer periods of time. Symptoms may be persistent or sporadic, as the pancreas is slowly but permanently impaired. More than 90% of pancreatic tissue will be destroyed before serious symptoms begin. Late signs of chronic pancreatitis include diabetes mellitus and mal-absorption syndromes in which nutrients are poorly absorbed from the digestive tract.

Causes and symptoms

There are a number of causes of acute pancreatitis, the most common of which are gallstones and alcoholism . These two diseases are responsible for more than 80% of all hospitalizations for acute pancreatitis. Gallstones may obstruct normal drainage from the pancreas into the small intestine , resulting in a backup of normal pancreatic secretions and inflammation of the pancreas until the obstruction is relieved.

The mechanism by which alcohol inflames the pancreas is not so well understood. It is thought that alcohol causes proteins to collect and result in obstruction and calcification of the pancreas.

Other factors in the development of acute pancreatitis include:

• certain drugs, including estrogens, sulfonamides, and diuretics
• infections
• structural problems of the pancreatic duct and common bile duct
• injury to the abdomen
• abnormally high levels of circulating fats in the bloodstream
• high blood levels of calcium
• complications from kidney failure or transplant
• a hereditary tendency toward pancreatitis
• various forms of vasculitis (inflamed blood vessels )

In pancreatitis, enzymes become prematurely activated so that they actually begin their digestive functions within the pancreas. The pancreas, in essence, begins digesting itself. Digestion of the blood vessels in the pancreas results in bleeding. Other active pancreatic chemicals cause blood vessels to become leaky, and fluid begins seeping into the abdominal cavity. The activated enzymes also gain access to the bloodstream through leaky, eroded blood vessels, and begin circulating throughout the body.

Pain is a major symptom in acute pancreatitis, and it is usually quite intense and steady, located in the upper abdomen, and radiating to the patient's back. Nausea and vomiting and abdominal swelling are also common symptoms. A patient will often have a slight fever , with an increased heart rate and low blood pressure .

Patients with acute pancreatitis are at risk of complications related to shock , a very serious syndrome that occurs when the blood pressure is too low to get adequate circulation to critical organs. Without adequate blood pressure, organs are deprived of oxygen, nutrients, and waste removal and may not function well. Kidney, respiratory, and heart failure are serious possible outcomes of shock.

Even if shock does not occur, circulating pancreatic enzymes and related toxins can cause damage to the heart, lungs , kidneys , lining of the gastrointestinal tract, liver , eyes, bones, and skin. As the pancreatic enzymes affect blood vessels, the risk of blood clots increases. When blood flow is blocked by clotting, the supply of oxygen is further decreased to various organs and additional damage done.

Other serious complications of acute pancreatitis include pancreatic necrosis, abcess, and pseudocyst formation. Pancreatic necrosis occurs when a significant portion of the pancreas is permanently damaged during an acute attack. Pancreatic necrosis has an increased risk of death and an increased chance of pancreatic infection . A pancreatic abscess is a local collection of pus that may develop several weeks after the illness subsides. Another late complication of pancreatitis, occurring several weeks after the illness begins, is called a pancreatic pseudocyst, which occurs when dead pancreatic tissue, blood, white blood cells, enzymes, and fluid leaked from the circulatory system accumulate. Pseudocysts cause recurrent abdominal pain and also press on other nearby structures in the gastrointestinal tract, causing disruption of function. Pseudocysts are life threatening when they become infected (abscess) and rupture. Simple rupture of a pseudocyst causes death 14% of the time, but rupture complicated by bleeding causes death 60% of the time.

In very severe cases of pancreatitis, called necrotizing pancreatitis, the pancreatic tissue begins to die, and bleeding increases. Due to the bleeding into the abdomen, two distinctive signs may be noted in patients with necrotizing pancreatitis. Turner's sign is a reddish-purple or greenish-brown color to the area between the ribs and the hip (flank). Cullen's sign is a bluish color around the navel.

Alcohol abuse is the cause of tissue damage in 80% of cases of chronic pancreatitis. Tissue damage occurs more slowly, and many digestive functions become disturbed. The quantity of hormones and enzymes normally produced by the pancreas begins to decrease, resulting in the inability to appropriately digest food. Fat digestion, in particular, is impaired. A patient's stools become greasy as fats are passed out of the body. The inability to digest and use proteins results in smaller muscles (wasting)

KEY TERMS

Abscess —A pocket of infection; pus.

Acute —Of short and sharp course; illnesses that appear quickly and can be serious or life-threatening.

Chronic —Of long duration and slow progression; illnesses that develop slowly over time, and do not end.

Diabetes —A disease characterized by an inability to regulate blood sugar levels in the blood.

Endocrine —A system of organs that produces chemicals that go into the bloodstream to affect the function of other organs from a distance.

Enzyme —A chemical that speeds up or makes a particular chemical reaction more efficient.

Exocrine —A system of organs that produces chemicals that go through a duct (or tube) to affect the functioning of other organs.

Gland —A collection of tissue that produces chemicals needed for use outside of the gland itself.

Hormone —A chemical produced in one part of the body that travels to another part of the body in order to exert an effect.

and weakness. The inability to digest and use the nutrients in food leads to malnutrition, vitamin deficiencies, and a generally weakened condition. As the disease progresses, permanent injury to the pancreas can lead to diabetes.

Diagnosis

Diagnosis of pancreatitis, whether acute or chronic, is not simple. History and physical exam are very important, as well as imaging studies and laboratory tests. Levels of amylase and lipase that are three times above the upper limit of normal are very predictive of acute pancreatitis. Other abnormalities in the blood may also point to pancreatitis, including increased white blood cells, changes due to dehydration from fluid loss, and abnormalities in the blood concentration of calcium, magnesium, sodium, potassium, bicarbonate, and glucose.

X rays or ultrasound examination of the abdomen may reveal gallstones, possibly responsible for blocking the pancreatic duct. The gastrointestinal tract will show signs of inactivity (ileus) due to the presence of pancreatitis. Chest x rays may reveal abnormalities due to shallow breathing or due to lung complications from the circulating pancreatic enzyme irritants. Computed tomography (CT) scans of the abdomen may reveal the inflammation and fluid accumulation of pancreatitis.

In the case of chronic pancreatitis, lipase and amylase levels will no longer be elevated. However, blood tests will reveal the loss of pancreatic function that occurs over time. Blood sugar (glucose) levels will rise, eventually reaching the levels consistent with diabetes. The levels of various pancreatic enzymes will fall, as the organ is increasingly destroyed and replaced by nonfunctioning scar tissue. Calcification of the pancreas can also be seen on x rays. Endoscopic retrograde cholangiopancreatography (ERCP) may be used to diagnose chronic pancreatitis in unclear cases. In this procedure, the physician uses a medical instrument fitted with a fiber-optic camera to inspect the pancreas.

Treatment

Treatment of acute pancreatitis involves replacing lost fluids intravenously (in a vein). These IV solutions need to contain appropriate amounts of salts, sugars, and sometimes even proteins, in order to correct the patient's disturbances in blood chemistry. Pain is treated with a variety of medications, chiefly meperidine. To decrease pancreatic function, the patient is not allowed to eat. A thin, flexible tube (nasogastric tube) may be inserted through the patient's nose and down into the stomach . The nasogastric tube can empty the stomach of fluid and air that may accumulate due to the inactivity of the gastrointestinal tract.

The patient will need careful monitoring in order to identify complications that may develop. Infections will require antibiotics through the IV. Severe necrotizing pancreatitis may require surgery to remove part of the dying pancreas, especially if infection has begun. A pancreatic abscess can be drained by a needle inserted through the abdomen and into the collection of pus (per-cutaneous needle aspiration). An abscess may also require surgical removal. In 25–40% of cases, pancreatic pseudocysts may shrink on their own or continue to expand, requiring needle aspiration or surgery. Surgery may be necessary for the removal of gallstones.

Because chronic pancreatitis often includes repeated flares of acute pancreatitis, the same kinds of basic treatment are necessary. Treatment of chronic pancreatitis caused by alcohol consumption requires that the patient stop drinking alcohol entirely. A low-protein and low-fat diet is prescribed. As chronic pancreatitis continues and insulin levels drop, a patient may require insulin injections to be able to process sugars in the diet. Pancreatic enzymes can be replaced with oral medications. As the pancreas is progressively destroyed, some patients stop feeling the abdominal pain that was initially so severe. Others continue to have constant abdominal pain, and may require a surgical procedure for relief.

Prognosis

When necrosis and bleeding are present, as many as 50% of patients with pancreatitis may die.

Ranson's criteria can help determine the severity of the disease. The first five categories are evaluated when the patient is admitted to the hospital, including:

• age over 55 years
• blood sugar level over 200 mg/dl
• serum lactic dehydrogenase over 350 IU/L
• AST over 250 μ (a measure of liver function, as well as a gauge of damage to the heart, muscle, brain , and kidney)
• white blood count over 16,000 μL

The following six of Ranson's criteria are reviewed 48 hours after the patient's admission to the hospital, including:

• greater than 10% decrease in hematocrit (a measure of red blood cell volume)
• increase in BUN (blood urea nitrogen, an indicator of kidney function) greater than 5 mg/dL
• blood calcium less than 8 mg/dL
• PaO₂ (a measure of oxygen in the blood) less than 60 mm Hg
• base deficit greater than 4 mEg/L (a measure of change in the normal acidity of the blood)
• fluid sequestration greater than 13 pt (6 l) (an estimation of the quantity of fluid that has leaked out of the blood circulation and into other body spaces)

Once it is determined how many of Ranson's signs are present in the patient, the physician can better predict the risk of death. A patient with less than three positive Ranson's signs has less than a 5% chance of dying. A patient with three to four positive Ranson's signs has a 15–20% chance of death.

The results of a CT scan can also be used to predict the severity of pancreatitis. Slight swelling of the pancreas indicates mild illness. Significant swelling, especially with evidence of destruction of the pancreas and/or fluid build-up in the abdominal cavity, indicates more severe illness and a worse prognosis.

Health care team roles

The physician will make a full physical examination of the patient to determine which tests are necessary. Radiation technologists will perform imaging studies and clinical laboratory technicians will perform the laboratory tests. Nurses have an active supportive role throughout the patient's illness.

Prevention

Alcoholism is essentially the only preventable cause of pancreatitis. Patients with chronic pancreatitis must stop drinking alcohol entirely. The drugs that may cause pancreatitis should also be avoided when possible.

Resources

BOOKS

Izenberg, Neil, ed. Human Disease and Conditions. New York: Charles Scribner's Sons, 2000, pp.643-644.

Toskes, Phillip P., and Norton J. Greenberger. "Disorders of the Pancreas." In Harrison's Principles of Internal Medicine, edited by E. Braunwald, et al. New York: McGraw-Hill, 2001, pp.1788-1803.

PERIODICALS

Munos, Abilio, and David A. Katerndahl. "Diagnosis and Management of Acute Pancreatitis." American Family Physician 62 (July 2000): 164-73.

ORGANIZATIONS

National Digestive Diseases Information Clearinghouse. 2 Information Way, Bethesda, MD 20892-3570.

OTHER

National Institute of Diabetes and Digestive and Kidney Diseases. <http://www.niddk.nih.gov/health/digest/pubs/pancreas/pancreas.htm>.

The National Pancreas Foundation. <http://www.pancreasfoundation.org/diseases.html>.

Erika J. Norris

Pancreatitis

What Is Pancreatitis?

What Causes Pancreatitis?

How Is Pancreatitis Diagnosed?

How Is Pancreatitis Treated?

Resource

Pancreatitis (pan-kree-a-TY-tis) is a painful inflammation* of the pancreas.

* inflammation

(in-fla-MAY-shun) is the body’s response to infection or irritation, usually marked by heat swelling, redness, and pain.

KEYWORDS

for searching the Internet and other reference sources

Alcohol abuse

Biliary tract disease

Inflammation

What Is Pancreatitis?

The pancreas (PAN-kree-us) is a gland about 6 inches long that is shaped like a flattened pear and lies next to the stomach with its wider end near the duodenum (doo-o-DEE-num), the first part of the small intestine. The pancreas produces insulin and glucagon (GLOO-ka-gon), which are chemical messengers called hormones* that control the use of sugar in the body. The pancreas also secretes enzymes*, which are proteins that the body needs to digest other proteins, sugars, and fats. These digestive juices are carried to the small intestine by the biliary (BIL-ee-air-ee) system, which consists of a small pear-shaped organ called the gallbladder (GAWL-blad-er) and a network of ducts.

* hormones

are chemicals that are produced by different glands in the body. Hormones are like the body’s ambassadors: they are created in one place but are sent through the body to have specific regulatory effects in different places.

* enzymes

(EN-zymz) are natural substances that speed up specific chemical reactions in the body.

When the pancreas becomes inflamed, its powerful digestive enzymes leak out and begin to attack the pancreas itself. These enzymes cause damage that results in swelling of tissues and blood vessels. There are two forms of pancreatitis. Acute* pancreatitis occurs when the pancreas suddenly becomes inflamed but then gets better. Chronic* pancreatitis is persistent inflammation of the pancreas or a combination of persistent inflammation with repeated attacks of acute pancreatitis. Over time, the damage caused by chronic pancreatitis can lead to malabsorption (when the body cannot absorb the nutrients and calories it needs) and an abnormal secretion of insulin, that is, diabetes*.

* acute

means sudden.

* chronic

(KRON-ik) means continuing for a long period of time.

* diabetes

(dy-a-BEE-teez) is an impaired ability to break down carbohydrates, proteins, and fats because the body does not produce enough insulin or cannot use the insulin it makes.

What Causes Pancreatitis?

There are many causes of pancreatitis, but most cases of acute pancreatitis are caused by alcohol abuse or gallstones*. A patient usually feels severe pain in the upper abdomen* that may last for hours or for a few days. The abdomen may be swollen and tender. Other symptoms may include nausea, vomiting, fever, and an increased pulse rate.

* gallstones

(GAWL-stonz) are hard masses that form in the gallbladder or bile duct.

* abdomen

(AB-do-men), commonly called the belly is the portion of the body between the chest or thorax (THOR-aks) and the pelvis.

How Is Pancreatitis Diagnosed?

In addition to pain, patients with chronic pancreatitis usually show signs of long-term damage such as malabsorption or diabetes. Because acute pancreatitis causes an increase in certain levels of digestive enzymes in the blood, a blood test may confirm a diagnosis of the condition. Sometimes, x-rays such as CT scans* are used to make the diagnosis.

* CT scans

or CAT scans are the shortened names for computerized axial tomography (to-MOG-ra-fee), which uses computers to view cross sections inside the body.

How Is Pancreatitis Treated?

Treatment for pancreatitis depends on the type, cause, and severity of the condition. Although acute pancreatitis usually gets better on its own, patients often are hospitalized while the attack lasts. If the patient has gallstones, surgery may be needed to remove them.

Patients with chronic pancreatitis will be placed on a strict diet that limits fat and protein, which the damaged pancreas can no longer digest properly. Patients sometimes are given replacement enzymes to help digest their food, and a doctor may prescribe medication to relieve pain. Because both acute and chronic pancreatitis often are caused by alcohol, the best way to prevent the disease is to avoid drinking.

With treatment, the outlook for chronic pancreatitis often is good, but patients must stop drinking. Other less common causes of pancreatitis, such as infections, cancer*, and reactions to medicines or chemicals, need to be diagnosed properly in order to be treated the best way possible.

* cancer

is an uncontrolled growth of cells or tissue the natural (untreated) course of which is often fatal.

See also

Alcoholism

Diabetes

Gallstones

Resource

U.S. National Digestive Diseases Information Clearinghouse, 2 Information Way, Bethesda, MD 20892-3570. Part of the U.S. National Institutes of Health (NIH), the NDDIC publishes brochures about digestive diseases and posts a fact sheet about pancreatitis at its website.
Telephone 301-654-3810
http://www.niddk.nih.gov/health/digest/pubs/pancreas/pancreas.htm