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What is pancreatitis?
Your pancreas is a large gland behind your
stomach and close to your duodenum. The pancreas secretes
powerful digestive enzymes that enter the small intestine through
a duct. These enzymes help you digest fats, proteins, and
carbohydrates. The pancreas also releases the hormones insulin
and glucagon into the bloodstream. These hormones play an
important part in metabolizing sugar.
Pancreatitis is a rare disease in which the pancreas becomes inflamed. Damage to the gland occurs when digestive enzymes are activated and begin attacking the pancreas. In severe cases, there may be bleeding into the gland, serious tissue damage, infection, and cysts. Enzymes and toxins may enter the bloodstream and seriously injure organs, such as the heart, lungs, and kidney.
There are two forms of pancreatitis. The acute form occurs suddenly and may be a severe, life-threatening illness with many complications. Usually, the patient recovers completely. If injury to the pancreas continues, such as when a patient persists in drinking alcohol, a chronic form of the disease may develop, bringing severe pain and reduced functioning of the pancreas that affects digestion and causes weight loss.
What are the causes of pancreatitis?
An estimated 50,000 to 80,000 cases of acute
pancreatitis occur in the United States each year. This disease
occurs when the pancreas suddenly becomes inflamed and then gets
better. Some patients have more than one attack but recover fully
after each one. Most cases of acute pancreatitis are caused
either by alcohol abuse or by gallstones. Other causes may be use
of prescribed drugs, trauma or surgery to the abdomen, or
abnormalities of the pancreas or intestine. In rare cases, the
disease may result from infections, such as mumps. In about 15
percent of cases, the cause is unknown.
What are the symptoms of acute pancreatitis?
Acute pancreatitis usually begins with pain in
the upper abdomen, that may last for a few days. The pain is
often severe. It may be constant pain, just in the abdomen, or it
may reach to the back and other areas. The pain may be sudden and
intense, or it may begin as a mild pain that is aggravated by
eating and slowly grows worse. The abdomen may be swollen and
very tender. Other symptoms may include nausea, vomiting, fever,
and an increased pulse rate. The person often feels and looks
very sick.
About 20 percent of cases are severe. The patient may become dehydrated and have low blood pressure. Sometimes the patient's heart, lungs, or kidneys fail. In the most severe cases, bleeding can occur in the pancreas, leading to shock and sometimes death.
How is acute pancreatitis diagnosed?
During acute attacks, high levels of amylase (a
digestive enzyme formed in the pancreas) are found in the blood.
Changes may also occur in blood levels of calcium, magnesium,
sodium, potassium, and bicarbonate. Patients may have high
amounts of sugar and lipids (fats) in their blood too. These
changes help the doctor diagnose pancreatitis. After the pancreas
recovers, blood levels of these substances usually return to
normal.
Is there any treatment?
The treatment a patient receives depends on how
bad the attack is. Unless complications occur, acute pancreatitis
usually gets better on its own, so treatment is supportive in
most cases. Usually the patient goes into the hospital. The
doctor prescribes fluids by vein to restore blood volume. The
kidneys and lungs may be treated to prevent failure of those
organs. Other problems, such as cysts in the pancreas, may need
treatment too.
Sometimes a patient cannot control vomiting and needs to have a tube through the nose to the stomach to remove fluid and air. In mild cases, the patient may not have food for 3 or 4 days but is given fluids and pain relievers by vein. An acute attack usually lasts only a few days, unless the ducts are blocked by gallstones. In severe cases, the patient may be fed through the veins for 3 to 6 weeks while the pancreas slowly heals.
Antibiotics may be given if signs of infection arise. Surgery may be needed if complications such as infection, cysts, or bleeding occur. Attacks caused by gallstones may require removal of the gallbladder or surgery of the bile duct. Surgery is sometimes needed for the doctor to be able to exclude other abdominal problems that can simulate pancreatitis or to treat acute pancreatitis. When there is severe injury with death of tissue, an operation may be done to remove the dead tissue.
After all signs of acute pancreatitis are gone, the doctor will determine the cause and try to prevent future attacks. In some patients the cause of the attack is clear, but in others further tests need to be done.
What if the patient has gallstones?
Ultrasound is used to detect gallstones and
sometimes can provide the doctor with an idea of how severe the
pancreatitis is. When gallstones are found, surgery is usually
needed to remove them. When they are removed depends on how
severe the pancreatitis is. If it is mild, the gallstones often
can be removed within a week or so. In more severe cases, the
patient may wait a month or more, until he improves, before the
stones are removed. The CAT (computer axial tomography) scan may
also be used to find out what is happening in and around the
pancreas and how severe the problem is. This is important
information that the doctor needs to determine when to remove the
gallstones.
After the gallstones are removed and inflammation subsides, the pancreas usually returns to normal. Before patients leave the hospital, they are advised not to drink alcohol and not to eat large meals.
What is chronic pancreatitis?
Chronic pancreatitis usually follows many years
of alcohol abuse. It may develop after only one acute attack,
especially if there is damage to the ducts of the pancreas. In
the early stages, the doctor cannot always tell whether the
patient has acute or chronic disease. The symptoms may be the
same. Damage to the pancreas from drinking alcohol may cause no
symptoms for many years, and then the patient suddenly has an
attack of pancreatitis. In more than 90 percent of adult
patients, chronic pancreatitis appears to be caused by
alcoholism. This is more common in men than women and often
develops between 30 and 40 years of age. In other cases,
pancreatitis may be inherited. Scientists do not know why the
inherited form occurs. Patients with chronic pancreatitis tend to
have three kinds of problems: pain, malabsorption of food leading
to weight loss, or diabetes.
Some patients do not have any pain but most do. Pain may be constant in the back and abdomen, and for some patients, the pain attacks are disabling. In some cases, the abdominal pain goes away as the condition advances. Doctors think this happens because pancreatic enzymes are no longer being made by the pancreas.
Patients with this disease often lose weight, even when their appetite and eating habits are normal. This occurs because the body does not secrete enough pancreatic enzymes to break down food, so nutrients are not absorbed normally. Poor digestion leads to loss of fat, protein, and sugar into the stool. Diabetes may also develop at this stage if the insulin-producing cells of the pancreas (islet cells) have been damaged.
How is chronic pancreatitis diagnosed?
Diagnosis may be difficult but is aided by a
number of new techniques. Pancreatic function tests help the
physician decide if the pancreas still can make enough digestive
enzymes. The doctor can see abnormalities in the pancreas using
several techniques (ultrasonic imaging, endoscopic retrograde
cholangiopancreatography (ERCP), and the CAT scan). In more
advanced stages of the disease, when diabetes and malabsorption
(a problem due to lack of enzymes) occur, the doctor can use a
number of blood, urine, and stool tests to help in the diagnosis
of chronic pancreatitis and to monitor the progression of the
disorder.
How is chronic pancreatitis treated?
The doctor treats chronic pancreatitis by
relieving pain and managing the nutritional and metabolic
problems. The patient can reduce the amount of fat and protein
lost in stools by cutting back on dietary fat and taking pills
containing pancreatic enzymes. This will result in better
nutrition and weight gain. Sometimes insulin or other drugs must
be given to control the patient's blood sugar.
In some cases, surgery is needed to relieve pain by draining an enlarged pancreatic duct. Sometimes, part or most of the pancreas is removed in an attempt to relieve chronic pain.
Patients must stop drinking, adhere to their prescribed diets, and take the proper medications in order to have fewer and milder attacks.
This is based in part upon information from the National Institutes of Health (NIH).
Terms Related to Pancreatitis: Acute Pancreatitis;Most gallstones don’t cause problems. But if they get stuck while trying to pass from the gallbladder (where they form) to the small intestine, they can cause intense pain and, sometimes, nausea and vomiting. Surgery to remove the gallbladder usually is recommended if attacks become frequent and intense. Fortunately, today’s surgery, a procedure called laparascopic cholecystectomy, is a lot easier on patients than the operation of the past, which involved making a big incision in the abdomen. Now surgeons make several small incisions through which they insert their instruments and a small video camera in order to view, detach and remove the gallbladder. Because no abdominal muscles are cut, there is less pain, faster recovery and fewer scars than with the old operation. Most patients recover within days.
Patients who can’t tolerate, or want to avoid, surgery may be offered two other options: drugs to dissolve the gallstones or a procedure to fragment them with sound waves.
The drugs, ursodeoxycholic acid (Actigall) and chenodiol (Chenix) are bile salts that can help dissolve the stones, but treatment can take months, and stones can recur. The sound wave approach, called lithotripsy, rarely is used these days and is considered appropriate only for patients who cannot undergo surgery. It works best on single stones that are less than two centimeters in diameter. Risks of this procedure include pain and pancreatitis, an inflammation of the pancreas, which can occur within a month of treatment. There is also the risk that not all of the fragments will pass through the bile duct out of the gallbladder, leaving patients at risk for future and potentially serious problems.
Most gallstones are composed of cholesterol, and diet plays a role in their formation. You can try to prevent problems with them and thus forestall surgery with these dietary steps:
Andrew Weil, M.D.