PANCREATITIS

Diagnosis

While asking about a person's medical history and conducting a thorough physical examination, the doctor will order a blood test to assist in the diagnosis. During acute pancreatitis, the blood contains at least three times the normal amount of amylase and lipase, digestive enzymes formed in the pancreas. Changes may also occur in other body chemicals such as glucose, calcium, magnesium, sodium, potassium, and bicarbonate. After the person's condition improves, the levels usually return to normal.

Diagnosing acute pancreatitis is often difficult because of the deep location of the pancreas. The doctor will likely order one or more of the following tests:

Abdominal ultrasound. Sound waves are sent toward the pancreas through a handheld device that a technician glides over the abdomen. The sound waves bounce off the pancreas, gallbladder, liver, and other organs, and their echoes make electrical impulses that create a picture—called a sonogram—on a video monitor. If gallstones are causing inflammation, the sound waves will also bounce off them, showing their location.

Computerized tomography (CT) scan. The CT scan is a noninvasive x ray that produces three-dimensional pictures of parts of the body. The person lies on a table that slides into a donut-shaped machine. The test may show gallstones and the extent of damage to the pancreas.

Magnetic resonance cholangiopancreatography (MRCP). MRCP uses magnetic resonance imaging, a noninvasive test that produces cross-section images of parts of the body. The patient lies in a cylinder-like tube for the test which creates detailed images of the pancreas, gallbladder, and pancreatic and bile ducts.

Treatment

Treatment for acute pancreatitis requires a few days' stay in the hospital for intravenous (IV) fluids, antibiotics, and medication to relieve pain. The person cannot eat or drink so the pancreas can rest. If vomiting occurs, a tube may be placed through the nose and into the stomach to remove fluid and air.

Unless complications arise, acute pancreatitis usually resolves in a few days. In severe cases, the person may require intravenous feeding for several days to weeks while the pancreas heals.

Before leaving the hospital, the person will be advised not to smoke, drink alcoholic beverages, or eat fatty meals. In some cases, the cause of the pancreatitis is clear, but in others, more tests are needed after the person is discharged and the pancreas is healed.

Therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP) for Acute and Chronic Pancreatitis

ERCP is a specialized technique used to view the pancreas, gallbladder, and bile ducts and treat complications of acute and chronic pancreatitis - gallstones, narrowing or blockage of the pancreatic duct or bile ducts, leaks in the bile ducts, and pseudocysts - accumulations of fluid and tissue debris.

Soon after a person is admitted to the hospital with a suspected blockage in the pancreatic duct or bile ducts, a physician with specialized training may perform ERCP.

With the patient sedated, the doctor inserts an endoscope—a long, flexible, lighted tube with a camera—through the mouth, throat, and stomach into the small intestine. The endoscope is connected to a computer and screen. The doctor guides the endoscope and injects a special dye into the pancreatic or bile ducts that helps the pancreas, gallbladder, and bile ducts appear on the screen while x rays are taken.

The following procedures can be performed using ERCP:

Sphincterotomy. Using a small wire on the endoscope, the doctor finds the muscle that surrounds the pancreatic duct or bile ducts and makes a tiny cut to enlarge the duct opening. When a pseudocyst is present, the duct is drained.
Gallstone removal. The endoscope is used to remove pancreatic or bile duct stones. Gallstone removal is sometimes performed along with a sphincterotomy.
Stent placement. Using the endoscope, the doctor places a tiny piece of plastic or metal that looks like a straw in a narrowed pancreatic or bile duct to keep it open.
Balloon dilatation. Some endoscopes have a small balloon that the doctor uses to dilate, or stretch, a narrowed pancreatic or bile duct. A temporary stent may be placed for a few months to keep the duct open.

People who undergo therapeutic ERCP are at slight risk for complications, including severe pancreatitis, infection, bowel perforation, or bleeding. Complications of ERCP are more common in people with acute or recurrent pancreatitis. A patient who experiences fever, trouble swallowing, or increased throat, chest, or abdominal pain after the procedure should notify a doctor immediately.

Complications

Gallstones that cause acute pancreatitis require surgical removal of the stones and the gallbladder. If the pancreatitis is mild, gallbladder removal - called cholecystectomy -may proceed while the person is in the hospital. If the pancreatitis is severe, gallstones may be removed using therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Cholecystectomy is delayed for a month or more to allow for full recovery.

If an infection of the pancreas develops during a bout of acute pancreatitis, exploratory surgery may be necessary to remove severely damaged pancreatic tissue.

Pseudocysts - accumulations of fluid and tissue debris - that may develop in the pancreas can be drained using ERCP or EUS. If pseudocysts are left untreated, enzymes and toxins can enter the bloodstream and affect the heart, lungs, kidneys, or other organs.

Acute pancreatitis sometimes causes kidney failure. People with kidney failure need blood-cleansing treatments called dialysis or a kidney transplant.

In rare cases, acute pancreatitis can cause breathing problems. Hypoxia, a condition that occurs when body cells and tissues do not get enough oxygen, can develop. Doctors treat hypoxia by giving oxygen to the patient. Some people still experience lung failure -even with oxygen -and require a respirator for a while to help them breathe.

(1) Russo MW, Wei JT, Thiny MT, et al. Digestive and liver disease statistics, 2004. Gastroenterology. 2004;126:1448–1453.

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Symptoms

Most people with chronic pancreatitis experience upper abdominal pain, although some people have no pain at all. The pain may spread to the back, feel worse when eating or drinking, and become constant and disabling. In some cases, abdominal pain goes away as the condition worsens, most likely because the pancreas is no longer making digestive enzymes. Other symptoms include

Nausea
Vomiting
Weight loss
Diarrhea
Oily stools

People with chronic pancreatitis often lose weight, even when their appetite and eating habits are normal. The weight loss occurs because the body does not secrete enough pancreatic enzymes to digest food, so nutrients are not absorbed normally. Poor digestion leads to malnutrition due to excretion of fat in the stool.

Diagnosis

Chronic pancreatitis is often confused with acute pancreatitis because the symptoms are similar. As with acute pancreatitis, the doctor will conduct a thorough medical history and physical examination. Blood tests may help the doctor know if the pancreas is still making enough digestive enzymes, but sometimes these enzymes appear normal even though the person has chronic pancreatitis.

In more advanced stages of pancreatitis, when malabsorption and diabetes can occur, the doctor may order blood, urine, and stool tests to help diagnose chronic pancreatitis and monitor its progression.

The doctor will typically perform one or more of the following tests to diagnose chronic pancreatitis—abdominal ultrasound, CT scan, endoscopic ultrasound, and MRCP.

Treatment

Treatment for chronic pancreatitis may require hospitalization for pain management, IV hydration, and nutritional support. 

When a normal diet is resumed, the doctor may prescribe synthetic pancreatic enzymes to be taken with every meal.  These enzymes may lessen the pain of chronic pancreatitis and improve diarrhea. The next step is to plan a nutritious diet that is low in fat and includes small, frequent meals. A dietitian can assist in developing a meal plan.

People with chronic pancreatitis are strongly advised not to smoke or consume alcoholic beverages, even if the pancreatitis is mild or in the early stages.

Complications

People with chronic pancreatitis who continue to consume large amounts of alcohol may develop sudden bouts of severe abdominal pain.

As with acute pancreatitis, ERCP is used to identify and treat complications associated with chronic pancreatitis such as gallstones, pseudocysts, and narrowing or obstruction of the ducts. Chronic pancreatitis also can lead to calcification of the pancreas, which means the pancreatic tissue hardens from deposits of insoluble calcium salts. Surgery may be necessary to remove part of the pancreas.

In cases involving persistent pain, surgery or other procedures are sometimes recommended to block the nerves in the abdominal area that cause pain.

When pancreatic tissue is destroyed in chronic pancreatitis and the insulin-producing cells of the pancreas, called beta cells, have been damaged, diabetes may develop. People with a family history of diabetes are more likely to develop the disease. If diabetes occurs, insulin or other medicines are needed to keep blood glucose at normal levels. A health care provider works with the patient to develop a regimen of medication, diet, and frequent blood glucose monitoring.

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