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Pancreatitis (Acute)

Introduction

Acute pancreatitis is a serious condition where the pancreas becomes inflamed over a short period of time.

The pancreas is a small, tadpole-shaped organ that is located behind the stomach and below the ribcage. It has two important functions:

  • it produces digestive juices that are used by the intestines to help digest food
  • it produces powerful ‘messenger chemicals’ called hormones

Insulin, which regulates the levels of sugar (glucose) in the blood, is the most important hormone that the pancreas produces.

The most common symptoms of acute pancreatitis are:

  • the sudden onset of a severe pain in the centre of your abdomen
  • nausea (feeling sick)
  • vomiting (being sick)

See Acute pancreatitis - symptoms for more information.

In England, the two most common causes of acute pancreatitis are:

  • gallstones - which accounts for around a half of all cases
  • alcohol consumption - which accounts for about a quarter of all cases

See Acute pancreatitis - causes for more information.

Chronic pancreatitis is where the inflammation of the pancreas persists for many years. See the A-Z topic about Chronic pancreatitis for information relating to this form of pancreatitis.

Types of acute pancreatitis

Acute pancreatitis can either be:

  • mild - which accounts for four out of five cases
  • severe - which accounts for the remaining one in five cases

The two types are briefly described below.

Mild acute pancreatitis

In cases of mild acute pancreatitis, the inflamed pancreas usually improves within three to five days. The term ‘mild’ is often used to distinguish this form of the condition from severe acute pancreatitis. However, it is a slightly misleading term because mild acute pancreatitis will still make you feel very ill.

The term 'mild' is used to describe cases where a person recovers without any complications.

Severe acute pancreatitis

In cases of severe acute pancreatitis, the inside of the pancreas is severely inflamed. This can trigger two life-threatening complications:

  • inflammation spreads throughout the body, which can sometimes cause multiple organ failure
  • the tissues of the pancreas begin to die and become infected and can cause a life-threatening infection to spread throughout your body, which, again, can lead to multiple organ failure

It is not clear why some people develop mild acute pancreatitis while others develop severe acute pancreatitis.

Treating acute pancreatitis

There is currently no cure for acute pancreatitis. This means that treatment is based on supporting the functions of the body until the inflammation has passed.

Both types of acute pancreatitis will require admission to hospital. Mild acute pancreatitis can be treated in a general hospital ward. Severe acute pancreatitis will require admission to a high dependency unit or an intensive care unit (ICU). See Acute pancreatitis – treatment for more information.

If the tissues of the pancreas begin to die, surgery may be needed to remove the dead tissue. Antibiotics can also be used to treat any infection that is related to acute pancreatitis.

See Acute pancreatitis - complications for more information.

How common is acute pancreatitis?

Acute pancreatitis is an uncommon condition.

In England and Wales in 2007 there were 990 deaths caused by acute pancreatitis. It is estimated that most hospitals will treat one or two people with acute pancreatitis every week.

Rates of acute pancreatitis have risen sharply over the past 40 years. This is thought to be because of a rise in rates of alcohol use and obesity, which is a risk factor for gallstones.

Who is affected by acute pancreatitis?

Men are more likely to develop acute pancreatitis that is related to alcohol use while women are more likely to develop acute pancreatitis that is related to gallstones.

Alcohol-related acute pancreatitis is most widespread in middle-aged people, with the average age at diagnosis being 39 years of age.

Gallstones-related acute pancreatitis is most widespread in people of retirement age, with the average age at diagnosis being 69 years of age.

However, acute pancreatitis can affect people of all ages including children.

Outlook

The outlook for mild acute pancreatitis is good and most people are well enough to leave the hospital after 5 to 14 days.

However, mild acute pancreatitis that is associated with alcohol use should be taken as a serious warning sign that your current levels of drinking are placing your health at risk and you should stop drinking.

All patients who have had pancreatitis should avoid drinking alcohol for at least six months, whatever the cause of the pancreatitis.

See Acute pancreatitis - prevention for more information and advice.

The outlook for severe acute pancreatitis is much less favourable. If complications, such as multiple organ failure, develop, the risk of death can be as high as 1 in 3. If a person survives the effects of severe acute pancreatitis, it is likely to be several weeks or possibly months before they are well enough to leave hospital.

The pancreas

The pancreas is a small, tadpole-shaped organ that is located behind the stomach and below the ribcage. It has two important functions:

  • it produces digestive juices that are used by the intestines to help digest food
  • it produces powerful ‘messenger chemicals’ called hormones

Insulin, which regulates the levels of sugar (glucose) in the blood, is the most important hormone that the pancreas produces.

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Symptoms

The most common symptom of acute pancreatitis is the sudden onset of a severe dull pain in the centre of your upper abdomen, around the top of your stomach.

The pain of acute pancreatitis often gets steadily worse until it reaches a constant ache. The ache may travel from your abdomen and along your back and may feel worse after you have eaten. Leaning forward or curling into a ball may help to relieve the pain.

If you have acute pancreatitis that is caused by gallstones, the pain often develops after eating a large meal. If the condition is caused by alcohol, the pain often develops 6 to 12 hours after a drinking a significant amount of alcohol.

Other symptoms

Other symptoms of acute pancreatitis can include:

  • nausea (feeling sick)
  • vomiting (being sick)
  • diarrhoea
  • loss of appetite
  • a high temperature (fever) of 38°C (100.4°F) or above
  • tenderness of the abdomen and, less commonly
  • yellowing of the skin and the whites of the eyes (jaundice)

When to seek medical advice

You should contact your GP immediately if you suddenly develop severe abdominal pain. If this is not possible, telephone NHS Direct Wales or your local out-of-hours service for advice.

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Causes

Acute pancreatitis is poorly understood and there is much about the condition that remains unknown. For example, it is still unclear what triggers the inflammation inside the pancreas or why some people have the mild form of the condition and others have the severe form.

Trypsin

One theory is that acute pancreatitis is caused when something goes wrong with a chemical called trypsin. Trypsin is an enzyme that is produced by the pancreas and is used to break down the proteins in food to aid digestion.

When trypsin is produced by the pancreas, it remains in an ‘inactive’ state and has no digestive properties. It is not until it is moved out of the pancreas and into the intestines that it becomes active and is able to start breaking down proteins.

The theory suggests that something causes trypsin to become active while it is still in the pancreas, making it break down its own cells. In other words, the pancreas starts trying to digest itself, which causes it to become irritated and inflamed.

Alcohol consumption

It is not fully understood how alcohol causes the pancreas to become inflamed. One theory is that the ethanol molecules in alcohol interfere with the normal workings of the cells of the pancreas, causing them to activate trypsin prematurely.

Whatever the cause, there is a clear link between alcohol use and acute pancreatitis, and the more alcohol you drink, the higher your risk.

A very large study found that people who regularly drank more than 35 units of alcohol a week were four times more likely to develop acute pancreatitis than people who never drank alcohol (35 units is equivalent to drinking around 16 cans of strong lager or four bottles of wine a week).

Binge drinking, which is drinking a lot of alcohol in a short period of time, is thought to increase your risk of developing acute pancreatitis.

Gallstones

Gallstones are hard pieces of stone-like material that can form if your bile (digestive juices) has too much cholesterol in it. Sometimes a gallstone can move out of the gallbladder and block the openings (ducts) to the pancreas.

It is thought that the blockage causes a disruption in the chemical reactions that occur within the pancreas. This could lead to the activation of trypsin inside the pancreas and trigger the process of inflammation.

See the A-Z topic about gallstones for more information.

Other causes

Other, less common, causes of acute pancreatitis include:

  • accidental damage to the pancreas that occurs during a type of surgery known as endoscopic retrograde cholangiopancreatography (ERCP), which is used to remove gallstones or examine the pancreas or surrounding tissue
  • an unexpected side effect of certain types of medication in a small number of people, such as some type of antibiotics or chemotherapy medication
  • a viral infection, such as mumps or measles

Risk factors for severe pancreatitis

Little is known about why some people develop the severe form of acute pancreatitis. Several researchers have studied case files to see whether they could spot factors that make a person more likely to develop severe acute pancreatitis.

The results of this research strongly suggest that the following risk factors increase your risk of developing severe acute pancreatitis:

  • being 70 years of age or over
  • being obese - a person is considered obese if they have a body mass index (BMI) of 30 or above
  • having two or more alcoholic drinks a day
  • smoking

Researchers have also discovered that people with a specific genetic mutation, known as the MCP-1 mutation, are eight times more likely to develop severe acute pancreatitis than the population at large. A genetic mutation is where the instructions that are found in all living cells become scrambled, resulting in a genetic disorder or a change in characteristics.

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Diagnosis

Most cases of acute pancreatitis are diagnosed at hospital on an emergency admission basis.

The doctor in charge of your care will ask you about the history of your symptoms. They may also carry out a physical examination. If you have acute pancreatitis, certain areas of your abdomen will be very tender to touch.

Blood tests

The next stage in the diagnosis is to carry out a blood test. During acute pancreatitis, your pancreas will begin to produce higher than usual levels of two chemicals called amylase and lipase. The blood test results will show whether the levels of these chemicals are raised.

Further testing

Further testing may be carried out in hospital to observe the extent of the inflammation of your pancreas and to assess your risk of developing more serious complications.

Tests that you may have include:

  • a computerised tomography (CT) scan - where a series of X-rays are taken to build up a more detailed, three-dimensional image of your pancreas
  • an endoscopic retrograde cholangiopancreatography (ERCP)

An ERCP uses a narrow, flexible tube, known as an endoscope, which has a camera on one end. The endoscope will be guided into your digestive system using an ultrasound scanner.

An ERCP can be useful in cases of gallbladder-associated acute pancreatitis because it can pinpoint exactly where the gallstone that is causing the problem is located. In some cases, it may be possible to pass surgical instruments down the endoscope so that the gallstone can be removed.

Mild or severe

In the early stages of acute pancreatitis, determining whether a person has the mild or severe form of the condition can be difficult based on the symptoms alone. Therefore, several tests are often required to help determine which form a person has. These tests include a range of blood tests and sometimes X-rays and a CT scan.

Your heart and breathing rates may also been measured. A heartbeat of 90 beats or more a minute or a breathing rate of 20 breaths a minute may suggest a diagnosis of severe acute pancreatitis.

These tests usually take about 24 hours to complete. After this time, the doctor who is in charge of your or your relative’s care should be able to tell you whether the acute pancreatitis is mild or severe.

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Treatment

The treatment that you receive for acute pancreatitis will depend on whether you have the mild form of the condition, which causes no complications, or the severe form, which can cause serious complications.

Mild acute pancreatitis

The treatment of mild acute pancreatitis is relatively straightforward and can usually be successfully carried out by admitting you to a general hospital ward.

You will not be able to eat until the inflammation inside your pancreas has resolved, which usually takes around five days. This is because trying to digest solid food could place too much strain on your pancreas.

Because pancreatitis can damage your lungs and affect normal lung function, your body will be supplied with oxygen through tubes that are connected to your nose. The tubes can then be removed after a few days once it is clear that your condition is improving.

Your body can become dehydrated during an episode of acute pancreatitis, so fluids will be provided through a tube that is connected to one of your veins.

The pain associated with even mild cases of acute pancreatitis can be severe, so you may require quite a strong, opiate-based painkiller which may make you feel very drowsy. Therefore, if you are visiting someone who is in hospital as a result of mild acute pancreatitis, you should not be alarmed or concerned if they appear drowsy or unresponsive.

Treating the underlying cause

Gallstones

If testing shows that a gallstone is responsible for the pancreatitis, surgical removal of the gallbladder will usually be recommended.

This may be done while you are in hospital or, alternatively, the surgery may be planned for a number of weeks in the future.

Having your gallbladder removed should have no significant affect on your health other than making it more difficult to digest certain foods, such as fatty or spicy foods, than it used to be.

See the A-Z topic about Gallbladder removal for more information.

Alcohol use

All patients who have had pancreatitis should avoid alcohol completely for at least six months, whatever the cause of the pancreatitis. This is because alcohol can cause further damage to the pancreas during the recovery phase, even if acute pancreatitis is caused by alcohol.

If you find this difficult to do, for example, if you have developed a dependence on alcohol, you will probably need additional treatment. Treatment options for alcohol dependence include:

  • one-to-one counselling
  • self-help groups, such as Alcoholics Anonymous
  • a medication called acamprosate that helps to reduce your cravings for alcohol

See Alcohol misuse - treatment for more information and advice.

Severe acute pancreatitis

If you are diagnosed with severe acute pancreatitis, you will need to be admitted to an high dependency unit or intensive care unit (ICU).

It is likely that the levels of fluids inside your body will have dropped significantly as your body diverts fluids and nutrients in an attempt to repair your pancreas. The drop in fluid levels can lead to a reduction in the volume of blood in your body, which is known as hypovolemic shock.

Hypovolemic shock can be life-threatening because your body can become quickly starved of the oxygen-rich blood that it needs to survive. To avoid going into hypovolemic shock, fluids will be pumped directly into your body through a tube that will be connected to one of your veins. These fluids are known as intravenous fluids or IV.

Oxygen will be supplied through tubes attached to your nose and ventilation equipment may be used to assist with your breathing. Feeding tubes may be used to provide your body with nutrients. Painkillers can help to relieve the symptoms of pain.

Treating the underlying cause

As with mild acute pancreatitis, if you have severe acute pancreatitis it will be necessary to treat the underlying cause.

If the cause is gallstones, it is likely that an ERCP procedure or removal of your gallbladder will be recommended. For more information about ERCP, see Acute pancreatitis - diagnosis. If the cause is alcohol use, stopping drinking and receiving treatment for alcohol dependency will be recommended (as discussed above).

Though, as mentioned above, even if the underlying cause has nothing to do with alcohol you should avoid drinking alcohol for at least six months as this can cause further damage to the pancreas during the recovery process.

Where will I be treated?

People with pancreatitis are usually treated at hospital in a specialist hepatology (disorders of the liver, gallbladder and biliary ducts) or haematology (blood disorders) unit. If the pancreatitis is caused by excessive alcohol intake, there is a range of services available to help you reduce your drinking or stop completely.

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Complications

Infected pancreatic necrosis

A common and serious complication of severe acute pancreatitis is infected pancreatic necrosis. This complication occurs in around a third of cases of severe acute pancreatitis.

In infected pancreatic necrosis, high levels of inflammation cause an interruption to the blood supply of your pancreas. Without a consistent supply of blood, some of the tissue of your pancreas will die. Necrosis is the medical term for the death of tissue.

The dead tissue is extremely vulnerable to infection from bacteria. Once an infection has occurred, it can quickly spread into the blood (blood poisoning) and cause multiple organ failure. If it is left untreated, infected pancreatic necrosis will almost certainly result in death.

Infected pancreatic necrosis usually develops 2-6 weeks after the onset of symptoms of acute pancreatitis and is marked by a worsening of your abdominal pain and a high temperature. The infection will need to be treated with injections of antibiotics. It will also be necessary to remove the dead tissue otherwise the infection will reoccur.

In some cases it may be possible to drain away the dead tissue using a thin tube known as a catheter, which is placed through the skin.

Alternatively, laparoscopic surgery (keyhole surgery) can be used. A small incision is made in your back and a small, flexible tube called an endoscope is inserted and used to wash away any dead tissue.

It isn't always possible to use a laparoscopic approach, for example, if you are very obese or the area of dead tissue is not easily accessible. In such circumstances an incision is made in your abdomen to allow the dead tissue to be removed.

Infected pancreatic necrosis is a very serious complication and even with the highest standards of medical care the risk of dying from organ failure is estimated to be around one in five.

Systemic inflammatory response syndrome (SIRS)

Another common complication of severe acute pancreatitis is systemic inflammatory response syndrome (SIRS). SIRS develops in an estimated one in ten cases of severe acute pancreatitis.

In SIRS, the inflammation that affects the pancreas spreads throughout the body, which can cause one or more organs to fail. It usually develops during the first week after the onset of symptoms of acute pancreatitis, with most cases developing on the same day.

Symptoms of SIRS include:

  • a rise in body temperature to more than 38°C (100.4°F) or, alternatively, a fall in body temperature to below 36°C (96.8°F)
  • a rapid heartbeat of more than 90 beats a minute
  • an unusually fast breathing rate (more than 20 breaths a minute)

There is currently no cure for SIRS, so treatment involves trying to support the body’s functions until the inflammation has passed. The outcome depends on how many organs fail. The higher the number of organs affected, the greater the risk of death.

Pseudocysts

Pseudocysts are another common complication of acute pancreatitis. These are sacs of fluid that can develop on the surface of the pancreas and are thought to affect around 1 in 20 people with acute pancreatitis (both the mild and severe forms).

Pseudocysts usually develop four weeks after the onset of the symptoms of acute pancreatitis. In many cases, they do not cause any symptoms and are only detected during a computerised tomography (CT) scan.

However, in some people, pseudocysts can cause the following symptoms:

If the pseudocysts are small and they are not causing any symptoms, there may be no need for further treatment as these types of cysts usually go away on their own.

Treatment will usually be recommended if you are experiencing symptoms or the pseudocysts are larger than 6cm (2.3 inches). Larger pseudocysts are at risk of bursting open, which could cause internal bleeding or trigger an infection.

Pseudocysts can be treated by draining the fluid out of the cyst. This can be done by inserting a needle through your skin and into the cyst or carrying out an endoscopy. This is where a thin, flexible tube called an endoscope is passed down your throat and tiny tools are used to drain away the fluid.

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Prevention

Alcohol misuse and gallstones are the two leading risk factors for acute pancreatitis. Both of these risk factors can be reduced by making changes to your diet and lifestyle.

Alcohol

Limiting the amount of alcohol that you drink can help prevent your pancreas being damaged and can lower your risk of developing acute pancreatitis. It can also lower your chances of developing other serious conditions, such as liver cancer.

The recommendations for the consumption of alcohol are that men should not drink more than three to four units of alcohol a day and women should not drink more than two to three units a day. A unit of alcohol is equal to about half a pint of normal strength lager, a small glass of wine or a pub measure (25ml) of spirits.

See the Lifestyle & Wellbeing section about drinking and alcohol for more information and advice.

Gallstones

The most effective way to prevent gallstones is to eat a healthy, low-fat diet that includes plenty of fresh fruit and vegetables (at least five portions a day). Your diet should also include whole grains, which are found in wholemeal bread, oats and brown rice. This will help to lower the amount of cholesterol in your bile.

Being overweight also increases the amount of cholesterol in your bile and your chances of developing gallstones. Maintain a healthy weight by eating a balanced diet and taking plenty of regular exercise.

For most people, at least 150 minutes of moderate-intensity aerobic activity a week is recommended. Examples of moderate-intensity exercise are walking fast, riding a bike on level ground, water aerobics and playing doubles tennis. Read more about the benefits of exercise.

However, if you have never exercised before, or if you have not exercised for some time, seek advice from your GP before starting a new programme of exercise.

See the following Lifestyle & Wellbeing sections for more information about exercise and healthy eating.

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