Pancreatitis

PANCREATITIS

Pancreatitis is inflammation of the pancreas. It is characterised by the sudden onset of upper abdominal pain which may be accompanied by nausea & vomiting.
Pancreatitis is most commonly acute, however there is a chronic form. Acute pancreatitis is most commonly due to gallstones or alcohol use. These two causes account for 60 to 75% of cases. While there are rare causes such as autoimmune, viral or medication induced, the next largest group is of unknown cause representing about 20% of cases.

 

TREATMENT

Most cases of acute pancreatitis require only supportive treatment. This includes intravenous fluid therapy, initially nothing to eat and possibly nothing to drink to allow the pancreas to rest.
An ultrasound may be done looking for evidence of gallstones. It is possible you may have a CT or MRI, though these are not always necessary.
Typically, these cases resolve within a week.

GALLSTONE PANCREATITIS

The pancreas lies against the back wall of the abdomen. It is responsible for producing hormones, such as insulin, and digestive enzymes which flow into the small intestine to aid digestion. The duct (or tube) which connects the pancreas to the duodenum shares a common exit with the common bile duct. This is where gallstones can lodge and cause pancreatitis by blocking the pancreatic duct.
If the gallstone passes spontaneously the treatment is supportive as for other forms of pancreatitis. However, if the gallstone remains obstructing both the ducts, it may be necessary to perform an ERCP to relieve the obstruction. Once you have fully recovered there will be a discussion about removing your gallbladder with a cholecystectomy. This is usually not done until at least 6 weeks after the pancreatitis has resolved.

 

SEVERE PANCREATITIS

A small proportion of cases, approximately 5-10%, will develop severe pancreatitis. The inflammation affects the whole body resulting in organ dysfunction in other parts of the body, such as the kidneys, lungs & heart. This requires very close care and monitoring, usually in the Intensive Care Unit or High Dependency Unit.
The pancreas itself may become so inflamed that parts of it or the nearby tissues die, this is called necrotising pancreatitis. On top of this, sometimes the necrotic tissue becomes infected. At this point patients are very unwell. While there is ongoing treatment for all the other systems which are affected, antibiotics will also be being given.
A discussion about the use surgery to remove the dead or infected part of the pancreas will be undertaken with you and your family. There will be an individualised treatment plan developed by your surgeon.
At this stage you should be under the care of an upper GI or HPB surgeon. The road to recovery can be long, sometimes patients remain in hospital for weeks with severe pancreatitis.

LONG TERM OUTCOMES

Most patients with mild to moderate pancreatitis will experience only the one episode, particularly if the cause can be treated or avoided eg gallstones or alcohol. A second episode of pancreatitis, without a clear cause, will usually lead to investigation for the rarer causes of pancreatitis.
Following severe pancreatitis, recovering patients sometimes find they have difficulty with symptoms of bloating, abdominal discomfort or diarrhoea after eating. If you’ve had severe pancreatitis leaving the pancreas scarred, surgery for necrotic pancreatitis or have suffered chronic pancreatitis, the pancreas may not produce enough digestive enzymes, known pancreatic enzyme insufficiency. This is worth discussing with your doctor, it can be treated with enzyme replacement.
A Pancreatic Enzyme Deficiency Clinic is being created at Royal North Shore Hospital to follow up and treat this under-recognised condition.

 

CHRONIC PANCREATITIS

Chronic pancreatitis is caused by persistent low grade inflammation of the pancreas. This results in chronic and unrelenting upper abdominal pain with occasional acute flares. This leads to pancreatic damage and can, if left untreated, eventually lead to irreversible loss of structure & function.
The most common cause of chronic pancreatitis is alcohol misuse. It can also be due to hereditary causes, cystic fibrosis and autoimmune disorders.
The aim of treatment is the stop the inflammatory process and control symptoms. This means ceasing all substances toxic to the pancreas, especially alcohol. This is the single most important step in managing chronic pancreatitis secondary to alcohol misuse. Otherwise management is aimed at controlling pain with adequate pain relief and using medication to reduce the inflammation.
With persisting disease and falling pancreatic function, there may be some symptoms of pancreatic enzyme deficiency. Multidisciplinary care and treatment for this is being arranged at the Pancreatic Enzyme Deficiency Clinic, at Royal North Shore Hospital.