Acute Pancreatitis

Dr. Pandol is Professor of Medicine, UCLA School of Medicine and Staff Physician, Department of Medicine, VA Greater Los Angeles Health Care System and University of California, Los Angeles.

The pancreas is an important gland located near the stomach and the small intestine which makes a variety of key chemicals ("enzymes") that help regulate different bodily processes. The pancreas secretes enzymes into the small intestine that help us digest food, and it also produces and then releases the hormones insulin and glucagon into the bloodstream to control the level of sugar (glucose).

Sometimes the enzymes become active while they are still inside the pancreas. When this happens, they damage the pancreas itself.

In a healthy person, digestive enzymes produced by the pancreas are activated when they reach the small intestine. Sometimes, however, the enzymes become active while they are still inside the pancreas. When this happens, they damage the pancreas itself ("pancreatitis") and cause a variety of other problems.

There are two kinds of pancreatitis: acute and chronic. Acute pancreatitis happens in sudden, brief attacks,while chronic pancreatitis lasts longer and causes a slow but steady destruction of the pancreas. Both can cause other serious problems such as bleeding, damage to the heart and other organs, and infection.

Acute Pancreatitis

The two main effects of acute pancreatitis are acute inflammation and damage to tissues inside the gland.(1) In its most severe forms, there can be a widespread inflammatory response involving organs both near to and distant from the pancreas; and actual death of some pancreatic tissue, a condition called necrosis.

The most common first symptom is abdominal pain, often accompanied by vomiting, fever, tachycardia (racing of the heart), high white blood cell count and increased levels of pancreatic enzymes in the blood and urine. In severe cases, acute pancreatitis affects other organs, (e.g., lungs, kidneys, liver, the cardiovascular and central nervous systems).

Acute pancreatitis can be further subdivided into mild and severe:(2) in the mild form, the disease causes little organ dysfunction and the body recovers more or less on its own; in the severe form, the disease causes multiple organ failure, tissue death, abscesses and pseudocysts. Pseudocysts are discussed below.

How Common is Acute Pancreatitis?

Studies show that approximately 70% of the cases of acute pancreatitis are related to gallstones or alcohol abuse.(3) Other causes account for another 20%, and about 10% of cases have no known cause. It is not known why and how some cases of acute pancreatitis lead to the chronic form of the disease.

There is uncertainty as well about how common acute pancreatitis really is. Estimates range from 5 people per 100,000 all the way up to 73 per 100,000. The reason for this is that pancreatitis is easy to miss or misdiagnose. Also, many people do not seek medical attention because their symptoms are mild or because of limited access to medical care.

Alcohol abuse is more commonly associated with male cases than female cases, whereas gallstone disease is more commonly associated with female cases. For this reason, the total number of acute pancreatitis cases, and the disease's distribution by sex, in different areas of the world have a lot to do with local alcohol customs and the prevalence of gallstones.

How the Disease Works

As stated above, the majority of people with acute pancreatitis either abuse alcohol or suffer from gallstones. We do not know, however, whether these factors actually cause acute pancreatitis directly. Significant progress, however, has been made in understanding how the disease works once it has started.(4)(5) Researchers are moving closer to identifying targets for therapy at the cellular level and, hopefully, this will soon lead to the development of more effective drugs to treat acute pancreatitis.

How Acute Pancreatitis Is Diagnosed

A person with acute pancreatitis most commonly seeks treatment for severe abdominal pain, sometimes radiating to the back. The pain is often accompanied by nausea and vomiting. Other symptoms may include rapid heart rate, low blood pressure and dehydration. Rarely, people with acute pancreatitis will have bruising around the belly button (Cullen's sign) or on the outside of the upper thigh (Grey Turner's sign) which suggest the presence of what is called hemorrhagic (bleeding) pancreatitis.

Where there are symptoms and signs of acute pancreatitis, tests such as measures of serum enzymes and pancreatic imaging studies (i.e., ultrasound, CT) are needed to establish the diagnosis. Table 1 presents an overview of the diagnostic tests.

Table 1.

Standard Diagnostic Tests.

Test	Sensitivity	Specificity	Comment
Serum enzymes	high	moderate	> 3x normal increases specificity
Ultrasound	moderate	high	Best for gallstones
CT	moderate	high	Detects calcifications, fluid collections
CT with pancreatic protocol and IV contrast	moderate	high	Detects necrosis

Adapted from (3), www.gastroslides.org

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