Pancreatitis and pancreatic insufficiency

What causes pancreatitis?

Acute pancreatitis has a long list of causes. The 2 most common causes of pancreatitis are:

(i) gallstones pancreatitis: a gallstone from the gallbladder migrates into the common bile duct. If the stone is big enough and settles in the wrong place, it can obstruct the main pancreatic duct. This causes a backup of pancreatic enzymes in the pancreas causing irritation, inflammation and damage to the pancreas.

(ii) alcohol-induced pancreatitis: the toxicity of alcohol damages the cells of the pancreas bringing them on a pathway of inflammation and ‘ auto-digestion ’. Alcohol can cause both ‘acute’ episodes of pancreatitis, as well as ‘chronic’ pancreatitis. The latter is generally caused by high levels of drinking over a long period of time is characterized by scarring and poor function.

Other causes of pancreatitis are:
-Medications – classically antibiotics, diuretics, and immunosuppressants.
-High triglycerides in the bloodstream
-High Calcium in the bloodstream
-Viruses – e.g. mumps and HIV
-Autoimmune diseases – e.g. lupus, IgG4 related disease
-Genetic diseases – e.g. cystic fibrosis

What are the symptoms of pancreatitis?

The most common symptoms of acute pancreatitis include:
(i) Pain – while this can vary in intensity it is often moderate to severe. Classically, the pain will start in the upper-mid abdomen and radiate to the back. Usually the pain is severe enough to require hospitalization.
(ii) Nausea +/- vomiting

Chronic pancreatitis can follow an episode of acute pancreatitis or it can slowly develop without a severe episode of acute pancreatitis. Chronic pancreatitis will often cause a persistent low grade pain in the upper central part of the abdomen that is worsened by eating. Nausea and bloating after eating are common symptoms.

If the chronic pancreatitis persists long enough, pancreatic insufficiency can occur. In pancreatic insufficiency, the pancreas does not have the ability to produce enough enzymes to adequately digest foods. The result is a chronic feeling of indigestion and bloating, followed by diarrhoea. The most difficult to digest foods are fatty foods. Pancreatic insufficiency will may also result in weight loss, micronutrient deficiencies, and can cause secondary diabetes.

How do you diagnose pancreatitis?

The diagnosis of acute pancreatitis is typically made in the Emergency Department (ED). It involves a clinical assessment by the doctor, blood testing, and diagnostic imaging (ultrasound and/or CT scan).
The diagnosis of acute pancreatitis requires 2 out of 3 of the following criteria (Atlanta criteria):
– abdominal pain suggestive of pancreatitis
– an elevated pancreatic enzyme level
– radiological imaging showing an inflamed pancreas.

A search for the underlying cause is also conducted. This will help guide treatment and help prevent recurrence.

Chronic pancreatitis/pancreatic insufficiency is typically assessed in clinic. Bloodwork and diagnostic imaging will be done. The 3 main objectives in the clinic are:
1) Find and treat the underlying cause of pancreatitis (if it has not already been identified)
2) Assess for complications of pancreatitis. The main complication that occurs is the formation of pancreatic cysts. These cysts can obstruct pancreatic drainage channels and put a significant amount of pressure on the stomach causing pain and nausea.
3) Test pancreatic function: The best test is the 72hour faecal fat test. In this test, a set amount of fat is ingested over a 3 day period. Stool tests are taken and the average amount of fat remaining in the stool is calculated. If there is more than 7g of fat per 100g of stool, the diagnosis of pancreatic insufficiency is made. In severe cases, the insulin producing capacity of the pancreas may also be impaired, therefore all patients are also screened for new onset diabetes.

How is pancreatitis treated?

The treatment of acute pancreatitis involves supportive care. This includes pain relief, aggressive fluid resuscitation and carefully managing other organ dysfunction such as kidney failure.  Most patients with acute pancreatitis require hospitalization.

The underlying cause of pancreatitis will also be treated:

1. Gallstones: if found to be blocking the pancreas, they may need to be removed using a procedure called ERCP. Paul Urquhart at Gastro IQ specializes in these procedures and has completed advanced training overseas in both advanced ultrasound techniques (see section on endoscopic ultrasound) and ERCP.  Once the stones are removed, the gallbladder will also need to be removed surgically (at a later date) to prevent future episodes of pancreatitis.
2. Alcohol: acute withdrawal symptoms are often best managed in hospital with a longer-term alcohol cessation strategy developed collaboratively.
3. Offending medications will be substituted with safe medications.
4. High triglycerides will be treated with a combination of dietary modification and lipid lowering medications.
5. Viral infections will be treated with anti-virals and autoimmune diseases will be treated with appropriate immunosuppressants.
6. Children with cystic fibrosis will be put into a cystic fibrosis treatment program that will treat all aspects of the disease.

Diligent follow is essential to monitor for complications related to acute pancreatitis.

For chronic pancreatitis there are several key aspects to management:

1. adequate pain relief
2. appropriate dietary and nutritional support – with chronic pancreatitis and pancreatic insufficiency, a specialized diet that consists of eating easy to digest fats, proteins, and carbohydrates may help alleviate symptoms as well as promote a healthy weight. A discussion with an experienced dietitian is essential in this setting.
3. pancreatic enzymes can also be used to help the pancreas digest foods. It’s important this is done with your doctor (or specialist) to get advice on the right dose and the right formulation.
4. monitoring for and treatment of complications such as pancreatic cysts and pancreatic cancer

Finally, if you are a smoker, and you have chronic pancreatitis, it is recommended that you stop smoking.  There is considerable evidence that smoking prolongs inflammation of the pancreas and is a key factor in development of pancreatic cancer.