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Acute pancreatitis is the result of too early activity of pancreatic proenzymes, which lead to self-digestion of this organ. In about 80% of cases, acute pancreatitis is associated with diseases of the bile ducts (gallstones) or alcohol abuse.
Acute pancreatitis is a disorder of the mechanisms that inhibit or stabilize the activity of enzymes in the follicular cells of the pancreas, which in turn activates enzymes around the pancreas. These enzymes cause the pancreas and adjacent organs to self-digest.
The result may be complete destruction of the pancreas, or internal hemorrhage, caused by the digestion of blood vessel walls and the gastrointestinal tract by active enzymes.
The pancreas is an organ that produces pancreatic juice and hormones that influence the body’s carbohydrate metabolism. Pancreatic juice is drained from the pancreas into the duodenum, where it is involved in the digestion of fat and protein from food. In abnormal conditions, the pancreas and surrounding tissues are self-digested as a result of the activation of proenzymes within the organ. Self-digestion automatically causes local inflammation in the area of the pancreas or general inflammation when other organs are also damaged. Inflammation is caused by premature activation of pancreatic proenzymes.
In most cases, the disease is mild. However, there are fatal cases (about 20-30%). The patient’s death occurs very early, even a week after the onset of the first symptoms, due to multi-organ failure. Death also occurs from sepsis around the third week of the disease, which also leads to an inflammatory reaction and thus an infection that may result in organ failure or dysfunction.
Acute pancreatitis – causes
Severe pancreatitis can be influenced by any factor that causes problems with the secretion of enzymes as a result of damage to the pancreatic alveoli. In most patients, the disease appears as a complication of gallstone disease and due to excessive alcohol consumption. The greatest number of cases is observed in patients between 50 and 70 years of age
Other causes of acute pancreatitis can include:
- viral infection,
- abdominal trauma,
- taking certain medications,
- complications after examination of the bile ducts and pancreas (ERCP),
- increase in blood triglycerides
- congenital defects in the development of the pancreas,
- human roundworm infection,
- autoimmune ailments,
- gene mutations: SPINK1, PRSS1, CFTR, promoting intracellular activation of pancreatic enzymes.
We speak of idiopathic pancreatitis when the etiology of the disease is unknown.
The incidence of acute pancreatitis
Obtaining reliable information is quite difficult, because if the doctor does not perform the appropriate tests, it can go unrecognized. In different parts of the world, the incidence of acute pancreatitis ranges from 10 to 44 cases per 100 inhabitants per year. In recent years, an increase in the number of cases of acute pancreatitis, which is mainly caused by gallstone disease, has been observed. Thanks to the increasing knowledge of doctors and the performance of specialized laboratory tests, it is possible to determine the activity of pancreatic enzymes in the blood and urine (even in unclear cases). Thanks to this, it is possible to diagnose acute pancreatitis.
Acute pancreatitis – symptoms
• sudden, severe abdominal pain radiating to your back (usually lasts more than a day, comes on suddenly and gradually gets worse),
• very intense vomiting,
• suspension of gas and stools,
• fairly rapidly increasing abdominal distension,
• drop in blood pressure,
• acceleration of the heart rate,
• often reddish color of the face.
Observation of the above symptoms requires immediate medical attention. Until an appropriate diagnosis is made, the patient should refrain from eating. You can drink a small amount of neutral fluids.
Acute pancreatitis – diagnosis
The diagnosis of acute pancreatitis is based on medical historyconcerning the symptoms mentioned above, on the results of the physical examination and on the laboratory tests. The signs of acute pancreatitis are primarily high fever, which occurs in most patients; soreness and tension of the abdominal wall during compression; tachycardia, no or less peristalsis. The main symptom reported by the patient is severe upper abdominal pain lasting several hours.
Some patients also develop jaundice during the disease, which is caused by obstructed drainage of bile.
W laboratory tests the activity of serum and urine amylase and serum lipase are determined. The magnitude of the increase in these parameters is not related to the severity of acute pancreatitis. An attack of acute pancreatitis for several days can cause serum and urine amylase levels to be low or even normal. On the other hand, a high concentration of bilirubin and an increase in alkaline phosphotase and aminotransferase suggest that the cause of the symptoms is gallstone disease.
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The causes of acute pancreatitis are also searched for on the basis of blood lipids and calcium levels. Patients should be monitored for the levels of electrolytes, creatinine and urea, which determine the functioning of the kidneys. It is also important to test glucose, which is significantly elevated when inflammation destroys the pancreatic parenchyma where insulin is produced. Hematocrit values below 47% may indicate high blood concentration caused by the exudation of plasma components into the body cavities. Leukocytosis is the result of an inflammatory process and the accompanying infection, and a C-reactive protein concentration below 150 mg / dL indicates a severe form of acute pancreatitis.
Imaging studies in the diagnosis of acute pancreatitis include:
- Ultrasound (helps to find the cause of acute pancreatitis, but is not used to assess the severity of the disease);
- computed tomography of the abdominal cavity;
- X-ray of the chest (checks for pulmonary complications) and the abdominal cavity (reveals signs of perforation, gallstone disease and signs of intestinal and gastric peristalsis paralysis);
- endoscopic ultrasound (EUS) – helps to find the causes of acute pancreatitis;
- ERCP with sphincterotomy of the hepatopancreatic bulb sphincter – performed in the case of biliary etiology of severe pancreatitis
Treatment of acute pancreatitis
In acute pancreatitis, intensive treatment is required in a surgical ward, often in an intensive care unit. Surgical treatment is required in seriously ill patients who have not been improved by conservative treatment, especially those with complications such as infected necrosis, pancreatic abscess, or diffuse peritonitis.
Mild acute pancreatitis is treated with a short-term fasting which usually lasts about four days. During this time, the patient should be rehydrated intravenously and given painkillers. Once the nausea, vomiting and abdominal pain have subsided, the patient can re-feed by mouth.
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If, in a mild form, the examination revealed the presence of cholelithiasis, removal of the gallbladder or endoscopic cutting of the hepatopancreatic bulb sphincter should be performed.
The situation is different if the acute pancreatitis is severe – then intensive medical care is necessary. Serious complications can develop, and the goals of treatment are to control the blood congestion, treat pulmonary / kidney complications, and prevent and treat infections. To this end, the patient is rehydrated in the early stages of the disease and is given painkillers. Patients with a severe form of the disease should be properly nourished, the most common is enteral or combined (enteral and parenteral) nutrition. If there is an infection, it is necessary to take antibiotics.
Doctors monitor the patient for possible complications:
- pseudocysts,
- bleeding inside the abdomen
- infection,
- abscess,
- fistulas,
- multi-organ failure.
Good medical care often requires the cooperation of a gastroenterologist with a surgeon and an anesthesiologist.
1. Mild acute pancreatitis usually resolves in all patients and leaves no complications in the abdominal organs. This is the case with single attacks of inflammation where the underlying cause (e.g. gallstones) has been removed. This helps to avoid relapse.
(2) Severe acute pancreatitis is associated with a certain percentage of deaths. It is possible to completely cure patients who undergo an acute attack of the disease due to the large functional reserve of pancreatic tissue. In some cases, after the end of treatment, long-term insulin therapy and replacement therapy with pancreatic enzymes (about a year) are needed.
What after treatment?
First of all, the patient should eliminate heavy foods and alcohol from his diet. In a situation where the cause of the disease was gallstone disease, after the inflammation subsides, the patient should undergo appropriate therapy for the treatment of gallstone disease within a few months. Patients after acute pancreatitis are recommended to be treated with pancreatic enzyme preparations, most often for a period of about 1 year after the episode of pancreatitis.
Prophylactically, you can drink an infusion of the pancreas – a mixture of herbs that supports the proper functioning of the pancreas.
If you know the cause of acute pancreatitis, avoid this factor. It is worth noting that obesity significantly increases the risk of gallstone disease, and in patients with acute pancreatitis – a more severe course of the disease.
It is therefore important to maintain a healthy body weight. Patients who abuse alcohol should be referred for specialist therapy.