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Pancreatitis

Dr Vivian Oputa

Pancreatitis is an inflammation of the pancreas that occurs when it is attacked by digestive enzymes from the small intestine. Pancreatitis can be acute (occurring suddenly, lasting a few days) or chronic (developing gradually and may persist for several years). Both forms of pancreatitis may present with mild to severe abdominal pain, nausea, vomiting and fever.

They may also lead to severe complications including death. The pancreas is an important organ for the digestion of food and regulation of metabolism. It is a long flat gland that lies behind the stomach between the duodenum (the upper small intestine) and the spleen. It produces digestive enzymes that break down protein, carbohydrate and fat in the small intestine and secretes the hormones Insulin and Glucagon that control blood glucose levels.

Most of the pancreas is made up of exocrine cells which produce the digestive enzymes and juices that flow through a series of ducts to the duodenum. The bile duct that carries bile from the gallbladder and liver connects to the pancreatic duct just before it empties into the duodenum. The pancreas also has small islands of endocrine cells within the exocrine tissue known as islets of Langerhans which secrete the hormones Insulin, Glucagon and Somatostatin.

Acute pancreatitis is sudden in onset with mild to severe upper abdominal pain which may radiate to the back and chest and is worsened by eating or consuming alcohol. The pain may be temporarily relieved by bending forward or curling into a foetal position. Nausea, vomiting and fever may accompany the pain and in severe cases, internal bleeding, dehydration, low blood pressure and shock and even death may result. Chronic pancreatitis on the other hand develops gradually and may present with abdominal pain or no pain at all. It is as a result of ongoing damage to pancreatic tissue. Other symptoms may include, bloating and flatulence, weight loss despite adequate food intake, oily offensive stools (steatorrhoea) due to malabsorption of fat and nutrients and the development of Diabetes .

In Hereditary pancreatitis the genetic defect that causes this condition is present at birth but symptoms don’t usually develop until the first or second decade of life. The disease is marked by recurrent acute attacks of pain, nausea, vomiting and fever lasting between 2 days and 2 weeks which eventually progress to chronic pancreatitis. Note that mild acute pancreatitis doesn’t usually affect the digestive process or glucose metabolism and blood sugar levels. A severe acute attack can damage the pancreas and trigger chronic pancreatitis with associated damage to the cells that produce enzymes and hormones.

Primary causes of acute and chronic pancreatitis include long term heavy alcohol abuse, smoking and the presence of gallstones. It is not clearly understood why alcohol abuse may lead to pancreatitis but it is known that the consumption of alcohol increases the permeability of the ducts to the digestive juices and this leakage damages the organ’s tissue. Alcohol also leads to the formation of protein plugs that block parts of the ducts. Gallstones form when bile is chemically unbalanced and these can migrate to the common bile duct and lead to blockage of the pancreatic duct which in turn leads to the backflow of digestive juices that end up digesting healthy pancreatic tissue.

Some cases may be due to genetic mutations or the use of certain drugs while no cause may be found in others. Other factors that may lead to the development of pancreatitis include hyperlipidaemia (increased blood levels of fatty triglycerides) and hypercalcaemia (high levels of calcium); Medications such as NSAIDs (Non steroidal anti-inflammatory drugs), corticosteroids, antibiotics such as tetracycline and sulfonamides and thiazide antihypertensives; abdominal surgery; infections such as mumps, hepatitis and Epstein-Barr virus and bacterial infections; pancreatic cancer which can lead to the obstruction of the pancreatic ducts and diseases like cystic fibrosis.

Mild attacks of acute pancreatitis often resolve spontaneously or with dietary changes while more severe cases require urgent medical attention to avoid fatal complications. Most cases of pancreatitis are likely due to a combination of genetic and environmental factors.

In diagnosing acute pancreatitis, blood tests may be done to check for elevated levels of pancreatic enzymes, lipase and amylase; an elevated white blood cell count; elevated blood glucose; elevated liver enzymes and bilirubin; and low blood calcium which may result from this condition. It is also necessary to visualise the pancreas by ultrasound or computerised tomography (CT) scan to check for structural problems, the presence of gallstones or duct blockage. Chronic pancreatitis may require investigations such as the blood tests mentioned above, stool tests to check for fat content, ultrasound, x-rays and pancreatic function tests.

Pancreatitis may be complicated by bacterial infection from the intestinal tract, the development of pseudocysts as a result of blocked ducts, abscess formation, bleeding, shock, respiratory failure, Diabetes, Malnutrition and weight loss, pancreatic cancer and death. Patients may also become addicted to pain medications used to relieve the pain associated with this condition.
Treatment is aimed at reducing the associated pain and allowing the pancreas to rest thus restoring the normal balance of pancreatic juices. Ingestion of food and fluid is stopped (because the pancreas goes to work as soon as food is consumed) and intravenous fluid and nutrition therapy is commenced. Chronic alcohol abuse, smoking and drug dependency must be addressed and gallstones should be treated to help relieve blockage. Chronic pancreatitis has the additional problem of malabsorption for which enzyme therapy is given. Diet should be modified to reduce fat intake and Diabetes should be treated if it develops. Steps that can be taken to reduce the risk of developing pancreatitis include, reducing alcohol consumption, limiting fat intake and stopping the habit of smoking.


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