Pancreatitis — Acute and Chronic

What Is Pancreatitis?

Pancreatitis is inflammation of the pancreas, an organ located behind the stomach that produces digestive enzymes and hormones. The condition occurs when digestive enzymes become activated prematurely within the pancreas itself, causing the organ to digest its own tissue. Pancreatitis can present as an acute episode or as a chronic, progressive disease.

Acute Pancreatitis

Acute pancreatitis is a sudden episode of pancreatic inflammation that can range from mild (most cases) to severe and life-threatening. The majority of patients recover fully with appropriate treatment, but approximately 20% develop a severe form with organ failure or local complications.

Chronic Pancreatitis

Chronic pancreatitis is a long-standing inflammatory condition that leads to irreversible damage to the pancreatic tissue, with progressive fibrosis, calcification, and loss of both exocrine and endocrine function.

Causes

Acute Pancreatitis

• Gallstones — the most common cause (approximately 40% of cases). A gallstone migrating through the common bile duct can temporarily obstruct the pancreatic duct at the ampulla of Vater.
• Alcohol — the second most common cause (approximately 30%). Typically requires prolonged, heavy consumption.
• Hypertriglyceridemia — triglyceride levels above 1000 mg/dL can trigger acute pancreatitis
• Post-ERCP pancreatitis — occurs in 3-5% of ERCP procedures
• Medications — azathioprine, valproic acid, ACE inhibitors, and others
• Autoimmune pancreatitis — a distinct entity responsive to steroid therapy
• Pancreatic duct anomalies — pancreas divisum, annular pancreas
• Idiopathic — no identifiable cause in approximately 15-25% of cases

Chronic Pancreatitis

• Chronic alcohol consumption — the predominant cause in Western countries
• Genetic factors — mutations in PRSS1, SPINK1, CFTR genes
• Autoimmune
• Obstructive — ductal strictures, tumors
• Recurrent acute pancreatitis — repeated episodes can progress to chronic disease

Symptoms of Acute Pancreatitis

• Severe upper abdominal pain — typically of sudden onset, radiating to the back, worsening after eating
• Nausea and vomiting — often persistent
• Abdominal tenderness and distension
• Fever and rapid heart rate
• In severe cases: signs of organ failure (respiratory distress, kidney failure, circulatory shock)

Diagnosis

Acute pancreatitis is diagnosed when at least two of three criteria are met:

• Characteristic abdominal pain
• Serum lipase or amylase elevated to more than three times the upper limit of normal
• Imaging findings consistent with pancreatitis (CT scan, MRI, or ultrasound)

Additional investigations include:

• Abdominal ultrasound — essential to evaluate for gallstones as a cause
• CT scan with contrast — typically performed 48-72 hours after symptom onset to assess severity, necrosis, and complications
• MRCP — to identify bile duct stones or pancreatic duct abnormalities
• Endoscopic Ultrasound (EUS) — EUS can detect small gallstones, microlithiasis, and early chronic pancreatitis changes that other imaging may miss

Treatment of Acute Pancreatitis

• Aggressive intravenous fluid resuscitation — the cornerstone of initial management
• Pain management — adequate analgesic therapy, often requiring intravenous medications
• Nutritional support — early oral feeding (within 24 hours) if tolerated; enteral nutrition via nasojejunal tube if oral intake is not possible
• Treatment of the underlying cause — addressing gallstones, stopping causative medications, treating hypertriglyceridemia
• Monitoring — close observation for organ failure and local complications (pseudocysts, pancreatic necrosis, walled-off necrosis)
• Antibiotics — not routinely used; reserved for documented infections such as infected pancreatic necrosis

The Role of ERCP in Biliary Pancreatitis

For patients with acute biliary pancreatitis (caused by gallstones), ERCP plays a critical role:

• Urgent ERCP (within 24 hours) is indicated when cholangitis (bile duct infection) is present alongside biliary pancreatitis
• Early ERCP (within 72 hours) is considered when bile duct obstruction persists
• ERCP with sphincterotomy clears bile duct stones and reduces the risk of recurrent pancreatitis
• Cholecystectomy should be performed during the same hospital admission or within 2-4 weeks to prevent recurrence

Chronic Pancreatitis Management

• Pain management — a stepwise approach from simple analgesics to specialized interventions (EUS-guided celiac plexus block)
• Pancreatic enzyme replacement therapy (PERT) — essential for managing exocrine insufficiency and malabsorption
• Diabetes management — monitoring and treating pancreatic (type 3c) diabetes
• Endoscopic therapy — ERCP for pancreatic duct stones and strictures; extracorporeal shock wave lithotripsy (ESWL) for large ductal calculi
• Surgical options — lateral pancreaticojejunostomy (Puestow procedure), or resection in selected cases

Diet After Pancreatitis

• Start with clear liquids, progressing to a low-fat diet as tolerated
• Eat small, frequent meals (5-6 times daily)
• Limit dietary fat to 30-50 grams per day initially
• Avoid alcohol completely — this is essential regardless of the cause
• Take pancreatic enzyme supplements as prescribed, with every meal and snack
• Ensure adequate intake of fat-soluble vitamins (A, D, E, K) with supplementation if needed
• Stay well hydrated

When to Seek Emergency Care

• Sudden, severe upper abdominal pain radiating to the back
• Persistent vomiting unable to keep down fluids
• Fever above 38.5 C with abdominal pain
• Jaundice accompanying abdominal pain
• Signs of dehydration (dizziness, decreased urine output)
• Rapid heartbeat and low blood pressure

Living with Chronic Pancreatitis

Chronic pancreatitis requires lifelong management and lifestyle adjustments. Absolute alcohol avoidance is paramount. Smoking cessation is equally important, as smoking accelerates disease progression. Regular follow-up with a gastroenterologist ensures timely management of complications, optimization of enzyme replacement therapy, and screening for pancreatic cancer (which is increased in chronic pancreatitis). Nutritional counseling and psychological support are valuable components of comprehensive care.