Pancreatitis: Causes, Symptoms, and Treatment of Acute and Chronic Pancreatitis

Pancreatitis can generally be divided into two forms:

• acute and
• chronic pancreatitis

Acute pancreatitis is a very painful, one-time, and sudden onset inflammation of the pancreas.

In over 80% of cases, the course of the disease is mild and self-limiting, resolving without significant long-term complications. 

In contrast, the severe form involving necrosis (tissue death) is a potentially life-threatening condition. This is called necrotizing infectious pancreatitis. It requires intensive medical care. Numerous complications can arise in such cases.

In the acute form of pancreatitis, physicians distinguish between:

• infectious and 
• non-infectious pancreatitis

The determining factor is the cause of the disease. Non-infectious causes of pancreatitis, such as excessive alcohol consumption and gallstones, are the most common triggers, accounting for 80% of cases.

Possible causes of infectious pancreatitis include viruses (such as mumps or Coxsackie viruses, etc.).

Chronic pancreatitis, on the other hand, occurs repeatedly with acute flare-ups of pancreatitis over an extended period of time. It leads to irreversible damage to the pancreas due to the progressive destruction of pancreatic tissue.

As a result, the enzyme deficiency leads to malabsorption and fatty stools. It also leads to what is known as pancreatic-deficient diabetes mellitus due to additional damage to the endocrine portion of the pancreas.

Pancreatitis is a relatively rare condition. However, its incidence has been rising worldwide in recent decades. 

In Germany and Central Europe, between 10 and 20 people per 100,000 inhabitants develop acute pancreatitis each year. Women are affected slightly more often than men.

Chronic pancreatitis occurs at a rate of about 8–10 new cases per 100,000 inhabitants. Men are affected more frequently than women.

In children and adolescents, a hereditary pancreatic disorder may also occur; in such cases, doctors refer to it as chronic hereditary pancreatitis.

In over 80 percent of cases, acute pancreatitis is caused by either:

• by gallstones moving through the common bile duct or 
• by alcohol abuse 

Other possible, though far rarer, causes that can contribute to pancreatitis include:

• Medications
• Viral infections
• Metabolic disorders
• Hereditary factors
• Malformations of the pancreatic ducts or
• damage to the pancreas caused by injury or surgery

In some rare cases, no cause can be identified as an indication of acute pancreatitis. Doctors then refer to this as idiopathic acute pancreatitis. 

The following causes are responsible for chronic pancreatitis, listed in descending order of importance:

• chronic alcohol abuse
• heavy smoking,
• metabolic disorders, and
• mechanical factors (obstruction of the pancreatic duct due to, for example, papillary tumors, etc.)

In rare cases, chronic pancreatitis can run in families and be hereditary. In these cases, genetic mutations—for example, in the digestive enzyme trypsinogen and the enzyme inhibitor SPINK1—are responsible. 

As a result, pancreatic juice becomes active prematurely within the gland, thereby triggering a chronic inflammatory reaction.

The symptoms of pancreatitis vary depending on whether the condition is acute or chronic.

Acute pancreatitis usually manifests as sudden, severe, belt-like pain in the upper abdomen that radiates to the back or chest.

The following symptoms may also occur:

• Nausea
• Vomiting
• Bloating
• Constipation and
• Fever

In addition, bowel function may be impaired, leading to the following symptoms:

• Intestinal obstruction
• Shock
• low blood pressure, and
• jaundice

In general, physicians distinguish between two forms of the disease:

• the mild form (80%) and
• the severe (20%) forms of acute pancreatitis

The mild form leads to rapid clinical improvement with appropriate treatment (fasting and fluid replacement). Complete recovery occurs.

In the severe form, tissue death (necrosis) occurs in the pancreas and surrounding areas. 

Doctors refer to this as acute necrotizing pancreatitis. In this case, the patient’s condition can rapidly deteriorate, leading to multiple organ failure. 

In this case, intensive care with mechanical ventilation, circulatory support using catecholamines, dialysis, etc., is necessary. This is therefore a life-threatening situation. 

It therefore requires treatment in a hospital as soon as possible. There, early, individually tailored treatment coordinated by an interdisciplinary team can be provided based on the severity of the condition.

Chronic pancreatitis, on the other hand, develops gradually. It typically presents with recurrent or persistent upper abdominal pain that radiates around the waist to the back. 

These symptoms may be accompanied by nausea and vomiting. Digestive problems arise due to the replacement of normal pancreatic tissue with connective tissue. 

This also leads to the following symptoms:

• Bloating
• Diarrhea
• Steatorrhea after consuming high-fat foods (exocrine pancreatic insufficiency)

This leads to weight loss.

The damaged pancreas is no longer able to produce insulin, the hormone that regulates blood sugar. 

As a result, about one-third of those affected develop diabetes mellitus as a consequence of chronic pancreatitis. 

Doctors refer to this as pancreatic diabetes mellitus, since the body no longer produces the hormone glucagon.

To diagnose acute pancreatitis, the doctor first asks the patient about their medical history during a medical history interview. 

This is followed by a physical examination. If the patient reports typical symptoms, gallstones, or excessive alcohol consumption, the doctor can already make a preliminary diagnosis.

A blood test is performed to confirm the diagnosis. The doctor has the levels of the pancreatic enzymes amylase and/or lipase in the blood measured so that treatment can be initiated accordingly.

Based on this triad (typical medical history, symptoms, and laboratory tests), the doctor can diagnose “acute pancreatitis.”

Since patients present to the doctor with acute symptoms, an abdominal ultrasound is usually performed. 

This can reveal, for example, gallstones, which help confirm the cause of gallstone-induced acute pancreatitis. Since the pancreas is located in the posterior abdomen and the abdomen is often distended, an ultrasound may not be conclusive.

Consequently, however, it is important to correctly assess the severity and thus the course of the disease. 

The distinction between mild and severe forms of acute pancreatitis is made by:

• measuring inflammatory markers and C-reactive protein (CRP), as well as
• contrast-enhanced computed tomography (CT)

The following imaging techniques are currently used to diagnose chronic pancreatitis:

• Endosonography
• CT
• Magnetic resonance imaging (MRI) combined with imaging of the bile and pancreatic ducts (MRCP)

These techniques reveal calcifications—a typical sign of chronic pancreatitis—and ductal abnormalities (e.g., stones in the pancreatic duct and ductal dilations).

In addition, a specialized endoscopic examination of the pancreatic duct and bile ducts, known as ERCP, is available. 

This is a procedure that can trigger pancreatitis. For this reason, it is now used only when specifically indicated. 

When indicated, doctors can remove stones from the pancreatic and bile ducts. In cases of jaundice, they insert a stent to drain bile.

In cases of a calcified tumor of the pancreatic head associated with chronic pancreatitis, doctors cannot rule out a malignant tumor with absolute certainty. Such a tumor can occur in up to 5% of cases with this condition.

In addition to these changes in organ structure and ducts, doctors assess the exocrine and endocrine function of the pancreas.

Doctors assess digestive function through a preliminary exocrine test by measuring stool elastase levels. 

The following procedures are available to assess endocrine blood glucose regulation:

• Measurement of fasting blood glucose and the 24-hour blood glucose profile
• Oral glucose tolerance test and
• Long-term blood glucose level (HbA1c)

Acute pancreatitis can be life-threatening in severe cases. Treatment therefore always takes place in a hospital. 

Mild cases can be treated on a general ward. Patients with severe acute pancreatitis, however, require intensive care in the ICU.

The patient is initially treated with antispasmodic medications to relieve the severe pain in the upper abdomen associated with acute pancreatitis and to facilitate drainage through the bile ducts

Treatment for acute pancreatitis involves fasting and the administration of adequate fluids and pain relievers. 

With these therapeutic measures, mild pancreatitis heals quickly, and the patient can resume eating soon.

Afterward, the exact cause must be determined. In cases of gallstone-induced pancreatitis, doctors should remove the gallbladder during the course of treatment. This is usually accomplished using a minimally invasive procedure.

In severe acute pancreatitis, digestive juices cause damage to the pancreas and the surrounding tissues. 

Doctors refer to this as necrotizing acute pancreatitis. In such cases, the focus of intensive care is initially on treating the effects on other organs: the lungs, kidneys, and heart.

It is not uncommon for these patients to require mechanical ventilation, dialysis, and medications to stabilize circulation. 

In cases of severe acute pancreatitis, treatment follows the so-called step-up approach: less invasive procedures are used initially, followed, if necessary, by drainage with irrigation or transgastric necrosectomy. If this is unsuccessful, minimally invasive or open surgery is required. Treatment is provided on an interdisciplinary basis in specialized general and visceral surgery clinics. Patients often require a long stay in the intensive care unit and the hospital. Despite modern methods, the mortality rate for necrotizing acute pancreatitis remains high at 10–20%.

Treatment of an acute flare-up of chronic pancreatitis is similar to that for acute pancreatitis.

In chronic pancreatitis, the patient must first avoid the factors that lead to the disease. 

This usually means permanently abstaining from alcohol and nicotine. 

Exocrine pancreatic insufficiency can be treated with enzyme capsules. In cases of endocrine insufficiency accompanied by pancreatic diabetes mellitus (type 3c diabetes mellitus), insulin therapy is administered.

Due to the chronic nature of this form of the disease, problems gradually increase. It has been shown that early surgical intervention leads to a more favorable course of the disease. 

Therefore, pancreatic surgeons should be involved in an interdisciplinary approach. This is an important recommendation in the current guidelines for the treatment of chronic pancreatitis.

A range of surgical procedures is available, each tailored to the individual patient’s case, including:

• Segmental resection
• Duodenum-preserving pancreatic head resection
• Whipple procedure and others

Mild acute pancreatitis usually progresses without complications and heals completely with proper treatment. However, in cases of acute pancreatitis caused by gallstones, the gallbladder should be removed laparoscopically. The severe form of the disease, involving necrosis, remains life-threatening; despite modern medical interventions, the mortality rate is 10–20%. Patients often require further interventional or surgical procedures as well as lifelong follow-up care at specialized centers for general and visceral surgery.

Chronic pancreatitis, on the other hand, leads to permanent damage to pancreatic tissue, resulting in exocrine and endocrine insufficiency. This causes digestive problems, diabetes mellitus, and complications affecting neighboring organs. Surgical interventions can slow the progression of the disease, but close medical monitoring remains necessary. In addition, the possibility of a pancreatic tumor should always be considered.