The pancreas is a glandular organ located transversely in the upper abdomen on the posterior abdominal wall. It is around 15 centimeters long and weighs 70 to 100 grams. The pancreas produces digestive enzymes (exocrine function) and hormones (endocrine function).
The location of the pancreas (bottom right) in the body © nerthuz | AdobeStock
The two most important functions of the pancreas include
- the release of over 20 different enzymes necessary for digestion into the duodenum and
- the release of the hormones insulin and glucagon, which are necessary for controlling blood sugar levels.
If the pancreas is inflamed, doctors refer to it as pancreatitis or pancreatitis. The exocrine functional side of the gland is primarily affected.
There are two main types of pancreatitis: acute and chronic pancreatitis.
Acute pancreatitis is a very painful, one-off and sudden inflammation of the pancreas.
In over 80 % of cases, the course is mild and self-limiting, which heals without any significant long-term consequences. In contrast, the severe form with necrosis (dying tissue) is a potentially life-threatening disease. Patients must then be treated in an intensive care unit. Numerous complications can occur in such cases.
In the acute form of pancreatitis, doctors differentiate between infectious and non-infectious pancreatitis. The decisive 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 (mumps or coxsackieviruses, etc.).
Chronic pancreatitis, on the other hand, occurs several times with acute pancreatitis attacks and over a longer period of time. It leads to irreversible damage to the gland due to the increasing destruction of the pancreatic tissue.
As a result, the lack of enzymes in the food leads to digestive disorders with fatty stools. Due to the additional damage to the endocrine part, it also leads to so-called pancreoprivic diabetes mellitus.
Pancreatitis is a rather rare disease. However, it has been on the rise worldwide in recent decades. In Germany and Central Europe, between 10 and 20 people per 100,000 inhabitants suffer from acute pancreatitis every year. Women are affected slightly more frequently than men.
Chronic pancreatitis occurs in around 8-10 new cases per 100,000 inhabitants. Men are affected more frequently than women.
In childhood and adolescence, a hereditary pancreatic disease can also occur, which is then referred to as chronic hereditary pancreatitis.
Acute pancreatitis is caused in over 80 percent of cases either by migrating gallstones in the common bile duct or by alcohol abuse. Other possible, but much rarer causes of pancreatitis include
- Medication,
- viral infections,
- metabolic disorders,
- hereditary factors,
- malformations of the pancreatic ducts or
- damage to the pancreas due to injury or surgery.
In some rare cases, no cause can be determined; doctors then speak of ideopathic acute pancreatitis.
Pancreatitis can be caused by gallstones © bilderzwerg | AdobeStock
In descending order of importance, chronic pancreatitis is mainly caused by chronic alcohol abuse and
- heavy smoking,
- metabolic disorders and
- mechanical factors (pancreatic duct obstructions caused by e.g. papillary tumors, etc.).
are responsible.
In rare cases, chronic pancreatitis can run in families and be inherited. In these cases, gene mutations, e.g. in the digestive enzyme trypsinogen and the enzyme inhibitor SPINK1, are responsible. As a result, the pancreatic juice becomes prematurely active in the gland, causing a chronic inflammatory reaction.
The symptoms of pancreatitis vary depending on whether it is an acute or chronic form of the disease.
Acute pancreatitis usually manifests itself in the form of sudden, severe girdle-shaped pain in the upper abdomen, which can radiate to the back or chest. Also
- Nausea,
- vomiting,
- flatulence,
- constipation and
- fever
may occur. In addition, it can lead to restricted bowel function and even intestinal obstruction, shock, low blood pressure and jaundice.
In principle, there are two different forms of the disease: Mild (80 %) and severe (20 %) acute pancreatitis.
The mild form leads to rapid clinical improvement with appropriate therapy (abstinence from food and fluid replacement) and complete healing.
In the severe form, tissue destruction (necrosis) occurs in the gland and the surrounding area. This is referred to as acute necrotizing pancreatitis. This can quickly lead to further deterioration of the patient's condition with multiple organ failure. In this case, maximum intensive therapy with ventilation, circulatory support with catecholamines and dialysis, etc. is necessary. It is therefore a life-threatening disease.
It therefore always requires the fastest possible treatment in hospital. Depending on the degree of severity, early, interdisciplinary, individualized treatment can be carried out here.
Chronic pancreatitis is typically characterized by repeated or persistent upper abdominal pain that can radiate into the back like a belt. It can be accompanied by nausea and vomiting. Digestive problems occur due to the connective tissue remodeling of the pancreas with destruction of the normal tissue. This is accompanied by
- Flatulence,
- diarrhea, and
- fatty stools when eating fatty foods (exocrine pancreatic insufficiency).
This results in weight loss.
The damaged pancreas is no longer able to produce the blood sugar-regulating hormone insulin. This is why around a third of those affected develop diabetes mellitus as a result of chronic pancreatitis. This is referred to as pancreoprivic diabetes mellitus, as the counter-regulating hormone glucagon is also no longer produced.
To diagnose acute pancreatitis, the doctor first asks the patient about their medical history as part of a medical history interview. This is followed by a physical examination. If the patient reports the symptoms typical of pancreatitis as well as gallstone disease or excessive alcohol consumption, this already provides the doctor with a suspected diagnosis of pancreatitis.
A blood test is then carried out to confirm the diagnosis. Among other things, the values of the pancreatic enzymes amylase and/or lipase are determined in the blood.
With this triad (typical medical history, symptoms and laboratory test), the diagnosis of "acute pancreatitis" can be made.
As patients come to the doctor and clinic with acute symptoms, an ultrasound of the abdomen is usually performed. Gallstones, for example, can be found to confirm the cause of gallstone-related acute pancreatitis. As the pancreas is located in the posterior abdominal cavity and the abdomen is often distended, ultrasound cannot provide a good indication of inflammation in the pancreas.
Subsequently, however, it is important to correctly assess the severity of the disease and thus its progression. The distinction between mild and severe forms of acute pancreatitis is made by
- determination of the inflammation value and the C-reactive protein (CRP) as well as
- contrast-enhanced computed tomography (CT).
For the diagnosis of chronic pancreatitis, imaging procedures such as
- Endosonography,
- CT and
- magnetic resonance imaging(MRI) combined with visualization of the bile and pancreatic ducts (MRCP)
are used. These can be used to visualize calcifications as a typical sign of chronic pancreatitis and duct changes (e.g. stones in the pancreatic duct and duct dilatation).
A special endoscopic examination of the pancreatic duct and the bile ducts, known as ERCP, is also available. This is an invasive procedure which has a particular risk of triggering pancreatitis and is therefore used selectively today. If indicated, stones can be removed from the pancreatic and bile ducts. In the case of jaundice, a stent is inserted to drain the bile.
In the case of a calcified pancreatic head tumor in chronic pancreatitis, a malignant tumor cannot be ruled out with absolute certainty. This can occur in up to 5 % of cases with this disease.
In addition to these changes in organ structure and function, the exocrine and endocrine function of the pancreas are also checked. Gross exocrine testing of digestive performance is checked by determining stool elastase. For the endocrine blood sugar regulation, the
- measurement of fasting blood glucose and the daily blood glucose profile,
- the oral glucose load test and
- the long-term blood glucose value (HbA1c)
are available.
Acute pancreatitis can be life-threatening if it is severe . Treatment is therefore always carried out in hospital. A mild form can be treated on a normal ward. Patients with severe acute pancreatitis, on the other hand, require maximum intensive care in an intensive care unit.
Acute pancreatitis is treated by abstaining from food and administering sufficient fluids and painkillers. With these basic therapeutic measures, mild pancreatitis heals quickly and the patient can resume eating quickly.
It is then necessary to determine the exact cause. In the case of gallstone-related pancreatitis, the gallbladder should be removed during the course of the disease - this is usually achieved using the minimally invasive method.
The gallbladder above the pancreas, on the right with gallstones © Henrie | AdobeStock
In severe acute pancreatitis, the digestive juice damages the gland and the area surrounding the pancreas. This is referred to as necrotizing acute pancreatitis. The initial focus of maximum intensive care is on treating the effects on the other organs: lungs, kidneys and heart.
These patients often have to be ventilated, dialyzed and their circulation supported with medication. If organ insufficiencies persist, the areas of necrosis that form are subjected to a so-called "step-up approach". This means that less invasive measures are initially taken and more invasive measures are only taken if necessary.
Patients with severe acute pancreatitis should therefore be treated in specialized clinics. Here, large-lumen drainage with irrigation and necrosectomies performed via the stomach (transgastric necrosectomy) are used.
If none of this is successful, minimally invasive and open necrosectomies are used. This means that the best individual treatment concept must be used on an interdisciplinary basis, depending on the extent of the disease.
In contrast to the past, pancreatic surgeons are much less involved in acute pancreatitis. However, one can imagine that these patients often have a very long intensive care and hospital stay.
Despite all good measures, this severe form of the disease is still associated with a high mortality rate of 10-20%.
An acute attack of chronic pancreatitis, which is usually mild, is treated in a similar way to acute pancreatitis.
In the case of chronic pancreatitis, the patient must first avoid the causes leading to the disease . As a rule, this means permanently abstaining from alcohol and nicotine. Pain is treated according to an adapted pain concept. Exocrine pancreatic insufficiency must be treated with enzyme capsules. In the case of endocrine insufficiency with the occurrence of pancreoprivic diabetes mellitus (diabetes mellitus type 3c), insulin therapy is administered.
Insulin therapy is necessary if diabetes develops as a result of pancreatitis © Sherry Young | AdobeStock
The chronic course of this form of the disease causes increasing problems. It has been shown that early surgical intervention can have a positive effect on the course of the disease. Pancreatic surgeons should therefore be involved at an early stage on an interdisciplinary basis. This has been included as an important recommendation in the current guideline for the treatment of chronic pancreatitis.
A number of procedures are available for surgical treatment, each adapted to the individual patient case, including
- Segmental resection,
- Duodenum-preserving pancreatic head resection,
- Whipple operation and others.
Mild acute pancreatitis usually does not result in any complications or long-term damage. With the right treatment, it usually heals quickly and completely. The prognosis is therefore favorable. However, in the case of acute pancreatitis caused by gallstones, the gallbladder should always be removed laparoscopically during the course of the disease.
In the severe form with necrosis formation, this is still a life-threatening disease. Despite all staged maximum therapeutic measures, the mortality rate is unfortunately 10-20%!
If this disease is overcome, defects often heal and further interventional and/or surgical interventions are required. In most cases, this form requires lifelong follow-up and medical care by a gastroenterologist and in specialized centers.
Chronic pancreatitis is characterized by irreversible damage to the pancreatic tissue. In addition to chronic pain, the loss of tissue leads to exocrine and endocrine pancreatic insufficiency. The inflammatory process also causes local complications in neighboring organs.
Surgical interventions can mitigate the progression of the disease and problems in neighboring organs and structures. Here too, as with acute necrotizing pancreatitis, lifelong medical supervision is necessary. The prognosis is good if the treatment measures are strictly tailored to the individual case and are carried out optimally. Early mortality is not to be deplored.
However, the possibility of the development of a malignant tumor should always be considered in chronic pancreatitis.