Pancreatitis – Acute Pancreatitis and Inflammation of the Pancreas

The pancreas is a glandular organ in the human body located transversely in the upper abdomen against the posterior abdominal wall. It is about 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 are:

• secreting over 20 different enzymes necessary for digestion into the duodenum and
• secreting the hormones insulin and glucagon, which are necessary for regulating blood sugar levels

If the pancreas is inflamed, doctors refer to this as pancreatitis. The exocrine portion of the gland is primarily affected.

In general, pancreatitis can be divided into two categories:

• 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 condition takes a mild, self-limiting course and resolves without significant long-term consequences. In severe cases involving necrosis (tissue death), however, it is a potentially life-threatening condition. Patients then require intensive 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 can 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, but far less common, causes of 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. Doctors then refer to this as idiopathic acute pancreatitis. 

Pancreatitis can be caused by gallstones © bilderzwerg | AdobeStock

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. They depend on whether the condition is acute or chronic. Acute pancreatitis usually presents with 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%) form 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. It is therefore a life-threatening condition.

It therefore requires treatment in a hospital as soon as possible. Depending on the severity, early, interdisciplinary, and individually tailored treatment can be provided there. Chronic pancreatitis typically presents with recurrent or persistent upper abdominal pain that radiates around the waist to the back. It may be accompanied by nausea and vomiting. Digestive problems arise due to the formation of connective tissue in the pancreas, which destroys normal tissue. 

This also leads to the following symptoms:

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

This results in weight loss.

The damaged pancreas is no longer able to produce insulin, the hormone that regulates blood sugar. Consequently, about one-third of those affected develop diabetes mellitus as a result of chronic pancreatitis. Doctors refer to this as pancreoprive diabetes mellitus, since the body no longer produces the hormone glucagon.

To diagnose acute pancreatitis, the doctor first interviews the patient about their medical history as part of a medical history review. 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.

To confirm the diagnosis, a blood test is performed. The doctor has the levels of the pancreatic enzymes amylase and/or lipase in the blood measured. Based on this triad (typical medical history, symptoms, and laboratory tests), the doctor can diagnose “acute pancreatitis.”

Since patients with acute symptoms visit the doctor, an abdominal ultrasound is usually performed. This can reveal, for example, gallstones to 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 of the disease and thus its course. 

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

• Measurement of 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 changes in the ducts (e.g., stones in the pancreatic duct and duct dilations). In addition, a specialized endoscopic examination of the pancreatic duct and bile ducts is available, known as ERCP. 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 evaluate exocrine digestive function using a stool elastase test. 

The following procedures are available for assessing 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 intensive care unit.

Treatment for acute pancreatitis involves fasting and the administration of adequate fluids and pain medication. With these therapeutic measures, mild pancreatitis heals quickly, and the patient can resume eating soon. The next step is to determine the exact cause. 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.

The gallbladder above the pancreas, on the right, with gallstones © Henrie | AdobeStock

In severe acute pancreatitis, digestive juices cause damage to the gland and the surrounding tissue. Doctors refer to this as necrotizing acute pancreatitis. Initially, the focus of intensive care is 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. The treatment of developing areas of necrosis, in cases of persistent organ failure, follows the so-called “step-up approach.” 

This means that less invasive measures are used first, with invasive measures employed only when necessary. Patients with severe acute pancreatitis should therefore be treated at specialized hospitals. Here, the placement of large-area drains with irrigation and necrosectomies (transgastric necrosectomy) are performed.

If these measures are unsuccessful, minimally invasive and open necrosectomies are performed. Treatment is interdisciplinary. Unlike in the past, pancreatic surgeons are now called upon significantly less often in cases of acute pancreatitis. However, it is easy to imagine that these patients often require a very long stay in the intensive care unit and the hospital. Despite all appropriate measures, this severe form of the disease is still associated with a high mortality rate of 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 trigger 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 pancreoprive diabetes mellitus (type 3c diabetes mellitus), insulin therapy is administered.

If diabetes develops as a result of pancreatitis, insulin therapy is necessary © Sherry Young | AdobeStock

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 disease course. 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 does not result in complications or long-term damage. With proper treatment, it typically heals completely and quickly. The prognosis is therefore favorable. However, in cases of acute pancreatitis caused by gallstones, the gallbladder should always be removed laparoscopically. In severe cases involving necrosis, the condition remains life-threatening. Despite all possible therapeutic measures, the mortality rate is unfortunately 10–20%!

If the patient survives this condition, defective healing often occurs, requiring further interventional and/or surgical procedures. In most cases, this form of the disease requires lifelong follow-up care and medical supervision by a gastroenterologist and at specialized centers. Chronic pancreatitis is characterized by irreversible damage to 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 slow the progression of the disease and reduce problems affecting neighboring organs and structures. Here, too—as with acute necrotizing pancreatitis—lifelong medical follow-up is necessary. The prognosis is good if treatment measures are strictly tailored to the individual case and carried out optimally. Early mortality is not a concern.

However, physicians should always consider the possibility of a malignant tumor in cases of chronic pancreatitis.

Acute inflammation of the pancreas is a serious condition that often develops suddenly and causes severe pain. Severe acute pancreatitis and necrotizing pancreatitis, in particular, can be life-threatening in severe cases and may require intensive care. Typical symptoms include severe pain in the upper abdomen, which often radiates around the waist to the back and appears suddenly. Acute pancreatitis is frequently caused by gallstones or triggered by excessive alcohol consumption.

In addition to these common triggers, there are other causes of the acute form, such as pancreas divisum or inflammation of the bile ducts, which can trigger pancreatitis. Statistically, per 100,000 people, this condition affects a certain number annually, with pancreatitis developing and, in some cases, progressing to an acute or chronic form. Chronic pancreatitis is a long-term inflammatory condition that can lead to digestive disorders and permanent damage to the pancreas.

Acute pancreatitis is diagnosed based on typical symptoms, laboratory test results, and imaging studies; early diagnosis of the acute condition is essential. Treatment for acute pancreatitis is usually provided in a hospital setting to prevent complications. In severe cases, surgical treatment may also be necessary, for example, at a clinic specializing in general and visceral surgery. The goal of treatment is to relieve pain and prevent the disease from progressing.

In the long term, treatment of chronic pancreatitis is also crucial to preserving pancreatic function as much as possible. The disease affects a central organ of digestion, which is why damage to the pancreas can have far-reaching consequences. Overall, it is clear that early diagnosis and consistent treatment are crucial, as pancreatitis often develops gradually or presents with sudden symptoms and, if left untreated, can lead to serious complications.

What is pancreatitis?

Pancreatitis is an inflammation of the pancreas that can be acute or chronic. Acute pancreatitis occurs suddenly and is a serious condition.

What are the most common causes of acute pancreatitis?

The most common causes include gallstones and alcohol consumption. Pancreatitis caused by gallstones is often the result of a blocked bile duct.

What are the symptoms of pancreatitis?

Typical symptoms include severe pain in the upper abdomen, nausea, and vomiting. The pain may radiate around the waist to the back and come on suddenly.

How is acute pancreatitis treated?

Acute pancreatitis is usually treated in a hospital. Depending on the course of the disease, pain medication, fluid therapy, or even surgical intervention may be used.

When is pancreatitis dangerous?

Severe acute pancreatitis or necrotizing pancreatitis can be life-threatening. In severe cases, intensive care is necessary.