Pancreatitis

Pancreatitis refers to inflammation of the pancreas. It can be categorised as acute pancreatitis or chronic pancreatitis. This section relates mainly to acute pancreatitis. 

Acute pancreatitis presents with a rapid onset of inflammation and symptoms. After an episode of acute pancreatitis, normal function usually returns. 

Chronic pancreatitis involves longer-term inflammation and symptoms with a progressive and permanent deterioration in pancreatic function.

Causes

The three key causes of pancreatitis to remember are:

• Gallstones
• Alcohol
• Post-ERCP

Gallstone pancreatitis is caused by gallstones getting trapped at the end of the biliary system (ampulla of Vater), blocking the flow of bile and pancreatic juice into the duodenum. The reflux of bile into the pancreatic duct, and the prevention of pancreatic juice containing enzymes from being secreted, results in inflammation in the pancreas. Gallstone pancreatitis is more common in women and older patients.

Alcohol is directly toxic to pancreatic cells, resulting in inflammation. Alcohol-induced pancreatitis is more common in men and younger patients.

I GET SMASHED is a popular mnemonic for remembering a long list of causes of pancreatitis:

• I – Idiopathic
• G – Gallstones
• E – Ethanol (alcohol consumption)
• T – Trauma
• S – Steroids
• M – Mumps
• A – Autoimmune
• S – Scorpion sting (the one everyone remembers)
• H – Hyperlipidaemia
• E – ERCP
• D – Drugs (furosemide, thiazide diuretics and azathioprine)

Presentation

Acute pancreatitis typically presents with an acute onset of:

• Severe epigastric pain
• Radiating through to the back
• Associated vomiting
• Abdominal tenderness
• Systemically unwell (e.g., low-grade fever and tachycardia)

Acute pancreatitis is a clinical diagnosis, based mainly on the presenting features and the amylase level. 

Investigations

Initial investigations are required as with any presentation of an acute abdomen. Importantly these need to include those required for calculating the Glasgow score:

• FBC (for white cell count)
• U&E (for urea)
• LFT (for transaminases and albumin)
• Calcium
• ABG (for PaO₂ and blood glucose)

Amylase is raised more than 3 times the upper limit of normal in acute pancreatitis. In chronic pancreatitis it may not rise because the pancreas has reduced function.

C-reactive protein (CRP) can be used to monitor the level of inflammation. 

Ultrasound is the initial investigation of choice in assessing for gallstones. 

CT abdomen can assess for complications of pancreatitis (such as necrosis, abscesses and fluid collections). It is not usually required unless complications are suspected (e.g., the patient is becoming more unwell).

Glasgow Score

The Glasgow score is used to assess the severity of pancreatitis. It gives a numerical score based on how many of the key criteria are present:

• 0 or 1 – mild pancreatitis
• 2 – moderate pancreatitis
• 3 or more – severe pancreatitis

The criteria for the Glasgow score can be remembered using the PANCREAS mnemonic (1 point for each answer):

• P – Pa0₂ < 8 KPa
• A – Age > 55
• N – Neutrophils (WBC > 15)
• C – Calcium < 2
• R – uRea >16
• E – Enzymes (LDH > 600 or AST/ALT >200)
• A – Albumin < 32
• S – Sugar (Glucose >10)

Management of Acute Pancreatitis

Patients with acute pancreatitis can become very unwell rapidly. They require admission to supportive management. Moderate or severe cases should be considered for management on the high dependency unit (HDU) or intensive care unit (ICU). 

Management involves:

• Initial resuscitation (ABCDE approach)
• IV fluids
• Nil by mouth 
• Analgesia
• Careful monitoring
• Treatment of gallstones in gallstone pancreatitis (ERCP / cholecystectomy)
• Antibiotics if there is evidence of a specific infection (e.g., abscess or infected necrotic area)
• Treatment of complications (e.g., endoscopic or percutaneous drainage of large collections)

Most patients will improve within 3-7 days.

Complications of Acute Pancreatitis

• Necrosis of the pancreas
• Infection in a necrotic area
• Abscess formation
• Acute peripancreatic fluid collections
• Pseudocysts (collections of pancreatic juice) can develop 4 weeks after acute pancreatitis
• Chronic pancreatitis

Chronic Pancreatitis

Chronic pancreatitis refers to chronic inflammation in the pancreas. It results in fibrosis and reduced function of the pancreatic tissue. Alcohol is the most common cause. It presents with similar symptoms to acute pancreatitis, but generally less intense and longer-lasting.

Key complications are:

• Chronic epigastric pain
• Loss of exocrine function, resulting in a lack of pancreatic enzymes (particularly lipase) secreted into the GI tract
• Loss of endocrine function, resulting in a lack of insulin, leading to diabetes 
• Damage and strictures to the duct system, resulting in obstruction in the excretion of pancreatic juice and bile
• Formation of pseudocysts or abscesses

Management of Chronic Pancreatitis

Abstinence from alcohol and smoking is important in managing symptoms and complications.

Analgesia can be used to manage the pain, although it can be severe and difficult to manage. 

Replacement pancreatic enzymes (Creon) may be required if there is a loss of pancreatic enzymes (i.e. lipase). Otherwise, a lack of enzymes leads to malabsorption of fat, greasy stools (steatorrhoea), and deficiency in fat-soluble vitamins.

Subcutaneous insulin regimes may be required to treat diabetes.

ERCP with stenting can be used to treat strictures and obstruction to the biliary system and pancreatic duct.

Surgery may be required by specialist centres to treat:

• Severe chronic pain (draining the ducts and removing inflamed pancreatic tissue)
• Obstruction of the biliary system and pancreatic duct
• Pseudocysts
• Abscesses

Last updated May 2021