Acute pancreatitis

Key symptoms of acute pancreatitis include:

• Abdominal pain: The primary symptom of acute pancreatitis is severe abdominal pain, usually located in the upper abdomen. The pain may:
• Nausea and vomiting: Patients often experience nausea and vomiting, which may accompany the abdominal pain. Vomiting is typically not relieved by eating or drinking.
• Fever: A mild fever may occur as part of the inflammatory process, though it can be more pronounced if there is an infection or complication.
• Bloating and distension: Abdominal bloating and distension may occur due to a buildup of gas and fluids in the abdomen.
• Jaundice: If the pancreatitis is caused by a gallstone obstruction or pancreatic duct obstruction, jaundice may develop.
• Increased heart rate: A rapid heart rate (tachycardia) is common, especially in severe cases, due to the inflammatory response and fluid loss.
• Low blood pressure: Hypotension (low blood pressure) may occur as a result of fluid loss from vomiting, fever, or a systemic inflammatory response.
• Dehydration: Severe vomiting, fever, and the body’s inflammatory response can cause significant fluid loss, leading to dehydration and electrolyte imbalances.

Key diagnostic methods include:

• Blood tests:
  • Elevated levels of pancreatic enzymes are the hallmark of acute pancreatitis. The key enzymes measured are:
    1. Amylase: Levels rise quickly after the onset of pancreatitis but return to normal within 48-72 hours.
    2. Lipase: This enzyme remains elevated for a longer period, typically up to 7 days, and is more specific to pancreatitis than amylase.
  • Other markers: White blood cell (WBC) counts and liver enzyme, blood glucose, and creatinine levels may also be elevated.
• Imaging Studies:
  • Abdominal ultrasound: This is the first imaging test used to check for gallstones, which are a common cause of acute pancreatitis, and to rule out other conditions such as liver disease or bile duct obstruction.
  • CT scan (Computed Tomography): A contrast-enhanced CT scan is often used to evaluate the severity of acute pancreatitis and detect complications such as pseudocysts, necrosis, or infection. It is also useful in identifying complications like pancreatic duct rupture.
  • MRI/MRCP (magnetic resonance imaging): MRI or Magnetic Resonance Cholangiopancreatography (MRCP) can help identify bile duct or pancreatic duct obstructions, and assess the severity of inflammation.
  • Endoscopic Ultrasound (EUS): EUS can be helpful in identifying gallstones, pancreatic masses, or ductal abnormalities, and is often used when other imaging methods are inconclusive.

Treatment of acute pancreatitis generally involves supportive care, management of complications, and addressing the underlying cause. The specific approach depends on the severity of the condition.

• Initial supportive care:
  • Fasting: The patient is typically not allowed to eat or drink (NPO, "nothing by mouth") for the first 24-48 hours to rest the pancreas and reduce further irritation.
  • Intravenous (IV) Fluids: Dehydration is common due to vomiting, fever, and third-spacing of fluid. Aggressive fluid resuscitation with IV fluids is essential to maintain blood pressure and organ perfusion.
  • Electrolyte correction: Correcting any electrolyte imbalances, such as hypokalaemia or hypocalcaemia, is crucial for recovery.
  • Pain management: Analgesics, particularly acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), are used to manage mild to moderate pain. Severe pain may require stronger medications such as opioids.
• Management of the underlying cause:
  • Gallstone pancreatitis: If gallstones are the cause, patients may require endoscopic retrograde cholangiopancreatography (ERCP) to remove the stones or drain bile if there is a bile duct obstruction.
  • Alcohol-induced pancreatitis: The first step is abstinence from alcohol. Patients may also benefit from nutritional support and treatment for any withdrawal symptoms.
  • Hypertriglyceridemia: In cases where high triglyceride levels are the cause, lipid-lowering agents, such as fibrates or statins, are used, and the patient may need plasmapheresis if triglyceride levels are very high.
• Nutritional support:
  • Once pain and inflammation are controlled, and bowel function returns, oral feeding can be gradually reintroduced. This is typically done with a low-fat diet to minimise stress on the pancreas.
  • In more severe cases, patients may require enteral nutrition (via a feeding tube) if oral intake is not possible.
• Treating complications:
  • Pseudocysts: If a pancreatic pseudocyst develops and causes symptoms or complications, it may require drainage via endoscopic, percutaneous, or surgical approaches.
  • Infection: Infection of pancreatic necrosis may require antibiotics or drainage procedures.
  • Organ failure: Severe cases of acute pancreatitis can result in multi-organ failure, including kidney failure, respiratory failure, or shock, which requires intensive care.
• Surgical intervention:
  • In rare cases where complications like infected pancreatic necrosis or perforation occur, surgical intervention may be necessary, including drainage, necrosectomy (removal of dead tissue), or even resection of the pancreas.

While acute pancreatitis may not always be preventable, certain measures can reduce the risk:

• Avoiding excessive alcohol consumption.
• Maintaining a healthy diet to control triglyceride and cholesterol levels.
• Treating underlying conditions like gallstones or hypertriglyceridemia early to prevent recurrence.
• Regular follow-ups for patients with a history of acute pancreatitis to monitor for complications.