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What is acute pancreatitis?
Acute pancreatitis is an acute, i.e. suddenly occurring, inflammation of the pancreas. It results in damage to the cells of the pancreas, which limits its function for a temporary period. Dependent on the severity of the damage, acute pancreatitis can also lead to the death of pancreatic cells, which results in various harmful substances being secreted into the body, which in turn can cause the patient to become critically ill. As a further consequence, other organs may be attacked and their function affected.
There is a long list of possible causes of acute pancreatitis. However, in Western Europe, gallstones and excessive alcohol consumption are responsible for 90% of cases. The harmful by-products of alcohol can cause a sudden inflammation of the pancreas. If a gallstone escapes from the gall bladder into the common bile duct, it can block the pancreatic duct, which joins the common bile duct shortly before the duodenum, and this can trigger an attack of acute pancreatitis. In addition to these common causes, there is a whole host of much rarer causes, such as infections, various forms of medication, and congenital defects in the pancreatic ducts. Finally, there is also a small number of cases of pancreatitis where no cause can be found.
There are basically two forms of acute pancreatitis which can be distinguished:
1. Acute oedematous pancreatitis
2. Acute necrosing pancreatitis
1. Acute mild (oedematous) pancreatitis
Around 85% of patients suffer from this form of the disease. It causes temporary damage to the pancreas, but does not normally affect any of the surrounding organs. In most cases, the patient recovers completely from the inflammation and there is no long-term damage to the pancreas.
2. Acute heavy (necrotizing) pancreatitis
Around 15% of patients suffer from this more serious inflammation of the
pancreas. Destruction of pancreatic tissue and the failure of other organs are
typical for the more serious form of acute pancreatitis, which can become a
serious threat to the patient's life. Even if the patient recovers, often the
function of the pancreas is permanently reduced, leading to digestion disorders
and/or diabetes. The greater the amount of pancreatic tissue that is destroyed,
the more serious the loss of function.
What are the causes of acute pancreatitis?
- Sudden onset
- Severe, but dull pain in the upper abdomen (often radiating round to the back, like a belt)
- Nausea, vomiting
- High temperature
- bad general health
Complications and Risks?
Long-term effects of acute pancreatitis Apart from the functional damage to the pancreas, such as disorders of the digestion due to the under-production of digestive enzymes in the remaining part of the pancreas, or the development of diabetes mellitus due to the under-production of insulin, the following problems can arise:
1. Formation of pseudocysts
Damage to the pancreatic tissue can lead to a tear forming in the pancreatic duct system. The pancreatic juices which leak out gradually gather in or around the pancreas. This accumulation of pancreatic juices is known as a pseudocyst. Often pseudocysts disappear in the course of time without any specific treatment. On the other hand, there are pseudocysts which steadily increase in size and can eventually cause symptoms such as nausea, vomiting, pain and weight loss. In the case of pseudocysts causing these symptoms, an operation is normally required. During the operation, a part of the small intestine is sewn on to the cyst so that its contents can simply drain directly into the intestine.
2. Pancreatic Abscesses
In exceptional cases, after the acute phase of the inflammation has died down, a build-up of pus in the region of the pancreas can occur, which is called an abscess. This can cause recurrent attacks of fever. Normally it is possible to puncture the abscess under local anaesthetic and closely monitored by ultrasound or CAT, and to inset a catheter to allow the pus to drain away. If this is not successful, an operation will be required. In addition, the patient will be treated for a certain period with antibiotics.
3. Pancreatic fistula
In the course of a severe inflammation of the pancreas or following an operation made necessary by such an inflammation, a so-called fistula can form, which is a passage between the pancreas and another organ (e.g the colon) or to the outside (the skin). This can result in pancreatic secretion leaking, which can continue on for some time before spontaneously healing, or it must be treated by another operation.
Part of my pancreas has been removed - what happens now?
Patients who have had a part or the whole of their pancreas removed may experience a reduction in the functioning of their pancreas, dependent on how much of the organ has been lost. This leads to two problems, above all: · Too few pancreatic enzymes (leading to digestion problems) · Too little insulin (leading to high blood-sugar levels) These deficiencies can be rectified by taking suitable medication.
What tests and preliminary investigations must be carried out in the case of acute pancreatitis?
Inflammation of the pancreas can normally be confirmed on the basis of the symptoms and blood analysis. However, the extent and the seriousness of the inflammation must also be established. This is best done between 48 to 96 hours after the symptoms begin by means of computerised tomography. The technique and quality of the CAT must be such that a serious form of the disease, with pancreatic necrosis, can be distinguished from the less serious form of acute oedematous pancreatitis.
Treatment of acute pancreatitis
The treatment of acute pancreatitis is largely determined by the patient's symptoms and differs according to the form of the disease (mild or severe). In general, any patient with acute pancreatitis should be monitored and treated in hospital. There the patient will be given nothing to eat or drink for the first days in order to allow the pancreas to calm down. The patient will be given painkillers and fluids through an intravenous drip. In addition, the circulatory system, lungs and kidneys will be carefully monitored. Accordingly to the progress of the condition, the patient can sooner or later begin to eat light meals. If the severe form of acute pancreatitis is indicated, the patient will be treated in an intensive care ward. Dependent on the symptoms, treatment will continue for several days or even weeks.
When is an operation required?
On average, every third patient with acute pancreatitis requires an operation. If the patient's condition visibly deteriorates, a test will be carried out in which a fine needle is inserted into the pancreas. The procedure is radiologically monitored. If this "puncture" reveals bacteria or a fungal infection, an operation is necessary. The abdominal cavity is opened with either a horizontal or vertical incision, and the infected parts of the pancreas which have died off are removed. Finally several tubes are placed. These are used in the following days to flush out any remains of dead tissue or any new development thereof. In severe cases of acute pancreatitis, the patient may have to stay in hospital for a number of weeks or even months.
In addition to treating the acute symptoms, the cause of the disease must also be found. If a gallstone is responsible, then an attempt will be made to remove the stone using ERCP as early as possible. This will allow pancreatic enzymes and bile to flow into the duodenum once again and remove the immediate cause of the damage. After a patient has recovered from an attack of acute pancreatitis caused by gallstones, the gall bladder will have to be removed. In most cases, this is done by means of so-called keyhole surgery (laparoscopic cholecystectomy).
When dealing with a case of acute pancreatitis, doctors will always ask the patient about the amount of alcohol he drinks. Where alcohol is the cause, it is not always the case that the patient has been drinking to excess. There are some people who, as a result of increased sensitivity, develop acute pancreatitis after drinking only a moderate amount of alcohol. On the other hand there are people who drink to excess who never develop acute pancreatitis. Whatever the case may be, it is absolutely vital that patients who have suffered an attack of acute pancreatitis limit their alcohol consumption in future or, better still, give up alcohol altogether, even when the cause of the attack is clearly a gallstone or some other more unusual factor. Any recurrence of acute pancreatitis must be regarded as a serious danger to the patient's life.
After Care
A standard form of after care is not normally necessary, especially after an attack of the less serious form of pancreatitis. In the event of complications, such as the formation of pseudocysts or fistulae, however, patients must be given follow-up examinations by a specialised team of doctors. These check-ups usually consist of a computer tomography to determine the degree of changes and in order to plan further therapy.
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