Overview
Pancreatitis is inflammation of the pancreas. Acute pancreatitis comes on suddenly and usually resolves with treatment, though severe cases can be life-threatening. Chronic pancreatitis involves persistent inflammation causing irreversible damage, leading to malabsorption and diabetes. The two most common causes are gallstones and excess alcohol.
How common is it?
Acute pancreatitis affects approximately 56,000 people per year in the UK, with about 20,000 hospital admissions. Chronic pancreatitis affects about 6 to 8 people per 100,000 in the UK.
Causes and risk factors
The pancreas is damaged by activation of digestive enzymes within the gland rather than the intestine, causing autodigestion.
Common risk factors
- Gallstones (50% of acute pancreatitis cases)
- Alcohol excess (25 to 30% of acute cases; most common cause of chronic pancreatitis)
- Hypertriglyceridaemia (triglycerides above 11 mmol/L)
- Post-ERCP procedure complication
- Medications: azathioprine, thiazides, tetracyclines, valproate
- Autoimmune pancreatitis (IgG4-related)
- Genetic: PRSS1, SPINK1, CFTR mutations in chronic/hereditary pancreatitis
- Idiopathic (10 to 20%)
Symptoms
- Severe, persistent upper abdominal pain radiating to the back (the cardinal symptom)
- Nausea and vomiting
- Fever
- Tachycardia
- Abdominal tenderness and guarding
- Severe acute pancreatitis: shock, multiorgan failure, peritonitis
- Chronic pancreatitis: steatorrhoea (fatty, pale, foul-smelling stools), weight loss, chronic abdominal pain, diabetes mellitus
When to see a doctor
Severe constant upper abdominal pain with vomiting requires immediate emergency department attendance. Acute pancreatitis is a medical emergency.
Diagnosis
Serum amylase or lipase (3 times upper limit of normal or more confirms diagnosis). CT abdomen with contrast for severity assessment and complications (necrosis). Ultrasound for gallstones. MRCP for biliary causes. HbA1c and faecal elastase in chronic pancreatitis.
Treatments
Supportive care (acute pancreatitis)
IV fluids (early aggressive fluid resuscitation is critical), analgesia, nutritional support (enteral feeding preferred over parenteral, even in severe cases), and monitoring for complications.
Gallstone treatment
Laparoscopic cholecystectomy after the acute episode resolves prevents recurrent gallstone pancreatitis. ERCP is performed if gallstones are impacted in the common bile duct.
Management of severe acute pancreatitis
ICU level care, antibiotics only if infected necrosis confirmed, and surgical or endoscopic/percutaneous drainage of pancreatic necrosis if it becomes infected (step-up approach).
Chronic pancreatitis management
Pancreatic enzyme replacement therapy (PERT) for exocrine insufficiency — taken with every meal. Insulin or oral agents for diabetes. Pain management with WHO analgesic ladder, antioxidants, coeliac plexus block, or surgical drainage for dilated pancreatic duct.
Total alcohol abstinence
Stopping all alcohol is essential in alcohol-related pancreatitis. Continued drinking dramatically accelerates disease progression.
Self-care and lifestyle
- Stop alcohol completely if alcohol is the cause (absolute requirement)
- Low-fat diet is often needed in chronic pancreatitis
- Take PERT capsules with every meal and snack, not after eating
- Smoking accelerates chronic pancreatitis progression — stop
Prevention
Abstinence from alcohol and timely cholecystectomy for gallstones prevent the majority of pancreatitis cases. Avoiding hypertriglyceridaemia reduces a preventable cause.