Pancreatitis is the term used to describe inflammation of the pancreas. When inflammation of the pancreas occurs suddenly, i.e., sharply, we are facing an acute pancreatitis.
When inflammation is recurrent and there are persistent signs of pancreatic lesion, it is called chronic pancreatitis.
The pancreas is a large flattened gland, about 20 cm in length, located in the abdomen, behind the stomach. It has a close connection with the bile ducts and with the duodenum (the first part of small intestine).
The pancreas has two basic functions: it participates in the process of food digestion and produces important hormones to control blood glucose (blood glucose level), such as insulin and glucagon.
Location of the pancreas
The pancreas produces enzymes that help in the digestive process of proteins, fats and carbohydrates. These digestive enzymes, diluted in a solution called the pancreatic juice, are released directly into the duodenum where they will find food fresh from the stomach. The pancreatic juice is also rich in bicarbonate, which serves to neutralize the acidity of food coming from the stomach, which has a very low pH.
Similarly to the power stimulating the production of pancreatic juice to aid in the digestion of nutrients, it also induces the production of hormones that are released into the bloodstream. The two main hormones synthesized by the pancreas are glucagon and insulin produced by a group of cells called the islets of Langerhans.
Insulin is the hormone that allows cells to capture and use blood glucose as energy source. The main stimulus for insulin production is the increase in blood glucose levels that usually occurs after meals. When blood glucose rises, insulin produced by the pancreas, is released into the bloodstream, allowing cells capture the glucose that is coming from food.
If for some reason there is no insulin, there is no way the cells consume glucose in the blood, thereby leaving a constant high rate of blood glucose. This process gives rise to the famous diabetes.
Glucagon is a hormone antagonist of insulin, or carrying the inverse function of the latter. When glucose levels are too low, the pancreas prevents the release of insulin, and stimulates the production of glucagon, which also prevents the uptake of glucose by the cells, and acts on the liver by stimulating the production of glucose.
When glucose levels rise again, glucagon levels begin to fall and the insulin rises. Thus, the pancreas can always keep our glucose rate in the range of 60 mg/dl to 140 mg/dl, even after meals.
The digestive enzymes produced in the pancreas only become active after they reach the duodenum. Pancreatitis occurs when for some reason, these enzymes are activated while they are still within the pancreas, causing it to begin to be digested.
In over 75% of cases, acute pancreatitis occurs due to alcohol abuse or a bladder stone, which gets stuck in the output of the pancreatic duct, preventing drainage of enzymes into the duodenum.
Other less common causes of acute pancreatitis include:
Hypertriglyceridemia - pancreatitis can occur when triglyceride levels are very high, surpassing the barrier of 1,000 mg/dl
Hypercalcemia - high levels of blood calcium can also cause acute pancreatitis
Drugs - some drugs, such as azathioprine, corticosteroids, pentamidine, metronidazole, clomiphene, pravastatin, valproic acid, omeprazole, losartan, tamoxifen, isoniazid, furosemide and enalapril have been described as causes of pancreatitis. The relationship between cocaine and marijuana with the occurrence of acute pancreatitis is also well known
HIV and other infections such as cytomegalovirus, mumps, salmonellosis, amebiasis, toxoplasmosis, etc. can also attack the pancreas
The universal symptom of acute pancreatitis is abdominal pain. The pain tends to be located diffusely in the upper abdomen and may radiate to the back. Normally it is a pain triggered and worsened by eating. Unlike biliary colic, which also often appears after eating and lasts 6-8 hours, the pain of acute pancreatitis can last for several days. Another feature of the pain of acute pancreatitis is its partial relief when the patient bends forward.
The pain usually comes accompanied by nausea and vomiting in 90% of cases and can be so intense that the patient seeks medical attention quickly. However, there are cases of acute pancreatitis with not that intense pain, which is often difficult to diagnose because the patient delays seeking medical help.
The alcoholic acute pancreatitis is more common in individuals who drink chronically and usually appears within 24 to 72 hours after an episode of drinking.
Acute pancreatitis in over 80 % cases is cured with time and with medical assistance. In some patients, however, it can turn into a medical emergency. In more severe cases, inflammation can be so intense that spreads throughout the body, giving the patient a picture of circulatory shock and multiple organ failure.
The diagnosis of pancreatitis is usually done with blood from two dosage pancreatic enzymes that are very high in cases of inflammation of the pancreas: amylase and lipase.
Computed tomography (CT) is an important complementary examination, not only to help in the diagnosis of doubtful cases, but also to assess the presence of complications such as necrosis and abscesses in the pancreas. Through the CT it is possible to find out the severity of pancreatitis from A to E, with A being the lightest and E with a severe signs of complications.
In general, all patients with acute pancreatitis should remain hospitalized. If the case is mild to moderate, resolution is spontaneous.
In this initial period, the patient must remain in fast for at least 3 to 7 days, since the food stimulates the production of pancreatic enzymes, which further damage the pancreas. For patients not to be malnourished, enteral feeding is needed. For this purpose we introduce a probe into the small intestine causing the food reach the intestines only after the duodenum and thus do not stimulate the production of pancreatic enzymes. But if patients show signs of pancreatitis activity even with enteral nutrition, the solution is parenteral nutrition administered through the veins.
As the pancreas will regenerate, oral feeding can be reintroduced slowly.
If the cause of acute pancreatitis is gallstone obstruction, they must be removed surgically or endoscopically. Since the recurrence of acute pancreatitis by biliary calculi reaches 50 %, the most suitable solution is the removal of the vesicle, which makes the formation of new calculations an unusual event.
In more severe cases, the infection and / or extensive necrosis of the pancreas, antibiotics and surgery to remove the dead tissue may be required. As has been previously mentioned, sometimes the picture is so intense that the patient develops hypovolemic shock, renal and pulmonary complications requiring patient to stay in an ICU.
If acute pancreatitis is too long or if the patient has repeated episodes of acute pancreatitis, this intense and repeated inflammation can cause irreversible damage to pancreatic tissue, leading to what we call chronic pancreatitis.
The main cause of chronic pancreatitis is excessive and prolonged alcohol consumption. However, any situation requiring repeated cases of acute pancreatitis can lead to permanent damage of the pancreas.
As in acute pancreatitis, the main symptom of chronic pancreatitis is abdominal pain. However, in chronic pancreatitis pain is recurrent and does not disappear after a few days. The patient is usually very emaciated, as if feeding poorly, since the act of eating exacerbates the pain. The pain usually occurs after meals and lasts 30 minutes on average.
The pain in chronic pancreatitis is usually less intense than in acute pancreatitis and 20% of patients report feeling little or no pain. However, there can be periods of exacerbation of chronic pancreatitis, especially if the patient continues to drink. The patient can live more or less well with their chronic pancreatitis, but when they drink, similar crises of acute pancreatitis occur.
As the disease progresses, with permanent injury to the pancreas tissue, it starts to gradually decrease its ability to produce the enzymes responsible for the digestion of food. Thus, even if the pain does not impede the food, the patient cannot digest it so it could be absorbed and eventually the patient loses weight the same way.
When more than 90% of the pancreatic tissue is injured patient completely loses the ability to absorb dietary fats, emerging the framework of greasy diarrhea, called steatorrhea. The steatorrhea is characterized by stools mixed with fat droplets.
Following the same reasoning, the pancreas becomes unable to produce insulin and glucagon, leading the patient to a framework for diabetes mellitus.
Other complications of chronic pancreatitis include the formation of cysts around the pancreas, biliary tract obstruction and ascites.
In the radiograph above we can see a whole calcified pancreas, a sign of serious injury, indicating tissue healing by chronic pancreatitis.
Patients with chronic pancreatitis have a higher risk of developing pancreatic cancer.
Treatment of chronic pancreatitis is aimed at controlling pain and symptoms of pancreatic failure. It is imperative to stop the consumption of alcohol. The diet should be controlled, avoiding fatty foods, which primarily stimulate the onset of pain.
Patients with malabsorption syndrome need to take pancreatic enzyme supplements. Patients with diabetes need insulin.
In cases where pain cannot be relieved by drugs, pancreatic surgery may be necessary. In general, there is no cure for chronic pancreatitis. As has been already mentioned, the treatment is aimed at giving quality of life to the patient.
