Pancreatitis

What the pancreas does

The pancreas makes digestive enzymes that travel through ducts into the small intestine, and hormones such as insulin that control blood sugar. In pancreatitis, enzymes become active inside the pancreas and start to digest it, causing inflammation, swelling and, in severe cases, tissue death.

Acute vs chronic pancreatitis

See acute pancreatitis and chronic pancreatitis for more detail on each.

Symptoms

Acute pancreatitis

• Sudden, severe pain in the upper middle or upper left belly, often spreading to the back
• Pain that may ease slightly when leaning forward and worsens after eating
• Nausea and vomiting
• Tender, swollen belly
• Fever and fast heart rate
• In severe cases: low blood pressure, breathlessness, confusion and reduced urine

Chronic pancreatitis

• Recurring or persistent upper belly pain
• Steatorrhea: pale, oily, foul-smelling stools that are hard to flush, from poor fat digestion (pancreatic insufficiency)
• Weight loss and malnutrition
• Diabetes as insulin-producing cells are lost

Causes

• Gallstones: the most common cause of acute pancreatitis. A stone blocks the shared opening of the bile and pancreatic ducts.
• Alcohol: heavy drinking over years is a leading cause of both acute and chronic pancreatitis. See alcohol use disorder.
• Very high triglycerides, usually above 1,000 mg/dL.
• Procedures: ERCP (an endoscopic procedure on the bile and pancreatic ducts).
• Medicines: including azathioprine, valproate, some diuretics, and others.
• High calcium (hypercalcemia), often from overactive parathyroid glands.
• Smoking: an independent risk factor, especially for chronic pancreatitis.
• Genetic causes, including cystic fibrosis gene variants and hereditary pancreatitis.
• Autoimmune pancreatitis.
• Injury to the abdomen and, rarely, tumors blocking the duct.

Diagnosis

Acute pancreatitis is diagnosed when at least two of the following are present:

1. Typical upper belly pain
2. Blood lipase (or amylase) more than 3 times the upper limit of normal
3. Characteristic findings on CT, MRI or ultrasound

Other tests:

• Ultrasound of the gallbladder to look for gallstones
• Liver tests, triglycerides and calcium to find the cause
• Blood tests and scoring systems to judge severity
• CT scan if the diagnosis is unclear or the patient is not improving after 2 to 3 days, to look for complications
• For chronic pancreatitis: CT or MRI (MRCP) showing calcifications or duct changes, endoscopic ultrasound, and a stool elastase test for enzyme deficiency

Treatment

Acute pancreatitis

• Hospital care with IV fluids, given in measured amounts.
• Pain control, often with IV medicines.
• Early feeding: eating by mouth as soon as tolerated, usually within 24 to 48 hours in mild cases. Tube feeding if needed in severe cases.
• Treating the cause: gallbladder removal (cholecystectomy), usually during the same hospital stay for mild gallstone pancreatitis, ERCP for a stone stuck in the bile duct with infection or blockage, lowering triglycerides, stopping alcohol and causative medicines.
• Severe pancreatitis: intensive care, treatment of organ failure, and drainage or removal of infected dead tissue when needed.
• Antibiotics are not routinely given unless infection is confirmed or suspected.

Chronic pancreatitis

• Stop drinking and smoking: essential to slow damage and reduce pain.
• Pancreatic enzyme replacement capsules with meals and snacks for fatty stools and weight loss.
• Pain management, from simple pain relievers to nerve blocks. Long-term opioid use is avoided where possible.
• Endoscopic or surgical treatment for blocked ducts, stones or pseudocysts.
• Diabetes management.
• Nutrition support: small frequent meals, vitamin supplements (A, D, E, K) and a dietitian's advice.
• Surveillance: chronic pancreatitis raises the risk of pancreatic cancer, so new symptoms such as weight loss or jaundice need assessment.

Complications

• Pseudocysts (fluid collections)
• Infected or dead pancreatic tissue (necrosis)
• Organ failure: lungs, kidneys, circulation
• Blood clots in nearby veins
• Diabetes and malnutrition
• Recurrent pancreatitis if the cause is not addressed

Outlook

About 80 percent of acute pancreatitis cases are mild and recover within a week. Severe pancreatitis with persistent organ failure has a significant mortality. Removing the gallbladder after gallstone pancreatitis and stopping alcohol greatly reduce the chance of further attacks. Chronic pancreatitis is a lifelong condition, but symptoms can be managed.

Prevention

• Limit or avoid alcohol.
• Stop smoking.
• Have your gallbladder removed if you have had gallstone pancreatitis.
• Control triglycerides with diet, medicines and diabetes management.

Frequently asked questions

What are the first signs of pancreatitis?

The first sign is usually sudden, severe pain in the upper middle belly that may spread to the back, often starting after a meal or drinking alcohol. Nausea and vomiting are common. Pain that is constant and severe needs emergency care.

What causes pancreatitis?

The two main causes are gallstones and heavy alcohol use. Other causes include very high triglycerides, certain medicines, a procedure called ERCP, high calcium, smoking, genetic conditions, autoimmune disease and abdominal injury.

Where is pancreatitis pain felt?

Pancreatitis pain is usually felt in the upper middle or upper left part of the belly, just below the breastbone, and often spreads through to the back. It may ease slightly when sitting up and leaning forward and gets worse after eating.

What should you eat after pancreatitis?

After an attack, start with small, low-fat meals as you feel able. Avoid alcohol completely. People with chronic pancreatitis should eat small frequent meals and take enzyme capsules with food if prescribed. A dietitian can help plan a balanced diet.

Can pancreatitis be cured?

Acute pancreatitis usually resolves completely, especially if the cause, such as gallstones or alcohol, is removed. Chronic pancreatitis causes permanent damage and cannot be cured, but pain, digestion and blood sugar can be managed, and stopping alcohol and smoking slows progression.