What to know about pancreatitis? Acute, chronic: causes and manifestations

What is pancreatitis and how does it manifest itself?
What are the causes of acute and chronic forms, even in children?
Can it be mild or severe?
What is good for the pancreas and what is the treatment for inflammation?

Inflammation of the pancreas is technically called pancreatitis.

Pancreas = pancreas.

Pancreatitis affects a very high percentage of the human population.

Interesting:
Despite its high morbidity, it is an issue that quite often escapes the public's attention.
The reason for this is the lack of interest in the disease, which they believe is "not serious enough".

When people hear pancreatitis, their body hair stands on end because they associate it with pain and relatively short survival.
Pancreatitis is not a deterrent to them due to lack of information, and is therefore often underestimated.

Beware!
Even "ordinary" pancreatitis can lead to cancer, severe sepsis, abscess formation or internal organ failure!

Pancreatitis has several forms

Pancreatitis manifests itself in two basic forms, namely as acute pancreatitis or chronic pancreatitis. Further subdivision of the different forms of the disease is based on its severity and degree (form, advanced stage).

Table with basic and extended division of pancreatitis

Acute pancreatitis - primary non-infectious disease

Acute pancreatitis is an acute non-bacterial inflammatory disease of the pancreas caused by its auto-indigestion (self-digestion) with a subsequent inflammatory response. It has a variable course with variable damage to the surrounding tissue, but also to distant organs and tissues.

The most common causes of acute pancreatitis are:

• obstruction of the bile duct (by a stone, less often by a tumour)
• toxic influence of alcohol
• toxic influence of drugs and other substances
• metabolic diseases
• infectious diseases
• iatrogenic damage (ERCP, surgical procedures)

What is the course of acute pancreatitis?

Acute pancreatitis can occur without complications, but it can also have a complicated and very serious course. It is divided into mild acute pancreatitis and severe acute pancreatitis, depending on whether complications are associated.

With early diagnosis and treatment of the mild acute form, treatment ad integrum, i.e. complete healing of the pancreatic tissue and restoration of its functions to normal, is possible. Mortality does not exceed 2 %.

Interesting: despite advances in pancreatic diagnosis and treatment, mortality from severe acute pancreatitis is still high!

The manifestations of acute pancreatitis and treatment

The disease is manifested by severe abdominal pain localized in the upper part under the left rib arch. The pain may radiate to the surrounding area, therefore some patients report it in the entire upper abdomen, possibly with radiation to the back.

The pain is constant, severe and worsens in the supine position, i.e. lying down.

The abdominal pain is accompanied by a feeling of vomiting - nausea. The nausea is permanent or comes and goes in attacks. Typically, vomiting of gastric contents is present, with massive vomiting of bile only (yellow contents in small quantities).

Vegetative symptomatology also includes pallor of the face, flushes of cold sweat, dizziness and in more severe cases fainting, collapse.

In the severe form, the intestinal passage is quickly disturbed or even arrested, which is outwardly manifested by severe pain throughout the abdomen. The abdomen is distended, hard and painful. Stool and intestinal gas stop. A state of shock gradually develops.

A very serious symptom is Cullen's sign, which occurs in times of multiple organ failure with insufficient circulation. Cullen's sign is manifested by the appearance of subcutaneous blood pools on the front of the abdomen.

Treatment of acute pancreatitis:

• usually hospital admission is necessary (severe forms in the ICU).
• strict abstinence from alcohol
• fasting/parenteral nutrition by nasogastric tube
• sufficient fluid intake and infusion (volumotherapy)
• analgesic therapy (for pain) - paracetamol is the first choice
• antibiotics in case of secondary infection, but also preventive
• endoscopic management of pancreatic duct obstruction
• surgical - operative management of pancreatic duct obstruction
• treatment or surgical management of complications (abscess, dead tissue)

Chronic pancreatitis - an inflammatory process with irreversible damage

Chronic pancreatitis, like acute pancreatitis, is an inflammatory disease of the pancreas. Unlike its acute form, it is characterised by a prolonged inflammatory process with progressive fibrotic remodelling of the pancreas, leading to a reduction of the original functional tissue.

The gradual replacement of the pancreatic parenchyma by fibrotic tissue causes a disturbance of its exocrine as well as endocrine function.

The most common causes of chronic pancreatitis are:

• the toxic effect of alcohol in chronic use
• the toxic effect of drugs in polymorbid patients
• long-term poor dietary habits
• nicotinism
• genetic predispositions
• autoimmune diseases

How does chronic pancreatitis progress?

Chronic pancreatitis takes place over a long period of time. It is asymptomatic in the early stages of the disease, but already during this period there is inflammatory irritation of the nerve endings and increased pressure inside the pancreatic ducts and gradual fibrotic remodelling of the pancreas. The first manifestations usually come only when its function is impaired.

Interesting:
Chronic pancreatitis is on the rise everywhere in the world, despite slight geographical differences. It significantly impairs the patient's quality of life and also causes serious complications. Its danger also lies in the development of pancreatic cancer, for which it is a risk factor.

Manifestations of chronic pancreatitis and treatment

In the early stages of the disease, gradual changes in the pancreas may not be apparent. The first symptoms include, paradoxically, localised abdominal pain around the navel. It occurs after eating or after alcohol. It lasts for long hours, even days in some patients.

The pain is accompanied by vegetative symptoms such as nausea, vomiting, excessive sweating, pale face, low blood pressure or palpitations.

Patients with chronic pancreatitis have a typical stool appearance. The stool is bulky, pale (cholic), glossy due to a high content of undigested fats or undigested food debris, and has a strong to unpleasant odour. In some patients, fluid forms in the abdominal cavity - ascites.

A yellow discolouration of the skin and mucous membranes (icterus) is often observed due to pressure and obstruction of the pancreatic ducts. Gradually, the whites of the eyes become yellow (subicterus).

With the progression of the condition, frequent diarrhoea occurs. Through diarrhoea, the patient loses fluids and nutrients, i.e. dehydration is at the forefront. Eventually, malnutrition and weight loss occur. The onset of diarrhoea also signals the progression of the disease and a significant impairment of pancreatic function - insufficiency.

Treatment of chronic pancreatitis:

• Rest at home/hospitalization in hospital
• alcohol abstinence
• hunger strike/strict dietary restrictions
• sufficient fluid intake
• analgesic therapy (for pain) - tramadol is the first choice
• pancreatic enzyme supplementation in tablet form
• maintenance of gastric acid pH
• endoscopic management of pancreatic duct obstruction
• surgical - surgical management of pancreatic duct obstruction (drainage/resection)

What complications and consequences can pancreatitis cause?

Any disease, even the simplest, carries the risk of unexpected reversal and progression. The same is true for pancreatitis.

In a thousand people, it is uncomplicated and with typical symptoms. In the first thousand patients, it develops into a serious condition that puts the patient on the borderline between life and death.

In addition to the main complications of pancreatitis listed below, there are less common complications that are not described due to the rarity of their occurrence.

The most serious complication is pancreatic cancer with a high mortality rate

Malignant diseases are known to have a poor prognosis, especially when it comes to the pancreas.

Pancreatic adenocarcinoma accounts for the majority of pancreatic cancers, with few exceptions. It is characterised by rapid progression of the condition. From diagnosis to death, the patient usually has several months to live.

Almost 2% of patients are lucky to survive for 5 years. Instead of enjoying their last moments of life, patients suffer the severe pain that is typical of these cancers.

The disease, together with rapid weight loss, leaves the patient bedridden in a relatively short time.

Pancreatitis induces the formation of pancreatic cysts and pseudocysts

Pancreatic cysts and pseudocysts can be induced by pancreatitis itself, but they can also induce the development of pancreatitis.

The difference between a cyst and a pseudocyst is that a pancreatic pseudocyst does not have its own lining. It is surrounded by fibrous tissue and its cavity is filled with dead pancreatic cells, pancreatic enzymes, blood and free fluid. An abscess may form if it becomes secondarily infected.

A pancreatic cyst is also a cavity, but it has its own lining and is bordered by tissue. The centre of the cavity is filled with fluid, similar to a pseudocyst. They usually do not cause significant discomfort, but larger ones can cause abdominal pain, cyst rupture and mild bleeding.

From an innocent cyst to a pancreatic abscess

In pancreatitis, a secondary bacterial infection may occur. The bacteria produce pus, which accumulates and encapsulates to form a purulent pancreatic abscess. This may also form in a previous cyst or pseudocyst. Abscesses often arise as a late complication of pancreatic necrosis.

The risk of an abscess is its rupture and spread of infection to the surrounding area with subsequent sepsis. Pancreatic abscesses usually need to be surgically removed.

Death of pancreatic tissue - necrosis

Necrosis means the death of a specific part of the tissue. In pancreatic necrosis, either local or diffuse damage to the parenchyma occurs through a necrotic process.

Pancreatitis in which necrotic changes occur is called sterile necrotizing pancreatitis. The initially sterile necrotic lesions become secondarily infected with bacteria over a short period of time. Infected necrotizing pancreatitis is one of the most serious sudden abdominal events.

The greatest risk is a septic state, when the infection spreads to the surrounding area and a whole-body infection with multi-organ failure occurs.

Infection, whole-body sepsis, organ failure and death in the clinical picture of shock

Infection and sepsis can arise in two ways. The first way lies in the diagnosis itself - pancreatitis. The second way represents iatrogenic introduction of infection into the abdominal cavity, through surgical procedures (resection, removal of the cyst).

Regardless of the cause, this is always a very serious complication of the underlying disease.

In this case, sepsis - a whole-body infection - occurs. It attacks individual organs, which subsequently fail. Multi-organ failure occurs.

Multi-organ failure is a serious condition that is almost always fatal. The patient dies in the clinical picture of septic shock. It is characterised by low blood pressure, increased heart rate, poor blood supply and organ insufficiency, brain damage, impaired consciousness, breathing and death.

Pancreatitis in children - what you should know

Pancreatitis in children is not as common as in adults, but it is still encountered. The causes of pancreatitis in children differ to some extent from those of pancreatitis in adults, but some are the same.

Causes of pancreatitis dating back to fetal development

The origin of some pancreatitis in young children is due to the failure of the pancreas to develop during pregnancy. This is due to the failure of the middle section of the pancreas to disappear and to arise in the duodenum together with the physiological pancreatic duct.

The outlet of the middle section of the pancreas should disappear. Otherwise, it causes its outlet (but also the outlet of the gallbladder) to become frequently obstructed, causing an obstructive form of pancreatitis.

Proper embryonic development of the pancreas:
The pancreas develops with the anterior and posterior germinal leaf of the duodenum.
This curls to the right during growth. This results in the anterior portion merging with the posterior portion to form the head of the pancreas.

The body and tail of the pancreas form mainly from the posterior leaf. The individual parts and their ducts merge into one. The middle section becomes obstructed and gradually disappears.

Ultimately, the pancreatic duct, together with the gallbladder duct, exits into the duodenum.

From common childhood infections to the development of pancreatitis.

Children may not be spared from developing pancreatitis even if the pancreas has developed properly.

Another very common cause of their occurrence are infections of viral and bacterial origin, which abound in childhood.

These various infections can be uncomplicated or complicated with involvement of other organs including the pancreas. The most serious conditions end in sepsis (whole-body inflammation) progressing to septic shock and multi-organ failure.

The most common viral infections causing pancreatitis in children:

1. Influenza - known as influenza or simply the common cold, an infectious disease of the throat and respiratory tract caused by RNA virus types A and B
2. adenovirus infection - an inflammatory disease of the respiratory tract caused by adenoviruses
3. mycoplasma pneumoniae - a bacterial disease (previously thought to be a virus) causing pneumonia
4. coxsackie virus infections - an inflammatory disease affecting several organs and parts of the body, caused by coxsackie virus, a member of the RNA virus family of enteroviruses
5. mumps (parotid) - an inflammatory disease of the parotid glands, caused by an RNA virus of the paramyxovirus family
6. rubella - also known colloquially as rubella, an inflammatory disease affecting the skin (redness) caused by rubella virus of the togavirus family
7. hepatitis A and B - or hepatitis, an infectious inflammatory disease of the liver caused by various types of RNA and DNA viruses
8. Epstein-Barr virus - a human herpes virus causing a wide variety of diseases

Various causes of pancreatitis in children

The typical cause of pancreatitis in children is improper embryonic development of the pancreas. An even more common cause is viral infection. However, this is far from being the only cause of such a condition.

There are countless factors that can progress to pancreatitis and the consequences associated with it.

Less common causes of pancreatitis in children in the table