The pancreas produces enzymes that digest food and hormones that control blood sugar. In pancreatitis those digestive enzymes activate inside the gland itself and begin digesting it.
That mechanism explains both the severity of the pain and why the illness can become serious quickly.
Recognising an Acute Attack
The pain of acute pancreatitis is distinctive and severe.
- Severe pain in the upper abdomen, often described as boring or penetrating
- Radiating straight through to the back
- Worse lying flat, relieved somewhat by leaning forward or curling up
- Coming on over hours and remaining constant rather than colicky
- Persistent vomiting that does not relieve the pain
- Abdominal tenderness and distension
- Fever, rapid pulse and low blood pressure in severe cases
The relief from leaning forward is a useful clue. Anyone with severe constant upper abdominal pain radiating to the back should be assessed the same day through our emergency service.
The Two Dominant Causes
Gallstones and alcohol account for most cases, and identifying which applies determines what happens next.
Gallstones cause pancreatitis when a stone passes down the bile duct and obstructs the pancreatic duct where they join. Once this has happened, gallbladder removal is strongly recommended, ideally during the same admission, because recurrence risk is high.
Alcohol causes pancreatitis through direct toxic effects, typically after years of heavy intake, though a single binge can trigger an attack in a susceptible person.
Other causes include very high triglycerides, high calcium, certain medications, abdominal trauma, some infections, the procedure ERCP, and genetic factors. In a proportion no cause is found.
How It Is Diagnosed
Diagnosis requires two of three features: characteristic pain, raised enzymes, and imaging findings.
- Serum lipase raised more than three times normal, which is more specific than amylase
- Ultrasound to look for gallstones and bile duct dilatation
- CT scan, usually after forty eight to seventy two hours, since early scans underestimate severity
- Blood tests including calcium, triglycerides, liver function, glucose and inflammatory markers
- MRCP to examine the ducts in detail where a stone is suspected
Enzyme levels indicate the diagnosis but not the severity. A very high lipase does not mean a worse attack, which surprises patients looking at their reports.
Treatment of an Acute Attack
There is no drug that stops pancreatitis. Treatment is supportive, and aggressive early fluid replacement is the most important element.
- Intravenous fluids in substantial volumes in the first twenty four to forty eight hours, which improves outcomes measurably
- Pain control, often requiring strong analgesia
- Early feeding where tolerated, since prolonged starvation is no longer recommended and early nutrition improves outcomes
- Monitoring of oxygen, kidney function and blood sugar
- Treating the cause: urgent ERCP if a stone is obstructing with infection, gallbladder removal before or soon after discharge
Antibiotics are not given routinely, only where infection is proven or strongly suspected. Severe cases need intensive care, and our critical care unit manages organ support where needed.
How Severe Can It Get
Around eighty percent of attacks are mild and settle within a week. The remainder can become serious.
Severe pancreatitis involves organ failure, most commonly kidney, lung or circulatory. Parts of the gland can die, producing necrosis, which may become infected and require drainage or surgery. Fluid collections can form and persist as pseudocysts.
Warning signs of a severe course include persistent organ dysfunction beyond forty eight hours, high inflammatory markers, and extensive changes on CT. These patients need intensive monitoring from the outset.
Chronic Pancreatitis
Repeated inflammation causes permanent scarring, and the gland progressively loses function. This is a different and considerably more difficult problem.
- Chronic abdominal pain, which can be severe and difficult to control
- Steatorrhoea: bulky, pale, greasy stools that float and are difficult to flush, from failure to digest fat
- Weight loss and malnutrition
- Diabetes, as the insulin producing cells are destroyed
- Fat soluble vitamin deficiencies
Alcohol is the leading cause worldwide. In parts of India, tropical calcific pancreatitis affects younger patients without an alcohol history and presents with diabetes and pancreatic calcification.
Treatment includes pancreatic enzyme replacement with meals, pain management, diabetes control, nutritional support and complete alcohol cessation. Enzyme supplements must be taken with every meal to work.
Preventing Another Attack
What prevents recurrence depends entirely on the cause, and this is where follow up frequently falls short.
- Gallstone cause: gallbladder removal, which should not be deferred indefinitely
- Alcohol cause: complete abstinence, with support where needed
- High triglycerides: treatment with fibrates, dietary change and weight reduction
- Medication cause: stopping the offending drug
- Smoking cessation, which independently accelerates progression to chronic disease
Patients discharged after gallstone pancreatitis without arrangements for gallbladder removal have a substantial risk of a further attack within months, and the second one can be worse.
Diet After Pancreatitis
Nutrition matters both during recovery and in the long term.
- Low fat diet initially, gradually increasing as tolerated
- Small frequent meals rather than large ones
- Complete avoidance of alcohol, permanently
- Adequate protein to support recovery
- Avoiding fried and heavily oily food during recovery
- Enzyme supplements with meals where digestion is impaired
- Fat soluble vitamin supplementation where deficient
Our dietetics team works with patients through the reintroduction phase, which is often handled badly, with people either restricting excessively or returning to normal too quickly.
Severe constant upper abdominal pain going through to the back needs same day assessment. Most attacks settle with fluids and supportive care, but the essential step is identifying and treating the cause, particularly arranging gallbladder removal, so it does not happen again.
Our gastroenterology and surgical gastroenterology departments at T. Nagar manage pancreatitis and its causes.
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