Causes, treatment
and the consequences
of acute inflammation

• What are the causes of acute pancreatitis?
• 1. Acute oedematous pancreatitis
• 2. Acute necrotizing pancreatitis
• What are the symptoms?
• Treatment
• When is a surgery necessary
• Consequences of acute pancreatitis
• Part of my pancreas has been removed - what next?
• My spleen was removed - what happens next?

There is a long list of possible causes of acute pancreatitis. However, in Central and Western Europe, gallstones and excessive alcohol consumption are responsible for 90% of all cases. Alcohol and the products of its break-down can directly damage pancreatic tissue. If a gallstone passes from the gall bladder to the common bile duct, it can block the pancreatic duct (which merges with the common bile duct shortly before reaching the duodenum), and this can lead to acute pancreatitis. In addition to these common causes, there is a whole host of much rarer causes, such as infections, various forms of medication, and congenital defects in the pancreatic ducts. Finally, there are also a small number of cases, where to date no cause for pancreatitis has been found.

This is the milder form, and around 85% of the pancreatitis patients suffer from this form of the disease. It causes temporary damage to the pancreas, but does not normally affect any of the surrounding organs. In most cases, the patient recovers completely from the inflammation and there is no long-term damage to the pancreas.

Around 15% of the pancreatitis patients suffer from this most serious inflammation of the pancreas. Sudden widespread destruction of pancreatic tissue occurs. Furthermore, failure of other organs such as lungs and liver is frequent, often seriously endangering the patient's life. As a consequence of the disease, the function of the pancreas is in most cases permanently reduced, leading to digestion disorders and/or diabetes. Loss of function is proportionate to the amount of destruction of pancreatic tissue. In addition, dead tissue can lead to problems in the abdomen, such as pseudo-cysts, abscesses and obstruction of fluids in the bile ducts, as well as in the stomach or intestines. These complications have to be individually assessed and treated according to their severity, they often require surgery.

• Sudden onset
• Severe, dull upper abdominal pain (often radiating into the back like a belt)
• Nausea, vomiting, feeling of fullness
• Fever

Treatment of acute pancreatitis is largely determined by the patient's symptoms and varies according to the form of the disease (mild or severe). In general, patients with acute pancreatitis need to be monitored and treated in the hospital. The patient will be prevented from eating or taking fluids for a number of days to allow the pancreas to recuperate. Pain relief and fluids via intravenous drip will be administered. The circulatory system, lungs and kidneys will be monitored carefully. Nutrition can be phased in if treatment is successful. Intensive care must be administered if the severe form of acute pancreatitis is found. Restoring and monitoring organ function is imperative.

One out of three patients with acute pancreatitis requires surgery. Surgical intervention is indicated if the patient's condition deteriorates and an infection or hemorrhage is found in dead pancreatic tissue. The patient's abdomen is opened with a lengthwise incision, and infected and dead parts of the pancreas are removed to prevent further infections. Finally, drainage tubes are inserted through which the area around the pancreas is flushed to prevent further infections. In severe cases of acute pancreatitis, the patient may be required to stay in the hospital for several weeks.

Apart from treating the actual acute condition, physicians will also investigate the origin of the disease. Gallstones, if found to be the cause, will be removed with ERCP as early as possible. The flow of pancreatic enzymes and bile into the duodenum is thus restored and the immediate cause for the damage is removed. After the patient has recovered from acute pancreatitis caused by gallstones, the gall bladder will be removed. In most cases, this is done with keyhole surgery (laparoscopic cholecystectomy).

When dealing with acute pancreatitis, doctors will routinely ask about the patient's alcohol consumption. Where alcohol is the cause, excessive consumption may not always be to blame. Some people with increased sensitivity may develop acute pancreatitis after consuming moderate amounts of alcohol. Conversely, some excessive drinkers never develop acute pancreatitis. Whatever the case, it is imperative that acute pancreatitis sufferers at least temporarily discontinue their alcohol intake in the aftermath of the disease.

Apart from the functional damage to the pancreas such as digestive disorders due to the lack of digestive enzymes in the remaining part of the pancreas, or development of diabetes mellitus due to insufficient insulin production, the following problems can arise:

1. Formation of pseudocysts

Due to tissue damage of the pancreas including the destruction of entire duct sections, a loss of continuity in the pancreatic duct system can result. Leaking pancreatic fluids or blood collect in or around the pancreas. This collection of pancreatic fluids, blood, and dead tissue, which is found in or on the pancreas, is called a pseudocyst. They often disappear without any therapy; however, there are pseudocysts which get bigger and bigger resulting in complaints such as nausea, vomiting, pain, and weight loss. It can also happen that the passage of food in the stomach or intestines is hindered or the flow of bile is obstructed. Finally, there is the danger of them rupturing and emptying into the abdominal cavity. Pseudocysts causing symptoms, generally require surgery in which a section of the small intestine is opened and stitched onto such a pseudocyst, enabling the cyst contents to drain directly into the intestine. Often, an endoscopic drainage can be performed as well.

2. Pancreatic Abscesses

Sometimes, in the aftermath of an acute inflammation, an accumulation of pus can occur in the pancreas area, causing reoccurring instances of high temperature. Normally, the physician can puncture the abscess under a local anaesthetic (closely monitored by ultrasound or CAT). Pus can then be removed via catheter. If this is impossible, surgery will be required. The patient will also need antibiotic treatment.

Patients who have had part or all of their pancreas removed experience a reduction of the pancreas functions, depending on how much of the organ has been removed. This will cause the following deficiencies:

• Not enough pancreatic enzymes (digestive disorders)
• Insufficient insulin production (high blood-sugar levels)

These deficiencies can be compensated for by taking appropriate medication.

Pancreatic Enzyme Substitution

At present, drugs which substitute pancreatic enzymes are available. They must be taken with all meals and snacks. Correct doses vary from patient to patient and are determined by nature of food taken and by symptoms present in the patient. Bloated feelings and diarrhoea with excess fatty substances can be addressed and handled with these drugs. More capsules need to be taken with main meals than with snacks. Enzymes must be in direct contact with food in order to be effective and 6-12 capsules per day are needed. The doses may vary significantly and are governed by the nature of the drug (amount of enzymes contained in one capsule) and the remaining function of the pancreas.

Substitute enzymes are readily absorbed into the body and patients do not suffer side-effects. In very rare cases, the drug can cause an allergic reaction.

Insulin Substitution

If a pancreatic disorder or surgery has caused high blood sugar levels, patients will require some form of blood sugar level correction. Initially, and if levels are not severely elevated, this can be achieved by dietary measures and with medication which influence blood glucose levels. However, insulin treatment may be necessary if the amount on insulin producing cells in the pancreas has been reduced significantly. Treatment can be tailor-made to the requirements of the individual patient, as a variety of insulin types are now available. Thus, the patient's nutritional preferences can be respected. The goal of any such treatment is the well-being of the patient and efficient management of blood sugar levels. In this manner, doctors can avoid severe damage over the short and longer term. Close supervision by a GP or specialist is required in the initial phase of the treatment.

Sometimes the spleen is removed during pancreatic surgery.

It is quite possible to live without a spleen. The spleen plays a certain role in the human immune system. If it is removed, a person is more susceptible to bacterial infections. To provide protection against infection after removal of the spleen, the patient should be given certain inoculations after the operation. According to current guidelines, these inoculations should be repeated every 3 to 5 years. In addition, the patient should always seek medical help if he contracts a serious infection, and tell the doctor that he or she no longer has a spleen. The doctor can then decide whether treatment with antibiotics is required.

The removal of the spleen can also lead to a build-up of blood platelets (thrombo- cytes). It is important to have this situation regularly monitored. If the number of platelets is too high, this can lead to the thickening of the blood and a possible thrombosis. If the level is too high, your doctor will prescribe a temporary course of medication to thin the blood, in order to reduce the risk of thrombosis.