Acute and chronic pancreatitis: Pathophysiology, Causes, Symptoms, Diagnosis and Treatments.
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Pancreatitis is inflammation of the pancreas. The pancreas is both an exocrine gland producing digestive enzymes, and an endocrine gland secreting hormones that regulate blood sugar levels.
Pancreatitis can be acute or chronic:
- Acute pancreatitis develops quickly and lasts for a short time. Most people recover fully with no permanent damage but severe cases can be life-threatening.
- Chronic pancreatitis is a long-term, progressive condition that leads to gradual but irreversible damage of the pancreatic tissue, eventually resulting in loss of pancreatic functions. Patients with chronic disease may also have acute attacks.
Acute pancreatitis is typically initiated by premature activation of pancreatic digestive enzymes which normally activate only when they arrive in the intestine. Active digestive enzymes can cause auto-digestion of the pancreatic tissue and trigger inflammatory response, which may spread to other organs. Locally, this can cause edema, damage to abdominal organs, and formation of pseudocysts, which, if become infected, can be life-threatening. Once inflammation becomes systemic, multi-organ failure, with high morbidity and mortality, may result. Repeated acute attacks can also develop into chronic disease.
The leading cause of acute pancreatitis is ductal hypertension, such as when the pancreatic duct is obstructed by a gallstone, forcing digestive enzymes and proenzymes to back up and accumulate in the pancreas. Many toxins, in particular products of alcohol metabolism, can cause changes that stimulate early activation of proenzymes, or zymogens. These changes include: increased production of zymogens, weakening of zymogen granules, and increased intracellular calcium concentration. Some people may also be genetically predisposed to pancreatitis: they have mutations in genes involved in activation of trypsin, or mutations that make them more prone to ductal obstruction.
Chronic disease can eventually lead to loss of pancreatic functions which manifests as malabsorption, malnutrition, diabetes type 1, and hypoglycemia. The risk for pancreatic cancer is also increased.
The most prominent symptom is a moderate to severe upper abdominal pain that may radiate to the back. The pain is typically alleviated with sitting up or leaning forward; and worsens with lying flat, coughing, deep breathing and exercising. Pain from acute pancreatitis tends to be more severe and constant - it develops abruptly in gallstone pancreatitis; and gradually over a couple of days in alcoholic pancreatitis. Patients with chronic disease may initially experience pain episodically, typically after meals, but as the disease progresses, the pain can become constant. About 10% of chronic patients do not feel any pain.
Other symptoms of acute pancreatitis may include: nausea, vomiting, rapid heart rates, and rapid, shallow breathing. Blood pressure and body temperature may fluctuate high and low. Severe cases may present with signs of other organ failure.
Other symptoms are more subtle in chronic patients, with signs of pancreatic insufficiency develop slowly over time. These include indigestion, abdominal distention, oily stool, loss of appetite, unintended weight loss, and fatigue.
Acute pancreatitis is diagnosed based on the pain pattern, blood tests for elevated pancreatic enzymes, and imaging studies to detect swelling, fluid accumulation, gallstones, necrosis, and pseudocysts.
For chronic patients pancreatic function tests are performed to measure serum trypsinogen, fecal chymotrypsin, elastase, and fecal fat in patients with a high-fat diet. Pancreatic calcification can be detected with x-ray of the abdomen.
Treatment for acute pancreatitis is mainly supportive and typically includes intravenous fluid, pain reducer, and nutritional support. Severe cases may require intensive care. Patients must be observed closely; any complication must be identified and treated promptly.
Treatment for chronic pancreatitis includes life style changes, pain management, pancreatic enzyme replacement, and management of diabetes and other complications.
