Acute pancreatitis

The pancreas sits behind the stomach and makes the enzymes that break down food. Normally they only switch on once they reach the intestine. In acute pancreatitis they switch on early, while still inside the gland, and digest its own tissue. The inflammation builds within hours. For most people the attack settles within a week and leaves nothing behind, but in roughly one case in five it turns severe, with part of the gland dying and other organs failing. There is no telling in advance which it will be, which is why anyone with it is watched in hospital.

What it feels like

An attack almost always starts with pain. It sits in the upper abdomen, centrally under the ribs, builds over minutes to an hour and then stays constant, rather than coming in waves the way intestinal colic does.

• the pain spreads through to the back, as if it wrapped around the body;
• lying flat is unbearable; sitting up and leaning forward, or curling up, brings some relief;
• nausea and repeated vomiting that brings no relief;
• a swollen, tense abdomen that hurts to touch;
• fever, fast pulse, clammy sweating;
• sometimes the eyes and skin turn yellow, urine darkens and stools go pale: the flow of bile is blocked;
• eating or drinking makes things sharply worse, fatty food most of all.

When gallstones are behind it, the attack often starts a few hours after a heavy meal; with alcohol, usually 6 to 12 hours after a large amount. In older people, and in anyone taking painkillers regularly, the pain can be blurred, and weakness, confusion and a falling blood pressure come to the front instead.

When to call an ambulance

Acute pancreatitis is not something to sit out at home: severe upper abdominal pain lasting more than half an hour that does not settle with the usual remedies is reason enough to call your local emergency number.

Call straight away if any of these appear alongside the pain:

• vomiting so persistent that drinking is impossible;
• yellowing of the skin or eyes;
• fever with shivering;
• fast shallow breathing or a feeling of not getting enough air;
• pounding heartbeat, cold sweat, dizziness on standing;
• confusion or unusual drowsiness; very little or no urine for several hours.

While you wait, do not eat or drink, do not warm the abdomen and do not take painkillers: heat feeds the inflammation and medicines blur the picture.

Why the gland becomes inflamed

Two causes account for about eight cases in ten.

• Gallstones. A small stone lodges exactly where bile and pancreatic juice drain into the gut. With the outlet blocked, pressure inside the pancreas rises and the enzymes break out into its tissue.
• Alcohol. What counts is not one occasion but years of regular drinking; the attack is more often set off by a single heavy session.

The rest are rarer, but they are what is looked for when there are no stones and the person does not drink:

• very high blood triglycerides, roughly above 11 mmol/L, or a raised calcium level from overactive parathyroid glands;
• a side effect of medication: certain diuretics, anti-epileptics, immune-suppressing drugs, some diabetes medicines;
• injury to the abdomen, or a procedure on the bile ducts, including a diagnostic one;
• viral infections such as mumps; autoimmune pancreatitis, where the immune system attacks the gland;
• inherited forms and variations in the ducts: attacks then begin young and keep coming back.

Smoking raises the risk in its own right and makes the course worse, independently of alcohol.

The cause that must not be missed

Sometimes what blocks the duct is not a stone but a tumour of the pancreas, or of the point where it drains into the gut. Pancreatitis then becomes its first and only sign. The combination that should prompt a second look: someone past fifty, no stones on testing, no alcohol, and yet an attack. Ultrasound alone is not enough there: more detailed imaging is arranged, with a repeat review a few weeks after the inflammation settles. This is the situation in which the work-up is carried through to the end.

What happens in hospital

The diagnosis rests on three things: the characteristic pain, pancreatic enzymes in the blood (lipase or amylase at least three times above the upper limit of normal) and what the scans show. Ultrasound is done for everyone on the first day and looks for stones. A contrast CT scan is more informative a few days in: earlier it may not yet show the areas of dead tissue.

No drug can stop pancreatitis. Treatment is supportive, and the first day does much to decide the outcome:

• drips with electrolyte solutions: the inflamed gland pulls fluid towards itself and dehydration creeps up unnoticed;
• pain relief: for severe pain, opioids are used; enduring it achieves nothing and does harm;
• oxygen and close watch on breathing, intensive care if the attack is severe;
• early return to eating. The old approach of several days without food is gone: in mild cases eating is allowed as soon as the nausea eases. If that is not possible, feeding goes through a fine tube into the gut rather than a vein;
• antibiotics only for proven infection: they are not given "just in case", because that does not improve outcomes;
• dealing with the cause. If the bile ducts are infected, with jaundice and fever, the stone is removed endoscopically (ERCP). If the attack was caused by stones and stayed mild, the gallbladder is taken out before discharge: otherwise a repeat attack follows within weeks in many people.

Complications and why they are watched for

The first week carries the risk of organ failure: the kidneys, the circulation and above all the lungs, since a severe attack can trigger acute respiratory distress syndrome.

• Necrosis of the gland: part of the tissue dies because its blood supply fails.
• Infected necrosis comes in the second to fourth week: fresh fever and deterioration after an apparent recovery. It needs antibiotics and a procedure.
• Fluid collections and pseudocysts: pockets of pancreatic juice. They often shrink on their own; they are treated if they press, hurt or become infected.
• Diabetes and enzyme shortage, once much of the gland is lost: thirst, weight loss, greasy foul-smelling stools.
• Chronic pancreatitis: where repeated attacks end up, with constant pain and permanent scarring.

What to do after discharge

• No alcohol at all, whatever caused the attack. If stopping is hard, say so: talking therapies and medicines that reduce craving both help. Stopping smoking comes next.
• If gallbladder surgery has been put off, do not delay it further: while the gallbladder is still there, the risk of another attack stays.
• Eat normally, in smaller portions through the day, without loading up on fat. Lifelong strict diets are not needed if the gland was not badly damaged; crash dieting, though, encourages stones, so weight should come off gradually.
• Pain coming back, weight loss or greasy stools are reasons to get seen rather than wait for an appointment.

Online consultation: what it can do

The attack itself is dealt with in hospital, and remote care is no substitute for an ambulance. Everything around it can be discussed online: the discharge summary and test results, why surgery has been suggested and why delaying it is unwise, the tests still outstanding if the cause was never found, which signs matter at home. And if abdominal pain has only just begun, a consultation will quickly tell you whether it can be watched or needs urgent care.

This material is for information only and does not replace medical advice.