Introduction:
The pancreas is a small heterocrine gland located in the left part of the abdomen. It lies just behind the stomach. This gland mostly regulates blood sugar levels and secretes hormones like insulin, somatostatin, glucagon, and pancreatic polypeptide. It also secretes digestive enzymes, which help in the breakdown of carbohydrates, fats, and proteins. Due to some underlying causes and lifestyle habits, inflammation results in the pancreas, known as pancreatitis. There are mainly two types of pancreatitis; acute and chronic pancreatitis. If left untreated, they can also lead to pancreatic cancer, which has a very poor prognosis and can be life-threatening.
What Is Acute and Chronic Pancreatitis?
Pancreatitis is an inflammation of the pancreas that is caused by inappropriate activation of pancreatic enzymes in the body and the tissues surrounding the pancreas, resulting in edema, hemorrhage, or possibly necrosis of the pancreas. Acute pancreatitis is a potentially fatal condition that affects around 13 to 45 % per 100000 persons globally. Most acute pancreatitis cases occur due to chronic alcohol intake or gallstones. Chronic pancreatitis is painful pancreatic inflammation that can result due to pancreatic fibrosis, inflammation, or calcification. To reach chronic pancreatitis, the individual would have to face many episodes of acute pancreatitis.
What Causes Acute and Chronic Pancreatitis?
Around 80 % of cases of pancreatitis are caused due to excessive intake of alcohol and gallstone problems. Approximately around 45 % of cases occur due to alcohol abuse. In females, 30 % and in males, 60 % of cases result due to excess alcohol consumption. Factors that lead to pancreatitis include hypertriglyceridemia (a condition where there are too many triglycerides in the blood), mumps, abdominal trauma, smoking cigarette, hypercalcemia, and taking medications like Azathioprine, Valproic acid, ACE inhibitors, diuretics, thiazides, narcotics, steroids, and hormones. Pancreatitis can also result as a transient complication of ERCP (endoscopic retrograde cholangiopancreatography). Chronic pancreatitis can result due to persistent, progressive pancreatic destruction due to inflammation and fibrosis. Other causes include hyperparathyroidism, malnutrition, and cystic fibrosis.
What Are the Signs and Symptoms of Acute and Chronic Pancreatitis?
The characteristic signs and symptoms of acute and chronic pancreatitis are:
Acute Pancreatitis:
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Severe epigastric pain and tenderness can radiate to the back.
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Nausea and vomiting.
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Fever.
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Abdominal distention.
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Tachycardia (rapid heart rate)
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Diaphoresis (excessive abnormal sweating).
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Rebound tenderness.
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Dehydration.
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Shock.
In Chronic Pancreatitis:
Symptoms similar to acute pancreatitis, along with
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Nausea and vomiting.
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Jaundice.
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Food intolerance.
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Glucose intolerance.
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Steatorrhea (excretion of abnormal quantities of fat).
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Severe epigastric pain radiating to the back relieves on leaning.
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Sometimes chronic pancreatitis can be asymptomatic.
How Is the Diagnosis Made for Acute and Chronic Pancreatitis?
Diagnosis of acute and chronic pancreatitis is made by taking a thorough medical history and examinations of the vitals. Other tests include:
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Complete Blood Test- A detailed blood test is done to diagnose the condition.
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Complete Metabolic Panel Test- Detailed information on fluid balance, levels of electrolytes, and how well the kidney functions.
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Liver Function Test- The test detects the functionality of the liver.
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Blood Alcohol Level- Test that measures the level of alcohol in the blood.
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Lipid Panel Test- The test measures levels of triglycerides and lipids in the blood.
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CT Scans (Computed Tomography)- Imaging procedure that uses a combination of x-rays and computer technology.
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MRI Scans (Magnetic Resonance Imaging)- Imaging procedure that uses radio waves and a high magnetic field to produce images.
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Ultrasound: It helps in the evaluation of blocked ducts, gallstone-related issues, necrosis or edema, and abscess.
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Endoscopic Retrograde Cholangiopancreatography (ERCP): This test reveals strictures of the common bile duct and the pancreatic duct. Due to associated morbidities with these procedures, it is limited to high-suspicion patients.
In acute disease, there is always the presence of hypocalcemia (when levels of calcium in the blood are low), hypokalemia (low potassium levels), leukocytosis (high white blood cell count), and liver enzyme elevation, and patients often have hypoxemia in severe cases.
What Is the Treatment Provided for Acute and Chronic Pancreatitis?
Supportive treatment is the only main objective of the treatment. This treatment includes the administration of aggressive IV (intravenous) fluid to maintain blood pressure, IV (intravenous) medication to control pain, antiemetics to relieve vomiting and nausea, bowel rest, and correcting electrolyte imbalance, especially calcium. Providing treatment for the underlying cause is another line of treatment. Advanced diseased cases require Intensive care unit admission.
Along with the treatment, procedures avoiding alcohol and fatty foods can also help.
Endoscopic and surgical management may be required in selected cases. Cholecystectomy for gallstone removal should be delayed till the acute condition resolves.
What Are Nutritional Support Provided in Acute and Chronic Pancreatitis?
Besides the elevated triglyceride levels, there is a great connection between the diet and the pancreatic condition. The risk of inflammation is greater in obese individuals. Following a healthy diet, including vegetables, fruits, and a high fiber-rich diet, can reduce the risk of acute pancreatitis. In chronic pancreatitis, an imbalance between oxidative stress and antioxidant status is an important factor, and in such cases, high-dose antioxidant therapy intravenously can be helpful.
Nutritional Support In Acute Pancreatitis:
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Body Weight: Obese individuals are at more risk compared to normal-weight individuals. Increased weight increases the risk of multiorgan failure along with severe pancreatitis attacks. Gallstones are the most common risk factor for pancreatitis, which is seen more in obese individuals. A high-fiber diet along with low fat intake can help in reducing the risks associated with severe pancreatitis.
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Triglycerides: A restricted diet with low fat and simple carbohydrates is recommended, along with weight loss and alcohol abstinence. Avoid food with a high glycemic index, like sucrose, fructose, and corn syrup. Thai foods tend to raise triglycerides, and individuals are advised to choose a carbohydrate-rich diet that would not raise triglyceride levels.
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Fruits And Vegetables: Consuming fruits and vegetables reduce the risk of pancreatic disease. Fruits by 27 % and vegetables by 30 %, compared to persons who do not consume enough fruits and vegetables.
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Enteral Nutrition: Early administration of enteral nutrition is ideal in acute pancreatitis individuals. This helps in reducing infections, mortality, and multiorgan failure.
Nutritional Support In Chronic Pancreatitis:
It is seen that there is an increase in oxidative stress in individuals with chronic pancreatitis. This occurs due to the deficiency of fat-soluble vitamins, that is, A, D, E, and K. This deficiency is caused by malabsorption in pancreatitis. Controlled trials, along with antioxidants, are given to individuals with chronic pancreatitis. Antioxidant therapy consists mainly of a combination of beta carotene, selenium, vitamins C and E, N-acetylcysteine, and glutamine. Some are given in oral form, and some need IV administration. This therapy is effective when combined with methionine in reducing the pain of individuals with chronic pancreatitis.
Conclusion:
Management of acute pancreatitis differs from individual to individual based on the severity. The mortality rate is low, below 1 % in mild cases for about 75 % of the patients, but as the disease progresses, the increasing severity results in a mortality rate of 20 %. Enteral nutrition should be the preferred route for nutritional support in individuals with acute pancreatitis. This route is safer, cheaper, and more effective for suppressing immune-inflammatory responses. The use of probiotics is still controversial as a supplement in enteral nutrition.
