Pancreatitis

	Topic Overview
	Cause
	Symptoms
	What Happens
	What Increases Your Risk
	When To Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Home Treatment
	Medications
	Surgery
	Other Treatment
	Other Places To Get Help
	Related Information
	References
	Credits
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What is pancreatitis?

Pancreatitis is inflammation of the pancreas, an organ in your belly that makes the hormones insulin and glucagon. These two hormones control how your body uses the sugar found in the food you eat. Your pancreas also makes other hormones and enzymes that help you break down food.

Usually the digestive enzymes stay in one part of the pancreas. But if these enzymes leak into other parts of the pancreas, they can irritate it and cause pain and swelling. This may happen suddenly or over many years. Over time, it can damage and scar the pancreas.

What causes pancreatitis?

Most cases are caused by gallstones or alcohol abuse. The disease can also be caused by an injury, an infection, or certain medicines.

Long-term, or chronic, pancreatitis may occur after one attack. But it can also happen over many years. In Western countries, alcohol abuse causes most chronic cases.

In some cases doctors don't know what caused the disease.

What are the symptoms?

The main symptom of pancreatitis is medium to severe pain in the upper belly. Pain may also spread to your back.

Some people have other symptoms too, such as nausea, vomiting, a fever, and sweating.

How is pancreatitis diagnosed?

Your doctor will do a physical exam and ask you questions about your symptoms and past health. You may also have blood tests to see if your levels of certain enzymes are higher than normal. This can mean that you have pancreatitis.

Your doctor may also want you to have a complete blood count (CBC), a liver test, or a stool test.

Other tests include an MRI, a CT scan, or an ultrasound of your belly (abdominal ultrasound) to look for gallstones.

A test called endoscopic retrograde cholangiopancreatogram, or ERCP, may help your doctor see if you have chronic pancreatitis. During this test, the doctor can also remove gallstones that are stuck in the bile duct.

How is it treated?

Most attacks of pancreatitis need treatment in the hospital. Your doctor will give you pain medicine and fluids through a vein (IV) until the pain and swelling go away.

Fluids and air can build up in your stomach when there are problems with your pancreas. This buildup can cause severe vomiting. If buildup occurs, your doctor may place a tube through your nose and into your stomach to remove the extra fluids and air. This will help make the pancreas less active and swollen.

Although most people get well after an attack of pancreatitis, problems can occur. Problems may include cysts, infection, or death of tissue in the pancreas.

You may need surgery to remove your gallbladder or a part of the pancreas that has been damaged.

If your pancreas has been severely damaged, you may need to take insulin to help your body control blood sugar. You also may need to take pancreatic enzyme pills to help your body digest fat and protein.

If you have chronic pancreatitis, you will need to follow a low-fat diet and stop drinking alcohol. You may also take medicine to manage your pain. Making changes like these may seem hard, but with planning, talking with your doctor, and getting support from family and friends, they are possible.

Frequently Asked Questions

Normally, the structure of the pancreas and the pancreatic duct prevent digestive enzymes from damaging the pancreas. But certain conditions can develop that cause damage and pancreatitis.

Acute pancreatitis

Most attacks of pancreatitis are caused by gallstones that block the flow of pancreatic enzymes or by excessive amounts of alcohol. Sudden (acute) pancreatitis may happen after a drinking binge or after many episodes of heavy drinking.

Other causes of acute pancreatitis are:

• Infections, including mumps.
• Some medicines, including certain antibiotics, steroids, and blood pressure medicines.
• Injury.
• High triglycerides.

Sometimes the cause is not known.

Chronic pancreatitis

Excessive alcohol use is the major cause of ongoing pancreatitis (chronic pancreatitis). About 66 out of 100 cases of long-term pancreatitis are caused by alcohol abuse. It's not clear why only about 15 out of 100 people who drink heavily develop chronic pancreatitis.¹ Many experts believe that other factors—such as a high-fat diet or smoking—play a role in the disease.

Experts do not know how alcohol irritates the pancreas. Most believe that alcohol either causes enzymes to back up into the pancreas or changes the chemistry of the enzymes, causing them to inflame the pancreas.

The main symptom of sudden (acute) pancreatitis is sudden moderate to severe pain in the upper area of the belly (abdomen). Occasionally the pain is mild. But the pain may feel as though it bores through the abdomen to the back. Sitting up or leaning forward sometimes makes the pain less. Other symptoms of an attack of pancreatitis are:

• Nausea and vomiting.
• Fever.
• Fast heart rate.
• Sweating.
• Yellowing of the skin or the whites of the eyes (jaundice).
• Shock.

Long-term (chronic) pancreatitis also causes severe pain in the upper abdomen. As the condition progresses, fat may be released into your stools, indicating that your body is not absorbing fat and protein. As a result, you may have diarrhea and lose weight. You also could develop diabetes if your pancreas no longer produces enough insulin.

Other conditions that have similar symptoms include bowel obstruction, appendicitis, cholecystitis, peptic ulcer disease, and irritable bowel syndrome (IBS).

Pancreatitis usually appears as a sudden (acute) attack of pain in the upper area of the belly (abdomen). The disease may be mild or severe.

Acute pancreatitis

Most people with pancreatitis have mild acute pancreatitis. The disease does not affect their other organs, and they recover without problems. In most cases, the disease goes away within a week after treatment begins. Treatment takes place in the hospital with pain medicines and intravenous (IV) fluids. After inflammation goes away, the pancreas usually returns to normal.

Complications that may occur in or near the pancreas include tissue death, fluid buildup, and infection. Other complications in other parts of the body can also happen, including shock, respiratory failure, and kidney failure.

In some cases pancreatic tissue is permanently damaged or even dies (necrosis). These complications increase the risk of infection and organ failure.

In severe cases, pancreatitis can be fatal.

Chronic pancreatitis

Long-term pancreatitis (chronic pancreatitis) may develop after one or more episodes of acute pancreatitis. It usually occurs after at least 10 years of heavy drinking. It occurs in up to 15 out of 100 people of people who drink heavily.¹

What happens during the course of chronic pancreatitis varies. Ongoing pain and complications often develop. Complications may include flare-ups of symptoms, fluid buildup, and blockage of a blood vessel, the bile duct, or the small intestine.

If much of your pancreatic tissue has died, you may become malnourished because the pancreas no longer produces enzymes needed to digest fat and protein. When this happens, fat is released into your stool. This condition, called steatorrhea, causes loose, pale, unusually foul-smelling stools that may float in the toilet bowl.

If the damaged pancreas stops making enough insulin, you also may develop diabetes.

Chronic pancreatitis increases the risk of pancreatic cancer. About 4 out of 100 people with chronic pancreatitis develop this cancer.¹

Several factors can increase your risk of developing pancreatitis, including:

• Gallstones. A small gallstone can move far enough into the bile duct to block the flow of pancreatic enzymes into the small intestine.
• An excessive amount of alcohol. The amount needed to cause pancreatitis is not known. Alcohol tolerance varies from one person to another. Moderate consumption is considered no more than 2 alcoholic beverages per day for men and 1 per day for women and older people.
• A high level of fat (triglycerides) in the blood. The level of triglycerides needed to cause pancreatitis is greater than 1,000 mg/dL (11.3 mmol/L). Normal triglyceride levels are around 150 mg/dL (1.7 mmol/L).
• Taking certain medicines, including estrogen therapy and some antibiotics.
• Structural problems of the pancreas or the bile and pancreatic ducts, especially a condition in which the pancreas is divided and has two main ducts (pancreas divisum).

Call your doctor immediately if you have severe belly (abdominal) pain with vomiting that does not go away after a few hours, or mild to moderate pain that does not improve with home treatment after a couple of days. These symptoms may be caused by pancreatitis.

Watchful Waiting

Pancreatitis can be a severe, potentially life-threatening illness. It is not appropriate to take a wait-and-see approach, which is called watchful waiting, if you have severe pain in the upper area of the abdomen that does not go away in a few hours.

Who To See

The following health professionals can diagnose and treat pancreatitis:

• Family medicine physician
• Internist
• Gastroenterologist (specialist in diseases of the digestive system)
• Nurse practitioner
• Physician assistant
• Surgeon

To prepare for your appointment, see the topic Making the Most of Your Appointment.

If your doctor thinks you have pancreatitis, he or she will ask questions about your medical history and do a physical exam along with lab and imaging tests.

Two blood tests that measure enzymes are used to diagnose an attack of pancreatitis. These tests are:

• Serum amylase. An increase of amylase in the blood usually indicates pancreatitis.
• Serum lipase. Sudden (acute) pancreatitis almost always raises the level of lipase in the blood.

Other blood tests may be done, such as:

• A complete blood count (CBC). The number of white blood cells rises during an attack of pancreatitis, sometimes dramatically.
• Liver function tests. Increases in liver enzymes, particularly of alanine aminotransferase and alkaline phosphatase, can be a sign of sudden pancreatitis caused by gallstones.
• Bilirubin. The level of bilirubin in the blood may increase if the common bile duct is blocked.

Imaging tests that may be done include:

• CT scan with contrast dye. A CT scan can help rule out other causes of abdominal pain, determine whether tissue is dying (pancreatic necrosis), and find complications such as fluid around the pancreas, blocked veins, and obstructed bowels.
• Abdominal ultrasound. This test can locate gallstones. It also can show an enlarged common bile duct.
• Endoscopic retrograde cholangiopancreatogram (ERCP). This procedure allows the doctor to see the structure of the common bile duct, other bile ducts, and the pancreatic duct. ERCP is the only diagnostic test that also can be used to treat narrow areas (strictures) of the bile ducts and remove gallstones from the common bile duct.
• Endoscopic ultrasound. In this form of ultrasound, a probe attached to a lighted scope is placed down the throat and into the stomach. Sound waves show images of organs in the abdomen. Endoscopic ultrasound may reveal gallstones in the common bile duct.
• MRI. Occasionally an MRI is used to look for signs of pancreatitis. It provides information similar to that of a CT scan.
• Magnetic resonance cholangiopancreatogram (MRCP). This form of MRI can detect gallstones in the common bile duct. This test is not available everywhere.

If your doctor is not sure whether your pancreatic tissue is infected, he or she may use a needle to take some fluid from the inflamed area. The fluid is then tested for organisms that can cause infection.

In severe, chronic pancreatitis, a stool analysis may be done to look for fat in stools, which is a sign that you may not be getting enough nutrition. This happens when the pancreas no longer produces the enzymes you need to digest fat.

Treatment of pancreatitis depends on whether you have a sudden (acute) attack of pancreatitis or you have had the condition for a long time (chronic).

Initial treatment

For acute pancreatitis: You will receive treatment in the hospital to allow the pancreas to heal. You will receive intravenous (IV) fluids to replace lost fluids and maintain your blood pressure. And you will get medicines to control pain until the inflammation goes away.

To help rest your pancreas, you likely will not be given anything to eat for 3 to 7 days.

If gallstones are causing pancreatitis, you may have a procedure called endoscopic retrograde cholangiopancreatogram (ERCP) to remove the stones from the common bile duct. After recovering from pancreatitis, you may have surgery to remove the gallbladder. This surgery often prevents future attacks of pancreatitis. For more information, see the Surgery section of this topic.

For chronic pancreatitis: People who have chronic pancreatitis also may have episodes of acute pancreatitis, which are treated the same as an initial episode of acute pancreatitis.

Ongoing treatment

Excessive use of alcohol causes most cases of chronic pancreatitis. It is extremely important that you not drink any alcohol. Drinking even small amounts can cause severe pain and complications. Drinking large amounts of alcohol when you have chronic pancreatitis can shorten your life. For more information on quitting alcohol, see the topic Alcohol Abuse and Dependence.

If you have chronic pancreatitis, you may struggle with ongoing pain. Treatment for pain includes avoiding alcohol, eating a low-fat diet, using pain medicine, and in some cases taking enzyme pills to help rest your pancreas. You may be able to help your pain with over-the-counter pain medicines like acetaminophen, aspirin, or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. If over-the-counter pain medicines don't control your pain, you may need to have your doctor prescribe stronger narcotic pain medicines.

You may need surgery to widen a narrow pancreatic duct or to remove tissue or stones that are blocking the pancreatic duct. Surgery can also drain a pseudocyst or an obstructed duct.

In advanced chronic pancreatitis, your body may not absorb fat. This causes loose, oily, especially foul-smelling stools (called steatorrhea). You may lose weight as a result, because your pancreas no longer produces the enzymes you need to digest fat and protein. Pancreatic enzyme pills can replace lost enzymes.

You may need insulin if your pancreas has stopped producing enough of it.

Your health professional will want to see you every 3 to 6 months to make sure that your pain medicine is helping you and that you have not developed complications of chronic pancreatitis. Complications of chronic pancreatitis may include recurring flare-ups of symptoms, fluid buildup, and blockage of a blood vessel, the bile duct, or the small intestine. Chronic pancreatitis also increases your risk of pancreatic cancer.

Treatment if the condition gets worse

If acute pancreatitis is severe, you will be cared for in the intensive care unit (ICU) of the hospital, where you will receive intravenous fluids and pain medicines.

To help your pancreas heal, you will not eat. During this time, you will be nourished through enteral nutrition, in which liquid nutrients are pumped into your small intestine through a tube that is inserted in your nose. If you are not able to tolerate enteral feedings, you may receive total parenteral nutrition (TPN), in which liquid nutrients are given through a tube (catheter) that is placed in a large vein, usually in the neck or arm.

You may take medicine such as Pepcid, Zantac, Prilosec, or Prevacid to stop production of stomach acid. These medicines may help prevent the gastritis and bleeding in the stomach that may happen with pancreatitis. They do not treat pancreatitis.

In some cases, you may have a tube placed in your nose and down into your stomach to remove fluids that can irritate the pancreas. If you have to use this tube for a long time, you will receive TPN.

If your blood oxygen level is low because of respiratory complications, you may receive oxygen therapy.

If infection develops, you may need antibiotics and you might have surgery to remove the infected and dead tissue. But surgery is avoided when possible, because the pancreas is damaged easily.

You may need surgery if you develop complications from acute or chronic pancreatitis. Surgery also may be done if there is no infection and your condition has not improved.

You cannot completely prevent pancreatitis caused by gallstones. But you may be able to reduce your risk of forming gallstones by staying at a healthy weight with a balanced diet and regular exercise. For more information, see the topic Gallstones.

You can reduce your chance of having pancreatitis by not drinking alcohol excessively. The amount of alcohol needed to cause pancreatitis varies from one person to another. Generally, moderate consumption is considered no more than 2 alcoholic beverages per day for men and 1 per day for women and older people.

Smoking may increase your chance of having pancreatitis. If you smoke, it's a good idea to quit. For more information on quitting smoking, see the topic Quitting Smoking.

If you have ongoing (chronic) pancreatitis caused by excessive use of alcohol, you will need to quit drinking to reduce severe pain and complications. Drinking large amounts when you have chronic pancreatitis can shorten your life. For more information on quitting alcohol, see the topic Alcohol Abuse and Dependence.

Although the role of diet in pancreatitis is not clear, doctors recommend eating a low-fat diet and staying at a healthy body weight.

Medicines used to treat pancreatitis depend on whether the condition is sudden (acute) or ongoing (chronic) and whether it is mild or severe.

Acute pancreatitis

If you have acute pancreatitis, you will receive treatment in the hospital to allow the pancreas to heal. You will receive intravenous (IV) fluids to replace lost fluids and maintain your blood pressure. And you will get medicines to control pain until the inflammation goes away.

Chronic pancreatitis

In addition to pain medicine, people who have chronic illness may take pancreatic enzymes and insulin because their damaged pancreas no longer produces enough of these.

Medication Choices

You may need one or more medicines to treat chronic pancreatitis.

• Pain medicine. Mild pain is first treated with a medicine such as acetaminophen or ibuprofen. If you have stronger pain, you may be given a narcotic pain medicine (opiate). Health professionals also use other medicines and procedures to treat pain in chronic pancreatitis.
• Pancreatic enzyme supplements. In advanced chronic pancreatitis, the pancreas may stop producing the enzymes needed to digest fats, proteins, and carbohydrates. Enzyme supplements at meals can help the body digest fats, allowing you to retain nutrients and gain weight.
• Insulin. Advanced chronic pancreatitis can lead to diabetes if the part of the pancreas that produces insulin becomes damaged.

What To Think About

Side effects of pancreatic enzymes that are given to treat chronic pancreatitis include abdominal discomfort and soreness of the mouth and the anus. People who are allergic to pork or who do not eat pork for other reasons should not take these enzymes, because they are made of pork protein. In young children, high doses of pancreatic enzymes could cause a bowel obstruction.

Surgery to remove gallstones can relieve sudden (acute) pancreatitis caused by gallstones that are blocking the common bile duct. The gallbladder may be removed later to prevent future attacks from gallstones.

Surgery of the pancreas is avoided, if possible, because the gland is easily damaged. But surgery may be needed to remove infected or damaged tissue (pancreatic necrosis).

Several surgical procedures can be used to try to reduce pain in chronic pancreatitis. These procedures include removing stones from the pancreas, draining blocked ducts, and destroying certain nerves to reduce pain. But results vary, and surgical treatment of chronic pancreatitis may not be effective.

Surgery Choices

One of two surgeries can be done to remove the gallbladder if gallstones are causing pancreatitis:

• Laparoscopic gallbladder surgery
• Open gallbladder surgery

Endoscopic retrograde cholangiopancreatogram (ERCP) is a procedure used to remove one or more gallstones from the common bile duct.

Surgeons may choose among several techniques to remove damaged pancreatic tissue.

What To Think About

Gallstones sometimes form in the bile ducts years after surgery to remove the gallbladder (cholecystectomy).

Doctors debate how soon someone with damaged tissue that is infected (infected pancreatic necrosis) should have surgery. Generally, doctors try to wait at least a week because the pancreas is easily damaged. The outcome is better if surgery can be postponed until inflammation goes away.

Studies have shown that having surgery early in the course of pancreatitis does not improve survival rates.²

Surgery has the potential for complications, including infection, and artificial openings (fistulas) that can develop between the pancreas and the small intestine or other organs.

Survival after surgery depends on many factors, including your overall health and age (older people have a higher death rate), the extent of pancreatic necrosis, and whether the tissue is infected.

There are no other treatments for pancreatitis at this time.

Organizations

Related Information

• Gallstones

Citations

1. Forsmark CE (2006). Chronic pancreatitis. In M Feldman et al., eds., Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 8th ed., vol. 1, pp. 1271–1308. Philadelphia: Saunders Elsevier.

2. Steer ML (2006). Acute pancreatitis. In MM Wolfe et al., eds., Therapy of Digestive Disorders, 2nd ed., pp. 417–426. Philadelphia: Saunders Elsevier.

Other Works Consulted

• American Gastroenterological Association (1998). American Gastroenterological Association technical review: Treatment of pain in chronic pancreatitis. Gastroenterology, 115(3): 765–776.

• American Gastroenterological Association Institute (2007). Medical position statement on acute pancreatitis. Gastroenterology, 132(5): 2019–2021.

• American Gastroenterological Association Institute (2007). Technical review on acute pancreatitis. Gastroenterology, 132(5): 2022–2044.

• Banks PA, et al. (2006). Practice guidelines in acute pancreatitis. American Journal of Gastroenterology, 101(10): 2379–2400.

• Greenberger NJ, Toskes PP (2008). Acute and chronic pancreatitis. In AS Fauci et al., eds., Harrison's Principles of Internal Medicine, 17th ed., vol. 2, pp. 2005–2017. New York: McGraw-Hill.

• Kocher HM, Froeling FEM (2008). Chronic pancreatitis, search date April 2008. Online version of BMJ Clinical Evidence: http://www.clinicalevidence.com.

• Tolstrup JS, et al. (2009). Smoking and risk of acute and chronic pancreatitis among women and men: A population-based cohort study. Archives of Internal Medicine, 169(6): 603–609.