What causes pancreatitis and how is it treated?

Causes and Treatment of Pancreatitis

The most common causes of pancreatitis are gallstones and excessive alcohol consumption, and treatment should focus on supportive care with fluid resuscitation, pain management, and early enteral nutrition, while addressing the underlying cause. 1

Causes of Pancreatitis

Acute Pancreatitis Causes

1. Gallstones - Most common cause 1

   • Biliary obstruction leading to inflammation
   • Higher risk in patients with Crohn's disease 1

2. Alcohol - Second most common cause 1

   • Typically requires prolonged excessive consumption

3. Drug-induced 1

   • Thiopurines (azathioprine, 6-mercaptopurine) - occurs in ~4% of treated patients
   • 5-ASA medications (less common)
   • Dose-independent reaction, typically within 3-4 weeks of starting treatment

4. Other causes:

   • Hypertriglyceridemia 2
   • Post-ERCP (endoscopic retrograde cholangiopancreatography) 1
   • Autoimmune pancreatitis (IgG4-related) 1
   • Idiopathic pancreatitis
   • Pancreatic duct obstruction 1
   • Genetic factors - HLA-DQA102:01-HLA-DRB107:01 haplotype increases risk of thiopurine-induced pancreatitis 1

Chronic Pancreatitis Causes

1. Alcohol - Responsible for 60-70% of cases 1
2. Pancreatic duct obstruction 1
3. Genetic factors (hereditary pancreatitis) 1
4. Idiopathic - 15-35% of cases have no apparent cause 1

Diagnosis

Diagnosis requires at least two of three criteria:

1. Upper abdominal pain
2. Elevated serum lipase/amylase (≥3 times upper limit of normal)
3. Characteristic findings on imaging 2

Treatment of Acute Pancreatitis

Mild Acute Pancreatitis

1. Fluid resuscitation - Aggressive early fluid replacement 1

2. Pain management - Adequate analgesia 1

3. Early oral feeding - Once pain and nausea improve 1

   • Can be progressively attempted once gastric outlet obstruction resolves
   • Monitor for pain relapse during refeeding

4. Treat underlying cause:

   • For gallstone pancreatitis: Cholecystectomy within 2-4 weeks 1
   • For alcohol-related: Alcohol cessation counseling

Severe Acute Pancreatitis

1. Intensive care management - All cases of severe acute pancreatitis should be managed in HDU/ICU setting with full monitoring and systems support 1

2. Fluid resuscitation - More aggressive than in mild cases 1

3. Nutritional support:

   • Early enteral nutrition preferred over parenteral nutrition 1
   • Jejunal feeding may be preferred in severe cases 1

4. Antibiotics:

   • Always recommended for infected pancreatic necrosis 1
   • Diagnosis may be confirmed by CT-guided fine-needle aspiration 1
   • Procalcitonin measurements may help predict risk of infected necrosis 1

5. Urgent ERCP:

   • For severe gallstone pancreatitis with biliary obstruction or cholangitis 1
   • Should be performed under antibiotic cover 1

6. Management of complications:

   • Drainage and/or necrosectomy for infected necrosis or pancreatic abscess 2
   • Referral to specialist tertiary centers for patients with local complications 2

Treatment of Chronic Pancreatitis

1. Lifestyle modifications:

   • Alcohol abstinence is crucial 1
   • Pain control before meals to increase food intake 1

2. Nutritional management:

   • More than 80% of patients can be treated with normal food supplemented by pancreatic enzymes 1
   • 10-15% require oral nutritional supplements 1
   • About 5% need tube feeding 1

3. Pancreatic enzyme replacement therapy:

   • For maldigestion with steatorrhea and azotorrhea 1
   • Helps prevent malnutrition and vitamin deficiencies

4. Pain management:

   • Critical component of treatment
   • Analgesics should be taken before meals to improve food intake 1

Monitoring and Complications

Complications to Monitor:

1. Local complications:

   • Pancreatic necrosis (sterile or infected)
   • Acute fluid collections
   • Pseudocysts
   • Pancreatic abscess 1

2. Systemic complications:

   • Organ failure (respiratory, cardiovascular, renal)
   • Sepsis
   • Nutritional deficiencies (especially vitamins A, D, E, K, calcium, magnesium, zinc, thiamine, and folic acid) 1

Pitfalls to Avoid:

1. Delayed fluid resuscitation - Early aggressive fluid therapy is critical in preventing early mortality 1
2. Delayed nutrition - Early enteral feeding is beneficial and should not be unnecessarily delayed 1
3. Missing gallstones - Ensure proper imaging to identify gallstones as the cause 1
4. Overlooking infected necrosis - Consider this diagnosis in patients with persistent fever or clinical deterioration 1
5. Delayed ERCP - In severe gallstone pancreatitis with biliary obstruction or cholangitis, urgent ERCP is indicated 1

Regular monitoring of clinical status, laboratory values, and appropriate imaging are essential for early detection and management of complications, which can significantly improve outcomes and reduce mortality.