Pancreatitis Relapsing

Relapsing pancreatitis is a condition where people experience repeated episodes of pancreatic inflammation that can progressively worsen over time, causing severe pain and potentially leading to permanent damage to this vital digestive organ.

Table of contents

• What is Pancreatitis Relapsing
• Symptoms
• Causes and Risk Factors
• Diagnosis
• Progression to Chronic Disease
• Treatment and Management
• Lifestyle Changes to Prevent Future Attacks

What is Pancreatitis Relapsing

• Pancreas

The pancreas is an organ located behind the stomach that plays a crucial role in your body. It makes special proteins called digestive enzymes that help break down fats, proteins, and sugars from the food you eat. The pancreas also produces important hormones, including insulin, which helps control blood sugar levels.^[2]

Acute pancreatitis occurs when the pancreas becomes damaged or inflamed. Most people will have just one episode and never experience another. However, when someone has more than two episodes of acute pancreatitis, they are diagnosed with acute recurrent pancreatitis.^[2]

Chronic relapsing pancreatitis is a disease characterized by recurring acute episodes of severe upper abdominal pain that are progressive. These episodes may gradually become so severe and frequent that they become very difficult to manage.^[1] About 25% of patients with acute pancreatitis experience recurrence.^[7]

Symptoms

Patients with relapsing pancreatitis experience symptoms related to inflammation in the pancreas. The main symptom is upper abdominal pain that may spread to the back. This pain can range from mildly uncomfortable to life-threatening in severity.^[2]

Early in the disease, the function of the pancreas and its specialized cells may be disturbed only during acute attacks. However, as the condition continues, these changes may become permanent.^[1] Other symptoms that may develop include:

• Nausea and vomiting
• Pain in the belly that gets worse when eating or drinking alcohol
• Diarrhea or oily stools that are unusually foul-smelling and light colored
• Weight loss
• Bloating

Moderate to severe attacks of pancreatitis may cause serious complications including multi-organ failure affecting the kidneys, lungs, or heart, bleeding or blood clot formation in blood vessels, destruction of pancreas tissue, infection, and formation of fluid collections called pseudocysts.^[14]

Causes and Risk Factors

Problems start happening when the pancreas releases digestive enzymes too soon and they attack the pancreas itself instead of breaking down food. The causes of relapsing pancreatitis are varied, and in most people there is probably a combination of genetic and environmental factors.^[2][3]

The most frequent cause of chronic pancreatitis is drinking too much alcohol, accounting for about 7 in 10 people with chronic pancreatitis. Excessive alcohol intake causes up to 70% of chronic pancreatitis cases and nearly half of acute pancreatitis.^[3][4] Smoking tobacco is also recognized as harmful to the pancreas.^[3]

Other important causes and risk factors include:

• Gallstones blocking the pancreatic duct
• High levels of fats in the blood, particularly triglycerides
• Genetic disorders, especially cystic fibrosis in children
• Anatomic abnormalities
• Certain medications
• Autoimmune disease
• High calcium levels
• Cystic tumors of the pancreas that obstruct or communicate with a pancreatic duct

Despite thorough investigation, the cause is not apparent in about 10% of cases, which are classified as idiopathic.^[5][7]

Diagnosis

Your healthcare provider will ask questions about your health history and symptoms, perform a physical examination, and check for pain or tenderness in your belly.^[20] You will be asked about your drinking history and any family history of pancreatic disease.^[4]

If chronic relapsing pancreatitis is suspected, contrast-enhanced computed tomography (CT) is the recommended initial imaging study for diagnosis.^[4] CT scans can show the extent of inflammation and calcification of the pancreas, which is common in chronic pancreatitis.^[1] However, CT may be inconclusive in early stages of the disease.^[4]

Other diagnostic tools that may be used include:

• Blood tests to check for high levels of pancreatic enzymes called amylase and lipase, which may spill into the blood
• Magnetic resonance imaging (MRI) or magnetic resonance cholangiopancreatography (MRCP)
• Ultrasound imaging to show gallstones or inflammation
• Endoscopic ultrasonography, which is favored because of its increased safety and ability to evaluate both the pancreatic tissue and duct system, with or without biopsy

One of the most important causes of relapsing pancreatitis is a cystic tumor of the pancreas. Patients with relapsing pancreatitis and a focal fluid collection should be investigated for the possibility of such a tumor. Fine needle aspiration of cyst fluid can help provide a diagnosis.^[12]

Progression to Chronic Disease

Relapsing pancreatitis often represents a continuum with chronic pancreatitis. If a person has acute recurrent pancreatitis and starts to have symptoms of permanent damage to the pancreas, their diagnosis has progressed to chronic pancreatitis.^[2][5]

Chronic pancreatitis is an irreversible and progressive disorder characterized by inflammation, fibrosis (scarring), and permanent destruction of pancreatic tissue. When the normal pancreas cells are steadily lost due to damage caused by inflammation, scar tissue forms in these inflamed areas, making the pancreas irregular and hard. In late stages, calcium deposits may form in the scarred areas, and large stones may develop.^[3][4]

As the disease progresses, both digestive and hormone-producing functions of the pancreas are lost. This can lead to permanent problems including:

• Steatorrhea (fatty stools due to inability to digest fats properly)
• Difficulty digesting foods and absorbing nutrients, leading to malnutrition
• Diabetes mellitus (because the pancreas can no longer make enough insulin)
• Deficiency of fat-soluble vitamins like A, D, E, and K
• Chronic pain that may become constant

For people with acute pancreatitis, 8 out of 100 may go on to develop chronic pancreatitis.^[3] Most children who develop chronic pancreatitis have a genetic, anatomic, or metabolic disorder that increases their risk.^[2]

Treatment and Management

Medical management begins with a hospital stay to manage symptoms and complications. Initial treatment includes keeping patients without food by mouth, providing intravenous fluids to maintain hydration, and administering pain medicines.^[10]

Medical treatment options include:

• Pain relief medications, with narcotics and antidepressants providing the most relief, though one-half of patients eventually require surgery^[4]
• Pancreatic enzyme replacement therapy to help digest food when the pancreas cannot produce enough enzymes^[4]
• Medications to reduce stomach acid production
• Drugs to reduce inflammation

Feeding is introduced enterally (through the digestive system) as symptoms improve. Patients can be started on a low-fat diet and do not necessarily need to begin with clear liquids only.^[10]

When medical treatment is insufficient, procedures may be needed:

• Therapeutic endoscopy is used to treat symptomatic strictures (narrowings), stones, and pseudocysts^[4]
• Endoscopic drainage of pseudocysts results in similar pain relief as surgery, with equivalent or lower mortality^[4]
• Decompressive surgical procedures are indicated for large duct disease (when the pancreatic duct is dilated to 7 mm or more)
• Resection procedures, such as the Whipple procedure, are indicated for small duct disease or pancreatic head enlargement^[4]
• Other surgical options include partial or total removal of the pancreas, sympathectomy, splanchnicectomy, and vagotomy^[1]

The risk of pancreatic cancer is increased in patients with chronic pancreatitis, especially hereditary pancreatitis. Healthcare providers should counsel patients on this increased risk and evaluate patients with weight loss or jaundice for possible cancer.^[4]

Lifestyle Changes to Prevent Future Attacks

By making important lifestyle changes and working closely with your doctor, you can help prevent future attacks of pancreatitis. Stopping future attacks is crucial because repeated flare-ups can eventually lead to pancreatic scarring.^[14]

Recommended lifestyle modifications include:

Stop drinking alcohol completely. Do not drink alcohol at all, as it may make your pain worse and cause other problems. If you need help to quit, counseling, support groups, and sometimes medicines can help you stay sober.^[13][14]

Quit smoking or chewing tobacco. Smoking can make outcomes worse, make chronic pancreatitis progress faster, and increase the risk of pancreatic cancer.^[14][16]

Follow a low-fat diet. Avoid high-fat foods, especially fried foods that can overload your digestive system. Focus on eating a diet with no more than 30 grams of fat per day.^[13][15] Foods to avoid include:

• Red meat, pork, and lamb
• All cooking oils, including olive oil, and fried foods
• Dairy foods such as all cheeses, margarine, butter, cream, regular milk, and ice cream
• All nuts and nut butters
• Chocolate
• Prepared snack foods like potato chips
• Coconut and avocado
• Fast food meals

Eat smaller, more frequent meals. Instead of three large meals, try eating 4 to 6 small meals and snacks throughout the day.^[13][19]

Choose nutritious foods. Eat a high-protein diet rich in vitamins and nutrients. Include a variety of vegetables and fruits, which are high in nutrition and low in fat. Choose whole grain cereals, breads, crackers, rice, or pasta.^[13][19]

Maintain a healthy weight. Lose weight if you are overweight.^[13]

Remove gallstones if present. If you are diagnosed with gallstones and have suffered an attack of pancreatitis, removing the gallbladder can help prevent future problems.^[14]

Early refeeding can increase the recurrence of acute pancreatitis, so it is important to follow your doctor’s instructions about when and what to eat.^[7] Defining the underlying cause of your pancreatitis is essential for reducing recurrence.^[7]

You may benefit from meeting with a dietitian to create a diet plan that provides sufficient calories while avoiding problem foods.^[15] Some patients may also benefit from taking artificial digestive enzymes, which help your body break down food and absorb nutrients and vitamins. Consult with your doctor about whether these would be helpful for you.^[13]

Living with relapsing pancreatitis requires ongoing attention to lifestyle and self-management. The disease can be bothersome both mentally and physically, even between attacks. However, with proper management and lifestyle modification, patients can improve their quality of life and reduce the frequency of attacks.^[18]