Acute pancreatitis

Disease Description (Causes and Symptoms)

• Definition: Acute pancreatitis is a condition in which pancreatic digestive enzymes (particularly trypsin) become activated and cause acute inflammatory damage to the pancreas itself and surrounding tissues.
• Main causes
  • Most common: Gallstones (transient biliary obstruction), excessive alcohol consumption
  • Other causes: Hypertriglyceridemia, hypercalcemia, certain medications (e.g., some diuretics and anticonvulsants), trauma, after ERCP (endoscopic retrograde cholangiopancreatography), infection, genetic predisposition (familial pancreatitis), etc.
• Pathophysiology summary: Biliary obstruction or alcohol/toxic factors cause premature activation of enzymes within the pancreas → destruction and inflammation → increased vascular permeability, edema, necrosis (in severe cases), and the possibility of multiple organ failure due to a systemic inflammatory response
• Main symptoms
  • Typical: Severe upper abdominal (epigastric) pain — may radiate to the back or shoulder (right or left); worsens when lying down, so the patient may prefer a position with the knees drawn up
  • Associated symptoms: Nausea and vomiting, abdominal distension, fever, jaundice (in gallstone-related cases), gray stools (with steatorrhea or impaired bile excretion)
  • Laboratory findings: Blood amylase and lipase levels elevated to more than three times normal (lipase is particularly more specific), leukocytosis, possible hyperglycemia and hypocalcemia
• Severity assessment: Mild ↔ severe disease (necrosis, infection, multiple organ failure) is distinguished based on clinical indicators (BISAP, Ranson, etc.) and whether organ dysfunction is present

Treatment Methods

• Initial (emergency) management — applies to all patients
  • NPO, prompt intravenous fluid replacement (preferred crystalloid fluid; adequate replacement during the initial 24 hours), monitoring of vital signs, urine output, and electrolytes
  • Pain control: IV analgesics (mainly opioids), antiemetics
  • Active treatment with oxygen and hemodynamic support when necessary (ICU care in severe cases)
• Nutrition
  • Begin nutritional support orally (or via the nasal route [nasogastric tube/enteral nutrition]) as soon as possible (recommended to attempt within 24–48 hours when symptoms and inflammatory markers improve)
• Imaging- and test-based treatment
  • When gallstone-related disease is suspected (or when obstructive jaundice or findings of cholecystitis are present) and biliary obstruction or acute ascending cholangitis is clinically suspected: Biliary drainage using ERCP (endoscopic retrograde cholangiopancreatography). However, immediate ERCP is not required for all cases of gallstone pancreatitis
  • CT: Mainly used to assist diagnosis early on; contrast-enhanced CT when necrosis or complications are suspected (lesions are generally easier to identify 48–72 hours after symptom onset)
• Antibiotics
  • The indiscriminate use of prophylactic antibiotics is not recommended. Appropriate antibiotics should be administered when infection (such as infected necrosis or an abscess) is confirmed or strongly suspected
• Treatment of severe disease and complications
  • Infected necrosis: Image-guided percutaneous drainage → endoscopic or surgical removal when necessary (a “step-up” approach is recommended)
  • Multiple organ failure: Intensive care (respiratory, renal, and hemodynamic support)
  • Hypertriglyceridemia-induced pancreatitis: Consider insulin therapy and, when acutely necessary, plasmapheresis
  • Pancreatic pseudocyst or abscess: Image-guided drainage or endoscopic drainage/surgery
• Prevention of recurrence of gallstone-related acute pancreatitis
  • In mild gallstone-related cases, cholecystectomy during the same hospitalization, either during admission or after recovery, is recommended when possible
  • When the bile duct is obstructed and jaundice/cholangitis is present, early ERCP
• Lifestyle management and precautions (for patients)
  • Abstain from alcohol (essential when alcohol is the cause), avoid high-fat foods (initially), drink sufficient fluids (during recovery), and consult a doctor about whether to stop prescribed medications or supplements
  • Stop the suspected causative medication if drug-induced pancreatitis is suspected

Checklist Before an Outpatient Visit (Including Items to Bring and Example Questions)

• Items to bring (when visiting the hospital)
  • List of currently used medications (including prescriptions, OTC medications, herbal medicines, and supplements)
  • Previous test results (blood tests, ultrasound, CT/MRI, etc.) or available images/reports
  • Record of when symptoms began and how they have progressed (pain severity, location, radiation, triggers), frequency of fever and vomiting, and changes in urine output
  • History of alcohol consumption (frequency and amount), history of gallstones or gallbladder surgery, and family history (pancreatitis or genetic diseases)
• Information to provide to the healthcare professionals during the outpatient visit
  • Recent meals (fat intake), and when medication use began (especially medications started recently)
• Example questions to check before the outpatient visit (to confirm for yourself during the medical visit)
  • Whether the pain persists, whether vomiting or fever is present, and whether there have been changes in urine or stool color (jaundice or steatorrhea)

Examples of General Questions to Ask the Doctor

• What do you think is causing this condition? (Gallstones, alcohol, medication, metabolic abnormalities, etc.)
• Is my condition severe, and do I need hospitalization or intensive care?
• In addition to the recommended initial treatments (fasting, fluids, and pain relief), what other treatments are needed?
• What are the side effects of this medication? (For medications scheduled to be administered)
• What are the risk of recurrence and the prognosis? What lifestyle changes should I make to reduce the risk of recurrence?
• If gallstones are the cause, when should cholecystectomy be performed?

Examples of Disease-Specific Questions

• If my pancreatitis is caused by gallstones, is ERCP immediately necessary, and when do you recommend cholecystectomy?
• My blood triglyceride level is very high. Are plasmapheresis or insulin therapy needed during the acute phase?

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