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Внезапни остри болки в горната част на корема може да е сигнал за акутен панкреатит – възпаление на задстомашната жлеза (панкреаса). Панкреасът се намира в горната част на корема. Отдава храносмилателни сокове в тънките черва и произвежда хормони (инсулин), които регулират кръвната захар. Внезапното възпаление на панкреаса (акутен панкреатит) обикновено се провокира от алкохол или жлъчни камъни. - Симптоми на заболяването: - Внезапни, остри болки в горната част на корема. Те се излъчват към гърба, понякога и към гърдите; - Гадене, повръщане, подуване на корема; - Температура, чувство за болест. Кои са причините за острия (акутен) панкреатит? Алкохолът е една от основните причини за възникване на острия панкреатит. При това количеството не е от решаващо значение. При някои хора възпалението може да се получи дори от малки количества. Заболявания на жлъчните пътища Камъните в жлъчката също са честа причина. Те могат да запушат както нейния канал, така и този на панкреаса. И двата се отварят в тънкото черво. Такова запушване задръства жлъчката. Възпалява обаче и задстомашната жлеза, тъй като храносмилателните сокове не могат да се оттичат. По-рядко причинителите са: - Определени медикаменти – диуретици, АСЕ-блокери, понижаващи мазнините в кръвта, някои антибиотици, цитостатици или болкоуспокояващи. - Смущения в обмяната на веществата (повишени триглицериди) - Хиперфункция на паращитовидната жлеза - Вирусна инфекция (морбили), бактерии (салмонели и др.) или инфекция с паразити - Механични прегради на изхода на жлезата като тумори - Геентични фактори – например наследствен панкреатит, муковисцидоза и др. - Пушенето също повишава риска от панкреатит. При част от пациентите първопричината за заболяването остава неизяснена. Как се поставя диагнозата Силните болки обикновено веднага водят пациентите при лекаря. Той ги разпитва за точните оплаквания, предишни заболявания и т.н. Тогава се прави физическо обследване на пациента. Кръвни изследвания Изследване на кръвта може да покаже повишени ензимни стойности. Особено важно е нивото на липазата. Често повишени са нивата на белите кръвни телца и други възпалителни маркери. Ако стойностите на SGOT, Gamma-GT, алкалните фосфати и билирубин са нагоре, значи проблемът е свързан и с жлъчката. Трябва да се провери дали първопричината не е жлъчен камък, който запушва каналите. Силни отклонения в С-реактивен протеин, кръвна захар, хематокрит и калций са признак за очаквано тежко протичане на панкреатита. Отклоненията в лабораторните стойности трябва да се тълкуват в контекста на цялостната клинична картина при пациента. Образни изследвания в помощ на диагнозата Ултразвуковото изследване дава представа за структурата на задстомашната жлеза. Понякога то открива и камъни в жлъчката, които провокират възпалението. Ендоскопското изследване дава още по-точен поглед върху състоянието на панкреаса. Възможно е още да се назначи образно изследване с компютърен томограф или ядрено-магнитен резонанс. Лечение на остър панкреатит По правило острият панкреатит се лекува в болница. Тежките случаи дори попадат в интензивното. Освен болкоуспокояващи пациентът получава и венозно вливане на течности. Около 80% от болните се възстановяват в рамките на една-две седмици. Около 15-20 процента протичат много тежко. Част от тъканите на панкреаса умират. Лечението е трудно и дълго. Рискът от сериозно усложнения нараства. Дали ще протече тежко или леко, не може да се каже в самото начало. Хранене при панкреатит В началото се препоръчва въздържане от храна. В леките случаи може да се яде след ден-два. Условието е симптомите като болка, гадене, повръщане да са отслабнали. Храната трябва са е лесносмилаема и бедна на мазнини. Ако панкреатитът продължава по-дълго или протича тежко, се прилага изкуствено хранене чрез сонда. През носа тя доставя нужните на организма хранителни вещества в стомаха или тънките черва. При тежко възпаление може да се получи събиране на течности в панкреаса. Бактериите се размножават, образува се гной. Това налага поставяне на катетър (малка тръбичка) с цел извеждане на гнойта. Ако има признаци на бактериална инфекция, се дава и антибиотик. Само в някои случаи се налага миниинвазивна операция за остраняване на мъртва тъкан от панкреаса. При тежко протичащ панкреатит пациентът може да стигне и до сепсис – отравяне на кръвта. Това е тежко състояние, при което може да откажат сърцето, белия дроб и бъбреците. На по-късен етап при панкреатит може да се образуват малки кухи пространства около панкреаса (псевдокисти). В тях може да се събере храносмилателен сок, който не може да се оттече. Препоръчително е изпразването на такива псевдокисти при определени предпоставки. След прекаран панкреатит, излекуван успешно, има някои препоръки към пациентите. Те трябва да се стремят към здравословен начин на живот. Той включва много движение и разнообразно здравословно хранене. Порциите трябва да са малки, но по-често. Кога може да се пие отново алкохол? Ако възпалението е предизвикано от алкохол, пациентът трябва да се откаже от консумацията му или да пие само по изключение. Повечето лекари препоръчват въздържание 6 до 12 месеца след прекаран панкреатит, каквато и да е първопричината за него. Консултант на статията е проф. Маркус Бюхлер, началник на Отселението по обща, висцерална и трансплантационна хирургия към Университета в Хайделберг.
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Topic Overview 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. The digestive enzymes are produced in one part of the pancreas and travel into the bowel along a duct. If the duct is blocked or injured, these enzymes can leak out 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 heavy alcohol use. 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, heavy alcohol use is the most common cause of 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 the middle of 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 examination 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 a CT scan, or an ultrasound of your belly (abdominal ultrasound) to look for gallstones. Sometimes a special MRI test (magnetic resonance cholangiopancreatography (MRCP)) is used to look for signs of blocked ducts as the cause of the pancreatitis. 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, these changes are possible. Health Tools Health Tools help you make wise health decisions or take action to improve your health. Cause 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 most common cause of ongoing pancreatitis (chronic pancreatitis).footnote 1 Other causes of chronic pancreatitis include cystic fibrosis or a blockage in the pancreas. Chronic pancreatitis may run in families. And smoking cigarettes seems to increase the risk for this disease. In about 1 out of 4 cases, doctors aren't sure what causes it.footnote 2 Experts don't 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. Symptoms The main symptom of sudden (acute) pancreatitis is sudden moderate to severe pain in the upper area of the belly (abdomen). Sometimes 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 reduces the pain. 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 pain in the upper abdomen. Other conditions that have similar symptoms include bowel obstruction, appendicitis, cholecystitis, peptic ulcer disease, and diverticulitis. What Happens 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 these people 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. 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 occur after one or more episodes of acute pancreatitis. The most common cause of chronic pancreatitis is long-term heavy alcohol use. What happens during the course of chronic pancreatitis varies. Ongoing pain and complications often occur. 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. This happens because the pancreas no longer produces enzymes needed to digest fat and protein. So 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.footnote 3 What Increases Your Risk Several things can increase your risk of pancreatitis, including: - Alcohol misuse. The amount needed to cause pancreatitis is not known. Alcohol tolerance varies from one person to another. Moderate consumption is considered no more than 3 alcoholic beverages a day for men and 2 a day for women and older people. - A family history of pancreatitis. - A high level of fat (triglycerides) in the blood. - Gallstones. A small gallstone can move far enough into the bile duct to block the flow of pancreatic enzymes into the small intestine. - Having cystic fibrosis. - Smoking cigarettes. - 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). - Taking certain medicines, including estrogen therapy and some antibiotics. When should you call your doctor? 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 Your family doctor or general practitioner can diagnose and treat pancreatitis. You may be referred to a specialist, such as a gastroenterologist (specialist in diseases of the digestive system). Examinations and Tests If your doctor thinks you have pancreatitis, he or she will ask questions about your medical history and do a physical examination 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. - Magnetic resonance cholangiopancreatogram (MRCP). This form of MRI can detect gallstones in the common bile duct. This test is not available everywhere. - 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. Sometimes an MRI is used to look for signs of pancreatitis. It provides information similar to that of a CT scan. 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 Overview 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 several 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 is the most common cause 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: Drinking and Your Health. 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 need surgery or another procedure 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. Your doctor will want to see you regularly to make sure that your pain medicine is helping you and that you do not have 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 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. 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. Prevention 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 3 alcoholic beverages a day for men and 2 a day for women and older people. Smoking may increase your chance of having pancreatitis. If you smoke, it's a good idea to quit. Home Treatment 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: Drinking and Your Health. Although the role of diet in pancreatitis is not clear, doctors recommend eating a low-fat diet and staying at a healthy body weight. Medications 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. Medicine choices You may need one or more medicines to treat chronic pancreatitis. Be safe with medicines. Read and follow all instructions on the label. - Pain medicine. Mild pain is first treated with a medicine such as acetaminophen or ibuprofen. If you have stronger pain, you may be given an opioid pain reliever. - 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 (belly) 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 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). The gallbladder may be removed to prevent future attacks from gallstones. Surgery choices One of two surgeries can be done to remove the gallbladder if gallstones are causing pancreatitis: Surgeons may choose among several techniques to remove damaged pancreatic tissue. Other Treatment Endoscopic retrograde cholangiopancreatogram (ERCP) is a procedure used to remove one or more gallstones from the common bile duct. ERCP can also be used to widen or drain blocked ducts and insert stents. Related Information References Citations - Forsmark CE (2010). Chronic pancreatitis. In M Feldman et al., eds., Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 9th ed., vol. Philadelphia: Saunders. - Cote G, et al. (2011). Alcohol and smoking as risk factors in an epidemiology study of patients with chronic pancreatitis. Clinical Gastroenterology and Hepatology, 9(3): 266–273. - Forsmark CE (2010). Chronic pancreatitis. In M Feldman et al., eds., Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 9th ed., vol. Philadelphia: Saunders. Other Works Consulted - 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. - Conwell DL, et al. (2015). Acute and chronic pancreatitis. In DL Kasper et al., eds., Harrison's Principles of Internal Medicine, 19th ed., vol. New York: McGraw-Hill Education. - Kocher HM, Kadaba R (2015). Chronic pancreatitis: Dietary supplements. BMJ Clinical Evidence. http://clinicalevidence.bmj.com/x/systematic-review/0417/overview.html. Accessed April 14, 2016. - Steer ML (2006). Acute pancreatitis. In MM Wolfe et al., eds., Therapy of Digestive Disorders, 2nd ed., pp. 417–426. Philadelphia: Saunders Elsevier. - 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. Credits Current as of: August 12, 2019 Author: Healthwise Staff Medical Review: Gregory Thompson MD - Internal Medicine Brian D. O'Brien MD - Internal Medicine Adam Husney MD - Family Medicine Kathleen Romito MD - Family Medicine Peter J. Kahrilas MD - Gastroenterology - Top of the page Next Section:Health Tools Previous Section:Topic Overview - Top of the page Next Section:Cause Previous Section:Health Tools - Top of the page Next Section:Symptoms Previous Section:Cause - Top of the page Next Section:What Happens Previous Section:Symptoms - Top of the page Next Section:What Increases Your Risk Previous Section:What Happens - Top of the page Next Section:When should you call your doctor? Previous Section:What Increases Your Risk - Top of the page Next Section:Examinations and Tests Previous Section:When should you call your doctor? - Top of the page Next Section:Treatment Overview Previous Section:Examinations and Tests - Top of the page Next Section:Prevention Previous Section:Treatment Overview - Top of the page Next Section:Home Treatment Previous Section:Prevention - Top of the page Next Section:Medications Previous Section:Home Treatment - Top of the page Next Section:Surgery Previous Section:Medications - Top of the page Next Section:Other Treatment Previous Section:Surgery - Top of the page Next Section:Related Information Previous Section:Other Treatment - Top of the page Next Section:References Previous Section:Related Information - Top of the page Next Section:Credits Previous Section:References - Top of the page Current as of: August 12, 2019 Author: Healthwise Staff Medical Review:E. Gregory Thompson MD - Internal Medicine & Brian D. O'Brien MD - Internal Medicine & Adam Husney MD - Family Medicine & Kathleen Romito MD - Family Medicine & Peter J. Kahrilas MD - Gastroenterology