Acute pancreatitis
Acute pancreatitis is sudden inflammation of the pancreas. It ranges from a mild, self-limiting illness that settles within a few days to a severe, life-threatening condition requiring intensive care. Most patients recover fully. The two priorities are supporting the patient through the acute illness and identifying the cause, because untreated causes recur.
How it forms
The pancreas produces powerful digestive enzymes, which are normally secreted in an inactive form and only activated once they reach the duodenum. Acute pancreatitis begins when these enzymes are activated prematurely, inside the gland itself. Trypsinogen converts to trypsin within the acinar cells, which then activates the remaining enzymes, and the pancreas begins to digest its own tissue.
This triggers an inflammatory cascade. In mild disease the process remains confined to the gland, producing oedema that resolves. In severe disease the inflammatory response becomes systemic, with release of mediators causing capillary leak, fluid loss into the tissues, organ dysfunction, and in some cases death of pancreatic tissue (necrosis), which may subsequently become infected.
The two dominant causes account for the majority of cases:
- Gallstones — a stone passing from the gallbladder obstructs the ampulla, where the bile and pancreatic ducts meet, and blocks pancreatic drainage. This is the commonest cause in Cyprus.
- Alcohol — through direct toxic effects on acinar cells and changes in secretion.
Other causes include high triglycerides, hypercalcaemia, certain medications, ERCP, trauma, viral infection, autoimmune pancreatitis, pancreas divisum, and obstruction by a tumour. In a proportion of cases no cause is found, and this group deserves particular attention — an unexplained episode in an older patient warrants imaging to exclude an underlying tumour.
Symptoms
- severe, constant upper abdominal pain, typically boring through to the back, often relieved by leaning forward
- nausea and persistent vomiting
- abdominal distension and tenderness
- fever
- rapid pulse, low blood pressure and confusion in severe disease
- jaundice if a stone remains obstructing the bile duct
How the diagnosis is made
Diagnosis requires two of the following three: characteristic abdominal pain; serum amylase or lipase at least three times the upper limit of normal; and characteristic findings on imaging. Lipase is the more specific test and remains elevated longer.
The height of the enzyme level does not indicate severity — a point worth making, as patients frequently assume it does.
Ultrasound is performed early in every case to look for gallstones and bile duct dilatation, because identifying a biliary cause changes management. CT is not needed to make the diagnosis and is best deferred for several days unless the diagnosis is in doubt, since necrosis takes time to become apparent; a scan performed too early underestimates it. MRCP or endoscopic ultrasound is used where a retained duct stone is suspected.
Severity is assessed clinically and by the presence of organ failure, using the revised Atlanta classification: mild (no organ failure or local complications), moderately severe (transient organ failure or local complications), and severe (persistent organ failure). Scoring systems assist, but persistent organ failure beyond 48 hours is the practical marker of severe disease.
Treatment
Supportive care — the mainstay
There is no drug that treats acute pancreatitis directly. Treatment is supportive and, done well, is what determines outcome:
- Fluid resuscitation — goal-directed intravenous fluid, with the balance mattering in both directions: too little worsens perfusion, too much causes complications.
- Analgesia — adequate pain relief, including opioids where required.
- Nutrition — early oral feeding as tolerated in mild disease, rather than prolonged starvation. Where oral intake is not possible, enteral feeding by tube is preferred to intravenous nutrition.
- Monitoring for organ dysfunction, with escalation to high-dependency or intensive care where needed.
Prophylactic antibiotics are not given routinely; they are reserved for proven or strongly suspected infection.
Treating the cause
This is where acute pancreatitis is genuinely prevented from recurring. For gallstone pancreatitis, cholecystectomy is recommended — during the same admission for mild disease, or deferred until inflammation settles in severe disease. Delaying it leaves a substantial risk of a further, potentially worse, attack. Urgent ERCP is indicated where there is cholangitis or persistent biliary obstruction.
Alcohol-related disease requires abstinence and proper support in achieving it. Metabolic causes require correction of triglycerides or calcium.
Managing complications
Local complications include acute fluid collections, pseudocysts, and necrosis which may become walled off. Many resolve without intervention, and the modern principle is to delay intervention wherever possible — typically beyond four weeks, allowing collections to become walled off, which makes treatment safer.
When intervention is required, a step-up approach is standard: percutaneous or endoscopic drainage first, progressing to minimally invasive necrosectomy only if drainage fails. Open surgical necrosectomy is now reserved for situations where less invasive approaches are not possible. This represents a substantial change from practice of twenty years ago and has improved outcomes considerably.
Recovery
Mild pancreatitis usually settles within three to seven days with full recovery. Severe disease may involve weeks in hospital, and recovery over months. Some patients are left with lasting pancreatic insufficiency requiring enzyme replacement, or diabetes, particularly after extensive necrosis.
Follow-up
Follow-up ensures the cause has been addressed — that the gallbladder has been removed, that alcohol has been tackled, that lipids are controlled. In cases where no cause was found, further imaging is arranged to exclude an underlying pancreatic tumour, particularly in patients over fifty.
When to seek medical attention
Severe, persistent upper abdominal pain with vomiting requires immediate assessment in hospital, not a routine appointment. Anyone who has had gallstone pancreatitis and has not yet had their gallbladder removed should ask when that is planned — the risk of recurrence in the interval is real and avoidable.
Common questions
What caused my pancreatitis?
In most people, one of two things: gallstones, which temporarily block the duct where bile and pancreatic juice leave, or alcohol. Together these account for the large majority. Other causes include high blood triglycerides, certain medications, a procedure on the bile duct, and occasionally a tumour. Identifying the cause matters, because it determines what is done to prevent a recurrence.
Why do I need my gallbladder removed?
Because if gallstones caused the attack, the risk of a further and possibly more severe attack is high — and it is highest in the first weeks. For a mild attack, removing the gallbladder during the same hospital admission is recommended rather than waiting, as delay carries a real risk of readmission with another attack.
Why am I being given so much fluid through a drip?
Because the inflamed pancreas leaks large volumes of fluid out of the circulation into the abdomen and tissues, so you become dehydrated even though nothing is visibly lost. Adequate fluid in the first day or two protects the pancreas and the kidneys, and it is one of the few treatments that genuinely changes the course.
Should I be starved?
No — this is a change from older practice. Eating as soon as you are able, rather than being kept nil by mouth for days, is now known to shorten the illness and reduce complications. If you cannot eat, feeding through a fine tube into the gut is preferred to feeding through a drip.
Do I need antibiotics?
Not routinely. Antibiotics given preventively do not improve outcomes and encourage resistant organisms. They are given where there is proven infection — typically infected dead pancreatic tissue, or infection in the bile duct — rather than because the pancreas is inflamed.
How serious is it?
Most attacks are mild and settle within a week with fluids, pain relief and nutrition. A minority become severe, with organ failure or death of pancreatic tissue, and those patients need intensive care and a considerably longer recovery. Severity is assessed over the first days rather than at presentation.
I have been told there is a collection around my pancreas. What happens now?
Often nothing immediately. Collections of fluid or dead tissue frequently settle on their own over weeks, and the modern approach is to leave them alone unless they become infected or cause symptoms. When intervention is needed it is done in steps, beginning with a drain placed through the skin or an endoscope, rather than with open surgery.
Will it happen again?
Not if the cause is removed. Having the gallbladder removed, stopping alcohol completely, treating high triglycerides and reviewing medication all prevent recurrence. Repeated attacks, particularly with continued alcohol use, can lead to permanent damage to the pancreas, which is a good reason to act on the cause.
Related conditions
Other conditions of the pancreas covered on this site:
- Pancreatic ductal adenocarcinoma
- Chronic pancreatitis and its complications
- Pancreatic cysts — IPMN and MCN
- Pancreatic neuroendocrine tumours
- Solid pseudopapillary neoplasm and other rare pancreatic tumours
- Periampullary lesions
- Pancreas divisum
- Annular pancreas
This page provides general information and does not replace an individual medical consultation. Assessment and treatment are decided for each patient after review of their history, examination and investigations.