Pancreatitis is a condition where the pancreas becomes inflamed. The pancreas is an organ located behind the stomach that produces enzymes that help digest food and hormones like insulin that regulate blood sugar levels. An inflamed pancreas can cause severe abdominal pain and other complications.
Pancreatitis often occurs as isolated incidents, known as acute pancreatitis, but some people experience repeated bouts of acute flareups. This is known as chronic pancreatitis. An acute flareup of chronic pancreatitis can cause serious health problems.
There are several potential causes of both acute and chronic pancreatitis. Understanding what might trigger pancreatitis to flare up can help patients avoid triggers and prevent repeated painful episodes.
Gallstones
One of the most common causes of pancreatitis, both acute and chronic, is gallstones. Gallstones are hard deposits that form in the gallbladder, which sits next to the pancreas. These stones can block the pancreatic duct, which normally allows digestive enzymes from the pancreas to flow into the small intestine.
Blocking this duct causes digestive enzymes to back up into the pancreas itself. The enzymes start “digesting” the pancreas, causing inflammation and potential tissue damage. Gallstones are responsible for 35-40% of cases of acute pancreatitis.
Gallstones usually form when there is too much cholesterol or bilirubin in the bile produced by the liver. Risk factors for developing gallstones include:
- Obesity
- Rapid weight loss
- Pregnancy
- Family history
- Age over 40
- High-fat, low-fiber diet
- Diabetes
- Liver cirrhosis
- Certain medications
An acute gallstone-related pancreatitis flareup often follows a fatty meal, which stimulates the gallbladder to contract. The stones get squeezed into the pancreatic duct and cause a blockage. Treatment involves pain management and may require surgery to remove the gallbladder.
Heavy Alcohol Use
After gallstones, alcohol consumption is the second leading cause of both acute and chronic pancreatitis. About 30% of cases of chronic pancreatitis are caused by alcohol abuse. Drinking heavily for many years can lead to permanent pancreatic damage.
The exact mechanism is not fully understood, but a few theories exist. Alcohol may:
- Damage pancreas cells directly
- Interfere with digestive enzymes so they activate inside the pancreas
- Cause sphincter muscles to spasm and block pancreatic ducts
- Lead to higher calcium levels inside pancreas cells, causing toxicity
The risk of alcoholic pancreatitis goes up the more heavily and frequently someone drinks. Binge drinking is especially linked to episodes of acute pancreatitis. Quitting alcohol use is key to preventing further damage and controlling flareups.
High Triglycerides
Triglycerides are a type of fat found in the blood. If triglyceride levels get too high, they can cause an attack of acute pancreatitis. About 10% of pancreatitis cases are related to high triglycerides.
Normal triglyceride levels are below 150 mg/dL. Triglyceride levels from 500-1,000 mg/dL increase the risk of pancreatitis. Levels over 1,000 mg/dL substantially increase the risk of recurrent acute pancreatitis.
Several medical conditions can cause high blood triglycerides, including:
- Obesity
- Metabolic syndrome
- Type 2 diabetes
- Hypothyroidism
- Chronic kidney disease
- Pregnancy
High triglycerides can also be caused by certain medications, cigarette smoking, excess alcohol, and a diet very high in carbohydrates. Losing weight, limiting alcohol, quitting smoking, and controlling diabetes and thyroid levels can all help lower triglycerides.
Medications
Some medications can cause drug-induced pancreatitis. The medication causes toxicity to the pancreas, triggering inflammation. Medications that pose a risk include:
- Azathioprine
- 6-mercaptopurine
- Pentamidine
- Sulfonamides
- Tetracycline
- Valproic acid
- Estrogen
- Furosemide
- Meglitinides
- ARBs (blood pressure medications)
In most cases, stopping the medication will resolve drug-induced pancreatitis. However, the condition can sometimes progress to chronic pancreatitis. Let your doctor know if you develop any symptoms of pancreatitis after starting a new medication.
Viral and Bacterial Infections
Viruses are responsible for about 10-15% of acute pancreatitis cases. The most common include:
- Mumps
- Coxsackie B virus
- Cytomegalovirus
- Hepatitis B
- HIV
- Varicella-zoster virus
It’s thought these viruses directly invade the pancreas cells and cause inflammation. In most cases, the pancreatitis resolves once the virus clears the body.
More rarely, bacteria like mycoplasma, salmonella, and legionella can reach the pancreas through the bloodstream or duct system and lead to an episode of acute pancreatitis. This accounts for less than 5% of cases. Again, the pancreatitis usually resolves once the infection is treated.
Genetic Mutations
In about 20% of cases, chronic pancreatitis is caused by genetic mutations passed down through families. Mutations in genes like PRSS1, CFTR, SPINK1 alter the production or function of digestive enzymes made by the pancreas.
This can lead to premature activation of enzymes inside pancreatic cells, causing autodigestion and chronic inflammation over time. Acute flareups also occur periodically in people with these genetic mutations.
Anatomical Abnormalities
Rarely, anatomical issues can obstruct the outflow of pancreatic enzymes, leading to pancreatitis. This includes:
- Pancreas divisum – the pancreatic ducts don’t fuse properly during development
- Sphincter of Oddi dysfunction – spasms in the sphincter muscles that regulate pancreatic flow
- Duodenal obstruction
- Cystic lesions that block ducts
These structural abnormalities usually require surgery or endoscopic procedures to resolve and prevent recurrent pancreatitis episodes.
Autoimmune Pancreatitis
In some cases, the immune system mistakenly attacks the pancreas, causing chronic inflammation known as autoimmune pancreatitis. This accounts for about 5% of chronic pancreatitis cases. The condition usually responds well to steroids to suppress the immune attack.
Trauma
Any trauma to the abdomen that damages the pancreas can trigger an episode of acute pancreatitis. This might include:
- Car accidents, especially with a steering wheel injury
- Falling and hitting the abdomen
- Surgery complications
- ERCP procedure complication
Blunt force trauma or surgery can bruise, lacerate, or damage the pancreas enough to cause leaking of enzymes. This type of pancreatitis is often severe but usually resolves as the pancreas heals.
Metabolic Disorders
Rare metabolic disorders like hypercalcemia (high calcium in the blood) and hyperlipidemia besides high triglycerides can increase the risk of recurrent acute pancreatitis episodes. The mechanism is not always fully understood.
Managing the underlying condition can help reduce flareup frequency. For instance, bringing down high calcium levels can help prevent hypercalcemia-related pancreatitis flareups.
Risk Factors
Aside from direct causes, several risk factors make people more vulnerable to acute and chronic pancreatitis. These include:
- Obesity
- Smoking
- Age – older than 65
- African American ethnicity
- Family history
- Cystic fibrosis
- Low antioxidant levels
- High calcium levels
The more risk factors someone has, the higher their vulnerability. However, even with risk factors, direct causes like gallstones usually precipitate an individual episode of acute pancreatitis.
Symptoms
Pancreatitis symptoms arise when digestive enzymes spawn an “attack” against the pancreas. In acute flareups, symptoms usually come on suddenly and severely.
Common symptoms include:
- Upper abdominal pain that radiates to the back
- Nausea and vomiting
- Fever
- Rapid heartbeat
- Tenderness of the abdomen
- Diarrhea
- Swelling or fluid buildup in the abdomen
With chronic pancreatitis, long-term inflammation destroys the pancreas over time. Attacks may produce less acute pain but can seriously impair production of insulin and digestive enzymes over time leading to diabetes and poor digestion.
Diagnosis
Acute pancreatitis is often diagnosed based on symptoms, along with blood tests and imaging scans. Tests used to diagnose pancreatitis and determine the cause include:
- Serum amylase/lipase – enzymes released by the inflamed pancreas
- Complete metabolic panel – checks pancreatic function
- CBC – checks for infection markers
- Triglycerides test
- Calcium test
- Imaging – CT scan, MRI, ultrasound of the pancreas
- MRCP or ERCP – views the pancreatic and bile ducts
- Stool test – checks for infectious causes
For chronic pancreatitis, blood tests, imaging, and biopsy may be used to confirm structural damage and diagnose the underlying condition causing it.
Treatment
Treatment during an acute pancreatitis flareup focuses on:
- Pain management – usually intravenous fluids and medications
- Preventing complications like organ failure, infection, and excessive enzyme release
- Providing pancreatic rest – no food or liquids by mouth for a brief time
- Treating any underlying causes – gallstones, high triglycerides, etc.
Severe cases may require intensive care. Once the flareup resolves, addressing any identified underlying cause can help prevent recurrence.
For chronic pancreatitis, treatment aims to relieve pain and preserve as much pancreatic function as possible. This can involve:
- Pain medication or surgery to block pain signals
- Treating any underlying conditions
- Pancreatic enzyme supplements
- Insulin for diabetes
- Low-fat diet
- Surgery in some cases
Quitting alcohol use and not smoking is also critical for chronic pancreatitis patients.
Prevention
It’s not always possible to prevent pancreatitis completely, especially if genetic factors are involved. But several strategies can reduce the odds of flareups.
- Prevent gallstones – eat a low-fat diet, lose weight if obese, control diabetes, and avoid rapid weight loss.
- Limit alcohol – stop heavy drinking, follow alcohol intake guidelines, and get help if needed.
- Control triglycerides – exercise, lose weight, limit carbs and fat, take medication if levels are very high.
- Be cautious with medications – avoid unnecessary medications associated with pancreatitis.
- Treat infections promptly – see a doctor for viruses and get appropriate treatment.
Patients who’ve had pancreatitis before should avoid known triggers. Report any concerning symptoms early to get treatment promptly.
Complications
Pancreatitis flareups can lead to life-threatening complications, especially in severe cases. Potential problems include:
- Dehydration – fluids are lost from vomiting, fever, and abdominal swelling.
- Low blood pressure – can develop from dehydration.
- Pleural effusion – fluid around the lungs.
- Acute respiratory distress syndrome – fluid in the lungs.
- Heart or kidney failure
- Gastrointestinal bleeding – enzymes digest organs near the pancreas.
- Impaired pancreatic function – inhibiting digestion and insulin over time.
- Diabetes – from loss of insulin-producing cells.
- Infection – bacteria reach damaged pancreatic tissue.
- Cysts or pseudocysts – fluid-filled sacs in the pancreas.
Patients hospitalized for pancreatitis need close monitoring for signs of these complications. Quick treatment is vital.
Outlook
Mild cases of acute pancreatitis often resolve in a few days with conservative treatment. Severe cases have a mortality rate around 10-30%. Prompt medical care lowers the risks.
Chronic pancreatitis cannot be cured but can be managed with lifestyle changes and treatment. This helps preserve pancreatic function and prevent flareups. Quitting alcohol and smoking greatly improves the long-term outlook.
By understanding what triggers pancreatitis flareups, patients can make appropriate lifestyle changes and work with their doctor to prevent attacks and complications.
Conclusion
Pancreatitis is a complex condition with several potential causes. Gallstones, alcohol abuse, high triglycerides, and certain medications are among the top triggers. Genetic and anatomical factors also play a role for some patients.
Losing weight, limiting alcohol intake, controlling related conditions, and avoiding medication risks can all help prevent flareups. Seeking prompt treatment when flareup symptoms arise allows for better management and reduces the risk of serious complications.
Patients with recurrent pancreatitis require diligent follow-up to preserve pancreatic function and prevent long-term damage. But with proper care and lifestyle adjustments, it’s often possible to manage chronic pancreatitis and maintain a good quality of life.