Pancreatitis Overview

Pancreatitis Overview

Pancreatitis simply means inflammation of the pancreas. Located in the upper part of the abdomen, behind the stomach, the pancreas plays an important role in digestion. The pancreas is a gland, producing two main types of substances: digestive juices and digestive hormones.

• Digestive juices include enzymes and bicarbonate. They travel through a small tube called the pancreatic duct that connects the pancreas to the small intestine to the small intestine (duodenum).
  • There, the enzymes help in the break down of proteins and fats in the foods that you eat to permit the nutrients to be absorbed.
  • The bicarbonate neutralizes stomach acid.


• Digestive hormones, mainly insulin and glucagon, are released into the bloodstream. They control the body's blood sugar level, a major source of energy, and are an important role in the cause of diabetes.

Inflammation of the pancreas has various causes. Once the gland becomes inflamed, the condition can progress to swelling of the gland and surrounding blood vessels, bleeding, infection, and damage to the gland. There, digestive juices become trapped and start "digesting" the pancreas itself. If this damage persists, the gland may not be able to carry out normal functions.

Pancreatitis may be acute (new, short-term) or chronic (ongoing, long-term). Either type can be very severe, even life-threatening. Either type can have serious complications.

• Acute pancreatitis usually begins soon after the damage to the pancreas begins. Attacks are typically very mild, but about 20% of them are very severe. An attack lasts for a short time and usually resolves completely as the pancreas returns to its normal state. Some people have only one attack, whereas other people have more than one attack, but the pancreas always returns to its normal state.
• Chronic pancreatitis begins as acute pancreatitis. If the pancreas becomes scarred during the attack of acute pancreatitis, it cannot return to its normal state. The damage to the gland continues, worsening over time.

About 80,000 cases of acute pancreatitis occur in the United States each year. Pancreatitis can occur in people of all ages, although it is very rare in children. Pancreatitis occurs in men and women, although chronic pancreatitis is more common in men than in women.

Pancreatitis Causes

Alcohol abuse and gallstones are the two main causes of pancreatitis, accounting for 80% to 90% of all cases.

Pancreatitis from alcohol use usually occurs in individuals who have been long-term alcohol drinkers for at least five to seven years. Most cases of chronic pancreatitis are due to alcohol abuse. Pancreatitis is often already chronic by the first time the person seeks medical attention (usually for severe pain).

Gallstones form from a buildup of material within the gallbladder, another organ in the abdomen (please see previous illustration). A gallstone can block the pancreatic duct, trapping digestive juices inside the pancreas. Pancreatitis due to gallstones tends to occur most often in women older than 50 years of age.

The remaining 10% to 20% of cases of pancreatitis have various causes, including the following:

• medications,
• exposure to certain chemicals,
• injury (trauma), as might happen in a car accident or bad fall leading to abdominal trauma,
• hereditary disease,
• surgery and certain medical procedures,
• infections such as mumps (not common),
• abnormalities of the pancreas or intestine, or
• high fat levels in the blood.

In about 15% of cases of acute pancreatitis and 40% of cases of chronic pancreatitis, the cause is never known.

Pancreatitis Symptoms

Acute Pancreatitis Symptoms

The most common symptom of acute pancreatitis is pain. Almost everybody with acute pancreatitis experiences pain.

• The pain may come on suddenly or build up gradually. If the pain begins suddenly, it is typically very severe. If the pain builds up gradually, it starts out mild but may become severe.
• The pain is usually centered in the upper middle or upper left part of the belly (abdomen). The pain is often described as if it radiates from the front of the abdomen through to the back.
• The pain often begins or worsens after eating.
• The pain typically lasts a few days.
• The pain may feel worse when a person lies flat on his or her back.

People with acute pancreatitis usually feel very sick. Besides pain, people may have other symptoms and signs.

• Nausea (Some people do vomit, but vomiting does not relieve the symptoms.)
• Fever, chills, or both
• Swollen abdomen which is tender to the touch
• Rapid heartbeat (A rapid heartbeat may be due to the pain and fever, dehydration from vomiting and not eating, or it may be a compensation mechanism if a person is bleeding internally.)

In very severe cases with infection or bleeding, a person may become dehydrated and have low blood pressure, in addition to the following symptoms:

• Weakness or feeling tired (fatigue)
• Feeling lightheaded or faint
• Lethargy
• Irritability
• Confusion or difficulty concentrating
• Headache

If the blood pressure becomes extremely low, the organs of the body do not get enough blood to carry out their normal functions. This very dangerous condition is called circulatory shock and is referred to simply as shock.

Chronic Pancreatitis Symptoms

Pain is less common in chronic pancreatitis than in acute pancreatitis.

Some people have pain, but many people do not experience pain. For those people who do have pain, the pain is usually constant and may be disabling; however, the pain often goes away as the condition worsens. This lack of pain is a bad sign because it probably means that the pancreas has stopped working.

Other symptoms of chronic pancreatitis are related to long-term complications, such as the following:

• Inability to produce insulin (diabetes)
• Inability to digest food (weight loss and nutritional deficiencies)
• Bleeding (low blood count, or anemia)
• Liver problems (jaundice)

When to Seek Medical Care

In most cases, the pain and nausea associated with pancreatitis are severe enough that a person seeks medical attention from a health care practitioner. Any of the following symptoms warrant medical attention:

• Inability to take medication or to drink and eat because of nausea or vomiting
• Severe pain not relieved by nonprescription medications
• Unexplained pain
• Difficulty breathing
• Pain accompanied by fever or chills, persistent vomiting, feeling faint, weakness, or fatigue
• Pain accompanied by presence of other medical conditions, including pregnancy

The health care practitioner may tell the person to go to a hospital emergency department. If a person is unable to reach a health care practitioner, or if a person's symptoms worsen after having being examined by a health care practitioner, an immediate visit to an emergency department is necessary.

Pancreatitis Diagnosis

When a health care practitioner identifies symptoms suggestive of pancreatitis, specific questions are asked about the person's symptoms, lifestyle and habits, and medical and surgical history. The answers to these questions and the results of the physical examination allow the health care practitioner to rule out some conditions and make the correct diagnosis.

In most cases, laboratory tests are needed. The tests check the functioning of several body systems, including the following:

• Pancreas, liver, and kidney functions (including levels of pancreatic enzymes amylase and lipase)
• Signs of infections
• Blood cell counts indicating signs of anemia
• Pregnancy test
• Blood sugar, electrolyte levels (an imbalance suggests dehydration) and calcium level

Results of the blood tests may be inconclusive if the pancreas is still making digestive enzymes and insulin.

Diagnostic imaging tests are usually needed to look for complications of pancreatitis, including gallstones.

Diagnostic imaging tests may include the following:

• X-ray films may be ordered to look for complications of pancreatitis as well as for other causes of discomfort. This may include a chest X-ray.
• A CT scan is like an X-ray film, only much more detailed. A CT scan shows the pancreas and possible complications of pancreatitis in better detail than an X-ray film. A CT scan highlights inflammation or destruction of the pancreas.
• Ultrasound is a very good imaging test to examine the gallbladder and the ducts connecting the gallbladder, liver, and pancreas with the small intestine.
  • Ultrasound is very good at depicting abnormalities in the biliary system, including gallstones and signs of inflammation or infection.
  • Ultrasound uses painless sound waves to create images of organs. Ultrasound is performed by gliding a small handheld device over the abdomen. The ultrasound emits sound waves that "bounce" off the organs and are processed by a computer to create an image. This technique is the same one that is used to look at a fetus in a pregnant woman.
• Endoscopic retrograde cholangiopancreatography (ERCP) is an imaging test that uses an endoscope (a thin, flexible tube with a tiny camera on the end) to view the pancreas and surrounding structures.
  • ERCP is usually used only in cases of chronic pancreatitis or in the presence of gallstones.
  • To perform an ERCP, a person is first sedated. After sedation, an endoscope is passed through the mouth, to the stomach, and into the small intestine. The device then injects a temporary dye into the ducts connecting the liver, gallbladder, and pancreas with the small intestine (biliary ducts). The dye makes is easier for the health care practitioner to see any stones or signs of organ damage. In some cases, a stone can be removed during this test.

Pancreatitis Treatment

Self-Care at Home

For most people, self-care alone is not enough to treat pancreatitis. People may be able to make themselves more comfortable during an attack, but they will most likely continue to have attacks until treatment is received for the underlying cause of the symptoms. If symptoms are mild, people might try the following preventive measures:

• Stop all alcohol consumption.
• Adopt a liquid diet consisting of foods such as broth, gelatin, and soups. These simple foods may allow the inflammation process to get better.
• Over-the-counter pain medications may also help. Avoid pain medications that can affect the liver such as acetaminophen (Tylenol and others). In individuals with pancreatitis due to alcohol use, the liver is usually also affected by the alcohol.

Pancreatitis Medical Treatment

Medical treatment is usually focused on relieving symptoms and preventing further aggravation to the pancreas. Certain complications of either acute pancreatitis or chronic pancreatitis may require surgery or a blood transfusion.

Acute Pancreatitis Treatment

In acute pancreatitis, the choice of treatment is based on the severity of the attack. If no complications are present, care usually focuses on relieving symptoms and supporting body functions so that the pancreas can recover.

• Most people who are having an attack of acute pancreatitis are admitted to the hospital.

• Those people who are having trouble breathing are given oxygen.

• An IV (intravenous) line is started, usually in the arm. The IV line is used to give medications and fluids. The fluids replace water lost from vomiting or from the inability to take in fluids, helping the person to feel better.

• If needed, medications for pain and nausea are prescribed.

• Antibiotics are given if the health care practitioner suspects an infection may be present.

• No food or liquid should be taken by mouth for a few days. This is called bowel rest. By refraining from food or liquid intake, the intestinal tract and pancreas are given a chance to start healing.

• Some people may need a nasogastric (NG) tube. The thin, flexible plastic tube is inserted through the nose and down into the stomach to suck out the stomach juices. This suction of the stomach juices rests the intestine further, helping the pancreas recover.

• If the attack lasts longer than a few days, nutritional supplements are administered through an IV line.

Chronic Pancreatitis Treatment

In chronic pancreatitis, treatment focuses on relieving pain and avoiding further aggravation to the pancreas. Another focus is to maximize a person's ability to eat and digest food.

• Unless people have severe complications or a very severe episode, they probably do not have to stay in the hospital.

• Medication is prescribed for severe pain.

• A high carbohydrate, low fat diet; and eating smaller more frequent meals help prevent aggravating the pancreas. If a person has trouble with this diet, pancreatic enzymes in pill form may be given to help digest the food.

• People diagnosed with chronic pancreatitis are strongly advised to stop drinking alcohol.

• If the pancreas does not produce sufficient insulin, the body needs to regulate its blood sugar, and insulin injections may be necessary.

Surgery

If the pancreatitis is caused by gallstones, an operation to have the gallbladder and gallstones removed (cholecystectomy) is likely.

If certain complications (for example, enlargement or severe injury of the pancreas, bleeding, pseudocysts, or abscess) develop, surgery may be needed to drain, repair, or remove the affected tissues.

Follow-up

The following recommendations may help to prevent further attacks or to keep them mild:

• Stop all alcohol consumption.
• Eat small frequent meals. If in the process of having an attack, avoid solid foods for several days to give the pancreas a chance to recover.
• Eat a diet high in carbohydrates and low in fats.
• If pancreatitis is due to chemical exposure or medications, the source of the exposure will need to be found and stopped, and the medication will need to be discontinued.

Pancreatitis Prevention

Completely eliminating alcohol is the only way to reduce the chance of further attacks in cases of pancreatitis caused by alcohol use, to prevent the pancreatitis from worsening, and to prevent the development of complications that can be very serious or even fatal.

Pancreatitis Prognosis

Most people with acute pancreatitis recover completely from their illness. The pancreas returns to normal with no long-term effects. Pancreatitis may return, however, if the underlying cause is not eliminated.

Some 5%-10% of people develop life-threatening pancreatitis and may be left with any of these chronic illnesses, or even die due to complications of pancreatitis:

• Kidney failure
• Breathing difficulties
• Diabetes
• Brain damage

Chronic pancreatitis does not resolve completely between attacks. Although the symptoms may be similar to those of acute pancreatitis, chronic pancreatitis is a much more serious condition because damage to the pancreas is an ongoing process. This ongoing damage can have any of the following complications:

• Bleeding in or around the pancreas: Ongoing inflammation and damage to the blood vessels surrounding the pancreas can lead to bleeding. Fast bleeding can be a life-threatening condition. Slow bleeding usually leads to low red blood cell count (anemia).
• Infection: Ongoing inflammation makes the tissue vulnerable to infection. The infection can form an abscess that is very difficult to treat without surgery.
• Pseudocysts: Small fluid-filled sacs can form in the pancreas as a result of ongoing damage. These sacs can become infected or rupture into the lower abdominal cavity (peritoneum), causing a serious infection called peritonitis.
• Breathing problems: The chemical changes in the body can affect the lungs. The effect is to reduce the amount of oxygen the lungs can absorb from the air a person breathes. The level of oxygen in the blood drops to lower than normal (hypoxia).
• Pancreas failure: The pancreas may become so severely damaged that it is unable to carry out its normal functions. Digestion of food and regulation of blood sugar - both very important functions - are affected. Diabetes and weight loss often result.
• Pancreatic cancer: Chronic pancreatitis can encourage the growth of abnormal cells in the pancreas, which can become cancer. The prognosis for pancreatic cancer is very poor.

ANAL FISSURE

What is an anal fissure?

An anal fissure is a tear in the lining of the lower rectum (anus) that causes pain during bowel movements. It is a common condition. Anal fissures do not lead to more serious conditions.

Most anal fissures heal with home treatment after a few days or weeks (acute anal fissures). If you have an anal fissure that has not healed after 6 weeks, it is considered a long-term problem (chronic). You may need medicine to help a chronic anal fissure heal. Surgery may be necessary for fissures that do not heal with medicine.

Anal fissures affect people of all ages, particularly young and otherwise healthy people. They are equally common in men and women.

Sometimes an anal fissure and a hemorrhoid develop at the same time.

What causes an anal fissure?

Anal fissures are caused by injury (trauma) to the anal canal. Injury can happen if:

• You pass a large stool that stretches the anal canal.
• You are constipated and try to pass a hard stool.
• You have repeated diarrhea.

Childbirth can also cause trauma to the anal canal. During childbirth, some women develop anal fissures. Fissures can also be caused by digital insertion (as during an examination), foreign body insertion, or anal intercourse.

Because many people get constipated or have diarrhea without getting anal fissures, many experts believe there is some other cause of anal fissures. Some people may have excessive tension in the two muscular rings (sphincters) controlling the anus. The external anal sphincter is under your conscious control. But the internal anal sphincter is not under your control. This muscle remains under pressure, or tension, all of the time. A fissure may develop if the internal sphincter's resting pressure becomes too high, causing spasm and reducing blood flow to the anus. This high resting pressure can also keep a fissure from healing.

In some cases, an anal fissure may be caused by Crohn's disease, an inflammatory bowel disease (IBD) that causes bloody diarrhea, abdominal (belly) pain, fever, weight loss, and fissures or fistulas near the anus.

What are the symptoms?

An anal fissure causes a sharp, stinging, or burning pain during a bowel movement. The pain, which can be severe, may last for a few hours.

Fissures may itch. They often bleed lightly or cause a yellowish discharge. You may see a small spot of bright red blood on toilet tissue or a few drops in the toilet bowl. The blood is separate from the stool. Very dark, tarry stools or dark red blood mixed with stool indicates some other condition, possibly inflammatory bowel disease (IBD) or colon cancer. You should contact a doctor if you have any bleeding with bowel movements.

Sometimes an anal fissure may be a painless wound that won't heal and that bleeds intermittently but causes no other symptoms.

How is an anal fissure diagnosed?

Most doctors can diagnose an anal fissure from symptoms and by looking at the anus. Usually, the doctor can see the fissure by gently separating the buttocks.

A doctor may use a gloved finger (digital rectal examination) or a lighted instrument (anoscope) to examine the fissure. But if the fissure is extremely painful, the doctor will usually wait until it has begun to heal before performing a rectal exam or using an anoscope (anoscopy) to rule out other problems. A topical anesthetic may be used if an immediate examination is necessary.

During an exam, a doctor can also find out whether another condition may be causing the fissure. If you have several fissures or have one or more in an area of the anus where fissures usually do not occur, you may have another condition such as inflammatory bowel disease, syphilis, a suppressed immune system, tuberculosis, HIV infection, or anal cancer. Most fissures occur along the midline—the top or bottom—of the anus.

How is it treated?

Most acute fissures need some home treatment, including soaking in a shallow tub of warm water (sitz bath) 2 or 3 times a day, increasing fiber in the diet, and taking stool softeners or laxatives. Some people find relief in a day or two of home treatment. Although your pain may go away, it may take several weeks for the fissure to heal completely. Sometimes fissures heal without treatment.

Try to prevent constipation, because it can keep a fissure from healing. The pain of a fissure may make you anxious about having bowel movements. But trying not to have bowel movements will only increase constipation and create a cycle that keeps the fissure open and painful.

Drinking lots of water or other fluids also will make stools softer and easier to pass.

You may want to use a nonprescription ointment such as zinc oxide, Preparation H, Anusol, or 1% hydrocortisone to soothe anal tissues. But evidence suggests that fiber and sitz baths help symptoms better than nonprescription creams.³ Talk with your doctor about whether you should use these medicines for a short period of time.

If a fissure lasts a long time, prescription medicine may help. Prescription medicines used to treat anal fissure include nitroglycerin, high blood pressure medicines, and botulinum toxin (Botox).

You may need to consider surgery if medicines do not stop your symptoms. The most commonly used surgery is lateral internal sphincterotomy. In this procedure, a doctor cuts into part of the internal sphincter to relax the spasm that is causing the fissure.

Learning about anal fissure:	What is an anal fissure? What causes an anal fissure? What are the symptoms? What is the treatment?
Being diagnosed:	How is an anal fissure diagnosed? What is anoscopy? Why is the location of a fissure important?
Getting treatment:	What can I do to treat an anal fissure? What medicines might I take? What is nitroglycerin ointment? How is Botox used to treat anal fissures? What surgery is done to heal an anal fissure?

Symptoms

Most anal fissures cause:

• A sharp, stinging or burning pain during a bowel movement. Pain from a fissure may be quite severe. It can be brief or last for several hours after a bowel movement.
• Itching.
• Bleeding, often a small spot of bright red blood on toilet tissue. Tell your doctor if you have any bleeding with a bowel movement.

An anal fissure can be a painless wound that won't heal and that bleeds intermittently but causes no other symptoms.

Exams and Tests

Your doctor can diagnose an anal fissure from your symptoms and a physical exam. The exam may include:

• Looking at the fissure by gently separating the buttocks.
• Digital rectal exam. The doctor uses a gloved finger to feel structures in the anal canal.
• Anoscopy. This exam involves using a short, lighted scope to look into the anal canal.

A doctor usually will wait until the fissure has begun healing before doing a digital rectal exam or anoscopy. If an exam needs to be done immediately, a topical anesthetic can be used to numb the area.

The location of a fissure is important in the diagnosis. If you have more than one fissure or have a fissure on the side of the anus (rather than at the top or the bottom), you may have another condition that is causing fissures. Possible conditions include inflammatory bowel disease (IBD), anal cancer, syphilis, tuberculosis, a suppressed immune system, or HIV infection.

A doctor may look for a small piece of loose skin (a skin tag) in the anus, often a sign of a long-term (chronic) fissure. Skin tags are often mistakenly identified as hemorrhoids.

Treatment Overview

Most short-term (acute) anal fissures can heal with home treatment in 4 to 6 weeks. Pain during bowel movements usually goes away within a couple of days of treatment.

Home treatment involves sitting in warm water (sitz bath) for 20 minutes 2 or 3 times a day, increasing fiber and fluids in the diet, and using stool softeners or laxatives to have pain-free bowel movements. Talk with your doctor about how long you should use laxatives.

Sometimes fissures do not heal with these remedies. A fissure that has not healed after 6 weeks is considered long-term, or chronic, and may need additional treatment.

Medication

Medicines are usually the first-line treatment for chronic fissures.

• A 0.2% nitroglycerin cream can reduce the pressure in the internal anal muscle (sphincter) and allow the fissure to heal. A pea-sized dot of cream is massaged into the fissure and the surrounding area. Do not use a larger amount at one time, because this medicine can cause headaches, lightheadedness, or fainting from low blood pressure. It is a good idea to either wear gloves when applying the nitroglycerin cream or wash your hands right after. The skin on your fingers can absorb the medicine and increase your chance of side effects.
• The calcium channel blockers nifedipine and diltiazem also may help healing, also by reducing the pressure in the internal anal sphincter. These two medicines are available as pills. Also, they can be made into a gel that can be massaged into the fissure and the surrounding area. The pill form of these medicines has more side effects than the gel form.
• Botulinum toxin (Botox) may be injected into the internal anal sphincter. Botox causes temporary paralysis of muscle, which can reduce muscle tension and help the anal fissure heal.

Surgery

Surgery may be done when more conservative treatments fail to heal an anal fissure.

The main surgery for chronic anal fissure is lateral internal sphincterotomy. The doctor makes a small incision into the internal anal sphincter to reduce anal resting pressure.

It is important to understand that, even with surgery, an anal fissure must heal on its own. A sphincterotomy involves operating on the sphincter muscles, not closing the actual fissure.

Lateral internal sphincterotomy has a better success rate than any medicine that is used to treat long-term anal fissures. The results last longer, and fewer people have anal fissures come back after surgery than after treatment with medicine.¹

In some studies, a greater number of people who had lateral internal sphincterotomy had some inability to control gas or stool (incontinence) after surgery compared to people treated with medicine. Despite these results, satisfaction with this surgery is high. And a review of many studies showed that the risk of incontinence was 8%. This means that about 8 out of 100 people who had the surgery had some problem with incontinence. But this rate was not very different from the rates seen in people who were treated with medicine for their chronic anal fissures.²

Another study showed that lateral internal sphincterotomy was better than nitroglycerin cream at healing chronic anal fissures. And there was no difference in long-term continence between the people who used nitroglycerin cream and the people who had surgery.⁴

In some cases, the risk of incontinence is too great to justify doing lateral internal sphincterotomy. This may be true for women who develop a fissure while giving birth, because they typically do not have a high resting pressure in their internal sphincter. A procedure called anal advancement flap may be done instead of sphincterotomy. In this procedure, the edges of the fissure are removed, and healthy tissue is sewn over the area.

Home Treatment

Most short-term (acute) and a few long-term (chronic) anal fissures will heal with home treatment.

• Avoid constipation:
  • Include fruits, vegetables, beans, and whole grains in your diet each day. These foods are high in fiber.
  • Drink plenty of fluids, enough so that your urine is light yellow or clear like water.
  • Get some exercise every day. Try to do moderate activity at least 2½ hours a week. Or try to do vigorous activity at least 1¼ hours a week. It's fine to be active in blocks of 10 minutes or more throughout your day and week.
  • Take a fiber supplement, such as Citrucel or Metamucil, every day if needed. Start with a small dose and very slowly increase the dose over a month or more.
  • Schedule time each day for a bowel movement. Having a daily routine may help. Take your time and do not strain when having a bowel movement.
• Stool softeners or laxatives can make bowel movements more comfortable. Ask your doctor how long you should take laxatives.
• Sitting in a tub filled with a few inches of warm water (sitz bath) for 20 minutes 2 or 3 times a day soothes the torn tissue and helps relax the internal anal sphincter. This may help heal the anal fissure.
• You may want to use ointments or creams such as zinc oxide, Preparation H, or Anusol (which includes an anesthetic). But evidence suggests that fiber and sitz baths help symptoms better than nonprescription creams.³ Creams with hydrocortisone (such as Anusol-HC) can reduce itching and inflammation.
• Although some people may be tempted to use a mirror or have a family member examine a fissure, do not separate the buttocks. Doing so might slow healing of the fissure.
• Instead of using toilet paper, use baby wipes or medicated pads, such as Tucks, to clean after a bowel movement. These products can be less irritating to an anal fissure.

Conservative treatment measures—including using stool softeners or bulking agents and taking regular sitz baths—allow about 9 out of 10 acute anal fissures to heal. And about 4 out of 10 long-term (or chronic) anal fissures will heal after conservative treatment is used.³