Recurrent acute pancreatitis (RAP)
What is it?
Pancreatitis is an inflammatory disease of the pancreas characterized by abdominal pain of pancreatic origin, which often recurs several times a year, and is also associated with biliary colic lasting several days and spontaneously regressing. The causes of recurrent episodes of pancreatitis are:
- congenital anomalies of the pancreas (for example, pancreas divisum occurs in about 7% of the population);
- presence of bile excessively rich in bile crystals or thick bile (lithogenic bile);
- presence of gallstones, sometimes small in size and not recognized by conventional methods of examination (ultrasound);
- presence of malfunction (dysfunction) of the Oddi’s sphincter, an anatomic structure through which the choledochus and the main pancreatic duct flow into duodenum;
- mutations in the CFTR gene (mucoviscidosis);
- vascular disorders;
- side effects of chronically taken medications.
In 30% of cases, however, there is no documented cause, and therefore pancreatitis is defined as idiopathic.
Which are the symptoms?
Biliary pain is localized in the right upper abdomen, radiates to the back of the abdomen in the direction of the right shoulder blade and alternates between high intensity and relief (colic). On the other hand, the pain in the pancreas is constant, dull, usually localized in the upper central part of the abdomen, radiates to the right and/or left side, and sometimes to the back (pain in the waist). In severe acute pancreatitis, pseudocysts or intra- and peripancreatic clusters may develop.
How is it diagnosed?
The diagnosis is usually made when the pain is associated with an increase in the concentration of amylase in blood serum and urine. The diagnosis of the recurrent pancreatitis is most often missed due to an incorrect interpretation of pain, which is most often attributed to irritable bowel syndrome or acute gastritis.
This is due to the fact that the increase in the level of pancreatic enzymes in most cases is short-lived, so by the time the patient undergoes laboratory tests, the indicators return to normal.
A number of studies make it possible to diagnose recurrent pancreatitis and identify its cause. The most commonly used is ultrasound scan of the upper abdominal cavity, which can also be performed after the administration of secretin, a synthetic hormone that is also produced by the body, especially during meals. Thus, the pancreas is visualized when imitating a meal, i.e. at a time when it is easiest to detect any deviations from the norm.
In cases where a more detailed visualization of the pancreas and biliary tract is required, endoscopic retrograde cholangiopancreatography (ERCP) and/or magnetic resonance cholangiopancreatography (MRI) is performed, which, unlike ERCP, is non-invasive. Like ultrasound, MRI is performed before and immediately after secretin administration. This increases sensitivity in the diagnosis of morphological changes in the biliopancreatic ducts and makes it possible to observe their emptying into the duodenum, which is often disturbed in this disease. Bile collection and light microscopic analysis reveals the unknown biliary nature of pancreatitis (biliary sandy pancreatitis). The search for mutations in the CFTR gene makes it possible to identify patients carrying the genotype of mucoviscidosis, which leads to the production of thicker than normal pancreatic juice.
The importance of conducting these studies and repeating them after a while is due to the possible development into chronic pancreatitis, a disease that can cause fat malabsorption and diabetes.
How is it treated?
- Medical therapy: in the case of lithogenic bile or biliary sediment, prolonged intake of bile salts (heno- or ursodeoxycholic acid and taurocholic acid) can change the composition of bile and prevent episodes of acute pancreatitis, if they are caused by it. There is no other effective medical therapy for this condition.
- Endoscopic therapy: endoscopic papillosphincterotomy performed during ERCP is the only surgical intervention that can prevent, with minimal trauma, the recurrence of pancreatitis episodes in a large percentage of cases. It cleanses the biliary tract of micro calcium or bile sand by dissecting the Oddi’s sphincter, eliminates the increase in endoluminal pressure that occurs in two areas, biliary and pancreatic, due to a malfunction of the sphincter, and treats the pancreatic divisum.
- Surgical treatment: in case of gallstones or complications of pancreatitis (pseudocysts, abscess), surgery is indicated.
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