Acute pancreatitis
This is a sudden inflammation of the pancreas producing characteristic pain in the upper abdomen radiating to the back, with nausea and vomiting. Most episodes are mild and settle within days, but a proportion take a severe course.
The commonest causes are gallstones and alcohol, followed by raised triglycerides, certain drugs and genetic causes. Identifying the cause is essential, because that is what determines whether it happens again.
After an episode, the work is not finished
Many patients are discharged without the cause being clarified or any plan made to prevent recurrence. If the cause is gallstones and the gallbladder is not removed, the risk of recurrence is high. Reviewing this is one of the most useful consultations available.
Chronic pancreatitis
This is progressive, permanent damage to the pancreas, with fibrosis, which gradually erodes both its functions: digestion and insulin production.
- Recurrent abdominal pain, sometimes severe and hard to control
- Loose, oily stools that are difficult to flush, from poor fat digestion
- Weight loss despite eating normally
- Deficiencies of fat-soluble vitamins and loss of bone density
- Onset of diabetes
What can be done
- Clarify and treat the cause: gallstones, alcohol, triglycerides, genetic cause
- Pain control with a stepped approach, avoiding dependence on opioids
- Pancreatic enzyme replacement at an adequate dose, which is where things most often go wrong
- Assessment and correction of nutritional status and vitamins
- Screening for diabetes and osteoporosis
- Surveillance for complications: pseudocysts, strictures, cancer risk
The enzyme dose is usually too low
This is the commonest error in treating pancreatic insufficiency. Many patients take enzymes and continue to digest poorly simply because the dose is inadequate or because they are taken at the wrong point in the meal.
My work in this area
I have been principal investigator at La Princesa University Hospital in several international clinical trials on acute pancreatitis, including the WATERFALL trial on fluid therapy in the early phase, whose results were published in The New England Journal of Medicine in 2022 and changed standard practice.
I have also been principal investigator for the WATERLAND and WATERFINDER trials and for a trial on preventing recurrent gallstone pancreatitis. Subsequent analyses of WATERFALL have been published in The American Journal of Gastroenterology and Clinical Gastroenterology and Hepatology.