Chronic pancreatitis is a long-term inflammation of the pancreas that gets worse over time. The pancreas is an important organ located behind the stomach that produces enzymes to help digest food and hormones like insulin to regulate blood sugar levels. In chronic pancreatitis, the pancreas becomes damaged and scarred, which can lead to serious complications.
People with chronic pancreatitis experience occasional flare ups where symptoms suddenly get much worse for a period of time before improving again. These flare ups can be extremely painful and disruptive to daily life. Understanding what causes flare ups to occur can help patients better manage this difficult condition.
What is a flare up in chronic pancreatitis?
A flare up, also sometimes called an acute exacerbation or acute attack, refers to a sudden worsening of chronic pancreatitis symptoms. Typical symptoms during a flare include:
- Severe abdominal pain that may radiate to the back
- Nausea and vomiting
- Fever
- Bloating
- Diarrhea or oily stools
- Unexplained weight loss
- Loss of appetite
For most patients, a flare up lasts between a few days up to a week or two. The abdominal pain is usually the most prominent and disruptive symptom. It can range from dull and aching to very intense and unrelenting.
In some cases, a severe flare up may lead to complications like:
- Dehydration from vomiting
- Malnutrition if eating becomes difficult
- Pancreatic pseudocysts – fluid collections around the pancreas
- Infection of the pancreas or surrounding tissues
- Worsening of diabetes control
- Acute pancreatitis – a sudden serious inflammation of the pancreas
Flare ups disrupt normal functioning and quality of life. Identifying and avoiding triggers is important for minimizing recurrences.
What triggers a flare up of chronic pancreatitis?
Doctors are not always able to pinpoint exactly what causes an episode of worsening symptoms. However, the most common flare triggers include:
Dietary factors
- Fatty, greasy foods – High fat foods require more enzyme secretion from the pancreas to digest. This can overwhelm the already damaged pancreas and trigger pain.
- Overeating – Eating large, heavy meals requires the pancreas to work harder, which can precipitate a flare up.
- Alcohol use – Consuming alcohol is a very common trigger. Alcohol is toxic to the pancreas.
- Caffeine – Coffee, tea, soda and energy drinks may exacerbate inflammation.
- Dehydration – Not drinking enough fluids can contribute to pancreatic secretions thickening and causing blockages.
Medications
- Estrogen therapy – Oral contraceptives and hormone replacement therapy have been associated with worsening symptoms.
- Azathioprine – This immunosuppressant medication can rarely cause pancreatitis flares.
- Certain antibiotics – Antibiotics that are toxic to the pancreas, like tetracyclines, may trigger attacks.
Infections
- Viral infections – Viruses like mumps, Coxsackievirus, hepatitis and HIV can infect and inflame the pancreas.
- Bacterial infections – Bacteria such as Mycoplasma, Legionella and Leptospira can cause pancreatic inflammation.
- Parasitic infections – Parasites like Toxoplasma and Cryptosporidium occasionally involve the pancreas.
Anatomic and structural factors
- Duct obstructions – Scar tissue or stones blocking pancreatic ducts can prevent enzyme secretion and cause backup.
- Dilated ducts – Pancreatic ducts weakened by chronic inflammation may balloon out and obstruct flow.
- Pseudocysts – Fluid collections from previous flares can compress or irritate the pancreas.
Other triggers
- Smoking – Cigarette smoking is harmful to the pancreas in many ways.
- Trauma – Any physical injury to the abdomen may precipitate a flare up.
- Stress – Stress hormones may worsen inflammation.
- Pregnancy – Hormone changes and abdominal compression can aggravate symptoms.
- Medications – Drugs like valproic acid, sulfa antibiotics, lasix, etc. may rarely cause flares.
- Idiopathic – In some cases, no precipitating factor can be identified.
Why do these triggers lead to flare ups?
Researchers believe several mechanisms may explain how these triggers precipitate flare ups in chronic pancreatitis:
- Increased enzyme and fluid secretion – Triggers like high-fat meals require more pancreatic secretion, which may overwhelm an already diseased pancreas.
- Toxic-metabolic effects – Substances like alcohol directly injure pancreatic cells.
- Oxidative stress – Triggers lead to an imbalance of free radicals that worsen inflammation and fibrosis.
- Immune effects – Factors that activate the immune system may incite pancreatic inflammation. The immune system mistakenly attacks the pancreas.
- Obstruction of flow – Structural issues like pseudocysts or duct strictures prevent normal drainage of pancreatic fluids.
- Neurogenic inflammation – Nerves in the pancreas are sensitized to stimuli and promote inflammation when triggered.
The pancreas of someone with chronic pancreatitis is vulnerable to these types of insults. Even mild triggers that would not affect a normal pancreas can set off an exaggerated inflammatory reaction and flare in someone with underlying pancreatic injury.
Are there any blood tests or markers that detect a flare up?
There are a few blood tests that may indicate the onset of a chronic pancreatitis flare up:
- White blood cell count – Levels usually elevate as a reaction to inflammation.
- Blood glucose – Hyperglycemia or hypoglycemia can occur if insulin secretion is impaired.
- Serum amylase/lipase – These digestive enzymes may rise, signifying pancreatic injury.
- Trypsinogen activation peptide – Levels increase when the pancreas is inflamed.
- C-reactive protein – This marker of inflammation commonly increases during flares.
However, these laboratory tests are not always reliable for diagnosing flare ups. Many patients with chronic pancreatitis have normal blood work during an attack. The levels can fluctuate and may not correlate with symptom severity.
Imaging studies like CT scan or MRI may also miss signs of a flare up. Repeat scanning usually isn’t recommended unless a complication like infection is suspected.
For this reason, flare ups are usually diagnosed based on clinical presentation and symptoms rather than blood tests or radiologic findings.
How are flare ups of chronic pancreatitis treated?
The main goals of treating a chronic pancreatitis flare up are:
- Relieving pain and nausea
- Correcting dehydration
- Providing nutritional support
- Preventing complications
- Identifying and treating any precipitating factors
Treatment typically involves:
- Pain medication – Strong analgesics like morphine are often required during severe flares. Some patients benefit from a short course of steroids like prednisone to help control inflammation and reduce pain severity.
- IV fluids – Dehydration is corrected by giving intravenous fluids, especially if the patient is vomiting and cannot keep down oral liquids.
- Antiemetics – Medications to control nausea and vomiting such as ondansetron or promethazine.
- Nutritional support – IV nutrition or enteral feeding may be used if normal food intake isn’t possible. Vitamin supplements are also frequently given.
- Blood sugar monitoring – Insulin therapy is administered if needed for diabetes control.
- Antibiotics – If an infection is suspected, broad spectrum antibiotics are started.
- Hospitalization – Patients with severe flares usually require hospitalization for pain control, hydration, and monitoring. Those with milder symptoms can often be managed at home.
As symptoms improve, patients can gradually return to a normal diet and resume taking their regular pancreatitis medications like pancreatic enzymes.
How can chronic pancreatitis flare ups be prevented?
Preventing flare ups is an important goal since repeated episodes can cause permanent damage to pancreatic function. Strategies to help reduce flares include:
Avoid trigger foods
Avoiding dietary triggers like high fat foods, alcohol, and large meals can help minimize flare ups. People with chronic pancreatitis are advised to follow a low fat diet and eat small, frequent meals.
Maintain good hydration
Drinking adequate fluids keeps pancreatic secretions from thickening and enables better flow through ducts. Alcohol and caffeinated beverages should be limited since these have a dehydrating effect.
Take pancreatic enzyme supplements
Pancreatic enzyme replacement helps properly digest food and takes some of the burden off the pancreas. This may help reduce inflammation.
Manage other health conditions
Optimizing conditions like diabetes and hyperlipidemia can help reduce pancreatic strain. Quitting smoking and limiting alcohol intake is also beneficial.
Reduce stress
Learning stress management techniques may help minimize flare triggers. Practices like meditation, yoga, or tai chi can dampen the body’s stress response.
Consider medications
Some patients benefit from taking daily medication like antioxidants or pancreatic enzymes to try preventing attacks. Talk to your doctor about whether any maintenance medications could be helpful.
Get prompt treatment for infections
Quickly treating any viral or bacterial illness may keep it from spreading to the pancreas and provoking inflammation. Staying up to date on vaccinations helps prevent infections.
Consider endoscopic or surgical interventions
Procedures to open blocked ducts, remove stones, drain pseudocysts, or reduce pancreatic pressure may be options to stabilize the pancreas and reduce flare ups for some patients.
Conclusion
Flare ups of chronic pancreatitis can be extremely painful and disruptive. But understanding potential triggers and how to prevent attacks can help patients better manage this condition.
Being aware of triggers like dietary fat, alcohol use, infections, smoking, and stress can enable patients to make lifestyle changes to avoid recurrences. Discussing any medications that seem to provoke flares with your doctor is also wise.
Although flare ups may still happen periodically, the severity and frequency can often be reduced with careful, preventive management. Working closely with your medical team and tailoring an individualized treatment plan is key to getting the symptoms under better control.