Acute pancreatitis is an acute inflammatory condition caused by the pancreas’s digestive enzymes digesting the pancreas itself; it is one of the more common conditions among acute abdominal emergencies. It most frequently occurs in young and middle-aged adults aged 20 to 50, with a slightly higher incidence in women than in men. The exact cause of this disease has not yet been fully elucidated.
In Traditional Chinese Medicine (TCM), this condition falls under the categories of “chest constriction,” “abdominal pain,” “epigastric pain,” and “spleen-heart pain.” TCM refers to the pancreas as the spleen, which is closely related to the liver and gallbladder; its functions are associated with both the liver and spleen. When pathological changes occur in the liver, gallbladder, or spleen, this condition may also develop.
I. Etiology and Pathogenesis
Traditional Chinese Medicine holds that this condition is often caused by irregular diet, emotional imbalance, ascending roundworms, and exposure to wind, cold, and dampness pathogens. These factors lead to functional disorders of the liver, gallbladder, spleen, and stomach; disruption of the ascending and descending movements of qi; and the obstruction of damp-heat in the middle jiao, thereby triggering the disease.
Modern medicine views acute pancreatitis as a complex pathological process, and its etiology cannot be explained by a single factor alone. Currently, the causes of acute pancreatitis are believed to include the following aspects:
(1) Obstructive Factors: Since the bile duct and pancreatic duct first converge and then enter the duodenum together—hence the “common duct theory”—there are numerous factors that can cause pancreatic duct obstruction, such as biliary tract diseases: biliary stones, biliary ascariasis, biliary tract infections, edema, spasm, or stricture of the sphincter of Oddi, pancreatic duct stones, pancreatic duct ascariasis, and inflammation or tumors of the pancreatic head or duodenum.
(2) Alcohol consumption: Heavy drinking stimulates increased secretion of pancreatic juice, which contains a high concentration of proteins that can form protein “emboli” and block the pancreatic duct. Additionally, prolonged alcohol consumption raises blood triglyceride levels, which can trigger pancreatitis.
(3) Dietary factors: Overeating can stimulate increased secretion of pancreatic juice. If there is an obstruction in the pancreatic duct or the lower part of the bile duct, the drainage of pancreatic juice is impeded, leading to high pressure within the pancreatic duct. This can cause the rupture of small pancreatic ducts or acini, resulting in the leakage of pancreatic juice. If pancreatic zymogen is activated, autodigestion may occur, leading to the onset of the disease.
(4) Other factors: These include surgery or trauma, vascular factors, infections (including viral infections), endocrine and metabolic factors, neurological factors, and certain medications. In some patients, the cause is unknown; this is referred to as idiopathic or spontaneous pancreatitis.
John H. C. Ranson, Associate Professor of Surgery at New York University School of Medicine, reported on a cohort of 500 cases of pancreatitis, with the following causes: alcohol intoxication accounted for 70%, cholelithiasis for 16%, postoperative complications for 5%, and other causes for 9%. In mainland China, acute pancreatitis caused by biliary tract diseases is more common.
II. Clinical Manifestations
According to Traditional Chinese Medicine (TCM), this disease generally has an acute onset and is primarily characterized by upper abdominal pain and distension. Severe pain feels like a knife cut; pain occurs when there is obstruction, which is consistent with the concept of obstruction in modern medicine. It is accompanied by fever, nausea, vomiting, jaundice, or even shock.
Modern medicine views this disease as presenting with a sudden onset of severe abdominal pain, the location of which is related to the site of the lesion. If the primary lesion is in the head of the pancreas, abdominal pain is mainly localized in the right upper abdomen and radiates to the right shoulder; if the lesion is in the neck or body of the pancreas, abdominal pain is mainly localized in the midline of the upper abdomen; if the lesion is in the tail of the pancreas, abdominal pain is mainly localized in the left upper abdomen and radiates to the left shoulder; if the entire pancreas is affected, abdominal pain presents as a belt-like pain in the upper abdomen that radiates to the area behind the shoulders.
Other manifestations of acute pancreatitis:
Gastrointestinal symptoms: Nausea, vomiting, abdominal distension, gastrointestinal bleeding, diarrhea, etc.
Fever: Abdominal pain accompanied by fever is one of the characteristic features of this disease. In the early stages, the fever is not caused by infection but rather by products of tissue damage; it generally does not exceed 39 degrees Celsius and is not accompanied by chills. It returns to normal 3 to 7 days after the onset of illness. If the fever does not subside or rises again after returning to normal, it is most likely caused by an infection.
Jaundice: Jaundice may occur following obstruction of the bile ducts; 20% to 25% of patients with pancreatitis may develop jaundice.
Shock: The early onset of shock indicates extensive pancreatic tissue necrosis.
Elevated Pancreatic Amylase: Patients with pancreatitis exhibit significantly elevated amylase levels in both blood and urine, generally exceeding 500 Sohli units and sometimes reaching over 2,000 units.
III. Classification of Acute Pancreatitis
There are dozens of classification systems for this disease, but from the perspective of clinical diagnosis and treatment, four classification methods are currently considered the most practical.
Classification by etiology includes the following types: ① Simple pancreatitis: The lesion is confined to the pancreas itself and is often caused by dietary or psychological factors; ② Cholelithic pancreatitis; ③ Infectious pancreatitis; ④ Traumatic pancreatitis; ⑤ Drug-induced pancreatitis; ⑥ Metabolic, alcoholic, familial, and idiopathic pancreatitis.
The clinical-pathological classification is divided into three types: ① Acute edematous pancreatitis; ② Acute hemorrhagic pancreatitis; ③ Acute necrotizing pancreatitis.
Classification by severity is divided into three types: mild, moderate, and severe.
Based on clinical subtypes, it is classified into ordinary, severe, and fulminant types.
IV. Acute Pancreatitis Must Be Distinguished from the Following Diseases
Acute gastritis; acute cholecystitis, cholelithiasis; acute gastric and duodenal perforation; myocardial infarction; acute renal colic; biliary ascariasis; acute intestinal obstruction; mesenteric vascular embolism.
V. Complications of Acute Pancreatitis
Acute pancreatitis has many complications and a high mortality rate. In addition to lesions of the pancreas itself, many patients die from its complications. The complications of this disease include the following: acute respiratory distress syndrome; disseminated intravascular coagulation; acute renal failure; pancreatic encephalopathy; diabetes; pancreatic abscess; cardiac insufficiency; intestinal obstruction; abdominal infection; and fluid and electrolyte imbalances, among others.
VI. Treatment of Acute Pancreatitis
Traditional Chinese Medicine (TCM) Differential Diagnosis and Treatment: TCM classifies acute pancreatitis into four types for treatment.
(1) Liver Qi Stagnation Type: Corresponds to mild edematous pancreatitis, often triggered by dietary factors or emotional changes. Patients present with persistent pain in the upper abdomen or left upper abdomen and varying degrees of tenderness, chest tightness and discomfort, accompanied by nausea and vomiting. The tongue coating is thin and white or slightly yellow, and the pulse is string-like and thin or tight. The treatment principle should focus on soothing the liver and regulating qi, as well as unblocking the viscera and clearing heat. Da Chai Hu Tang combined with white peony root (Bai Shao), wood fragrant (Mu Xiang), corydalis (Yuan Hu), and mirabilite (Mang Xiao) may be used.
(2) Spleen-Stomach Excessive Heat Pattern: Corresponds to a more severe form of edematous pancreatitis. Patients exhibit diffuse abdominal pain with tenderness, along with sensations of fullness, distension, dryness, presence of a mass, and hardness. They also suffer from dry mouth, thirst, scanty and reddish urine, and dry, hard bowel movements. The tongue has a thick yellow coating, and the pulse is rapid and full. The supports principle is to clear heat and purge, while regulating qi and resolving stagnation. Da Chengqi Decoction (Da Chengqi Tang) may be used, supplemented with Lonicera japonica (Japanese Honeysuckle), Aucklandia lappa (Wood Fragrance), Corydalis yanhusuo (Corydalis), and Forsythia suspensa (Forsythia).
(3) Damp-Heat in the Spleen and Stomach Type: Corresponds to cholelithiasis-induced pancreatitis. Patients present with distending pain in the upper abdomen and resistance to pressure, often accompanied by jaundice, chest tightness and discomfort, nausea and vomiting, fever or chills, constipation, scanty and reddish urine, a red tongue with a thick, greasy yellow coating, and a string-like, slippery, and rapid pulse. The treatment principle should be to clear heat and drain dampness, as well as to unblock the bowels and promote purgation. Treatment may involve Yinchenhao Decoction supplemented with Gentiana, Wood Fragrance, Corydalis, Moneywort, Areca Nut, and Cassia Seed.
(4) Ascending Ascaris Type: Corresponds to pancreatitis caused by ascaris in the biliary tract. Patients present with persistent upper abdominal pain accompanied by paroxysmal colic, characterized by a piercing, drilling pain. During episodes of pain, patients experience sweating and cold extremities, accompanied by nausea and vomiting; they may vomit ascaris worms. The tongue coating is thin and white or yellow and greasy, and the pulse is deep and tight or deep and string-like. The treatment principles should focus on regulating qi and calming the roundworms, as well as clearing heat and relieving pain. The formula Lianmei Anhuo Decoction may be modified by adding Melia azedarach bark, Bupleurum root, Corydalis root, White Peony root, Gardenia fruit, and Honeysuckle flower.
Modern medical treatment for acute pancreatitis: Mild edematous pancreatitis, where the condition is not severe, can usually be cured with one week of active treatment; however, hemorrhagic-necrotic pancreatitis requires immediate emergency treatment. Currently, non-surgical treatment is recommended for acute edematous pancreatitis, while surgical treatment is recommended for hemorrhagic-necrotic pancreatitis to reduce mortality.
(1) Non-surgical Treatment Methods
① After hospitalization, patients should be closely monitored for various clinical indicators, such as blood pressure, pulse, urine output, body temperature, and blood glucose levels, and undergo blood gas analysis and cardiopulmonary function tests.
② Pain relief and antispasmodic therapy: These measures can prevent the onset of shock. Drugs such as atropine and pethidine may be used, but morphine should be avoided.
③ Reduction of pancreatic secretion: This is achieved through fasting, gastrointestinal decompression, and the use of medications such as atropine and glucagon.
④ Administration of antibiotics: To prevent infection.
⑤ Use of traditional Chinese herbal medicine: Herbal formulas should be selected based on the patient’s condition; Da Chai Hu Tang with appropriate modifications has shown good efficacy for edematous pancreatitis.
(2) Surgical Treatment Methods
① Direct surgery: Incision of the pancreatic capsule for decompression with abdominal drainage; dissection of the pancreas and pancreatic bed for drainage; partial or extensive pancreatectomy, or even total pancreatectomy; resection of necrotic pancreatic tissue.
② Indirect Surgical Procedures: Biliary tract surgery; thoracic duct drainage; peritoneal dialysis; triple fistula creation; local hypothermic dialysis.
VII. Prevention
Actively treat biliary tract diseases, such as cholelithiasis, biliary ascariasis, and Oddi’s sphincter stenosis; avoid overeating; quit smoking and drinking; and avoid psychological stress and emotional fluctuations.