Preventing a second bout of acute pancreatitis



ESTES PARK, COLO. – Secondary prevention following a first episode of acute pancreatitis often goes underemphasized.

"If you have somebody who comes in with an MI, TIA, or stroke, you are not going to discharge them from the hospital without further evaluation and a plan for what you’re going to do in the future. Yet I would dare say that many of you have taken care of lots of patients with acute pancreatitis, and you wrote "pancreatitis, did fine," put that on the problem list, but you never addressed that in the future. You need to think about the natural history of acute pancreatitis, which is that 25% of the patients are going to have a recurrence, typically within 12 months," Dr. Peter R. McNally said at a conference on internal medicine sponsored by the University of Colorado.

This high recurrence rate can be reduced by determining the etiology of the pancreatitis and then taking steps to eliminate that trigger.

Dr. Peter R. McNally

Either gallstones or consumption of toxic quantities of alcohol underlie 80% of cases of acute pancreatitis. It’s a 50/50 split between the two etiologies. However, alcoholic pancreatitis is five times as common in men as in women, whereas gallstones as a cause of pancreatitis are far more common in women than men. Ultrasound is the best imaging study for finding those stones.

There are twice as many alcoholic men as women in the United States. The reason alcoholic pancreatitis is five times as common in men is that several of the genetic mutations associated with increased risk of chronic pancreatitis are X-linked.

It takes a lot of heavy drinking to trigger pancreatitis, an average of five or more drinks per day for 8-10 years. After a first episode of acute pancreatitis due to alcohol, a patient who becomes completely abstinent has a 14% risk of progressing to chronic pancreatitis, a painful condition caused by irreversible damage to the parenchyma and ducts. If after the first episode of acute pancreatitis the patient continues drinking but cuts back, the risk is 23%. And with no change in alcohol consumption, the risk climbs to 41%.

"These data clearly tell you that, if you don’t send them to inpatient rehabilitation, they will be back. Smoking is an independent and additive factor for relapse. So you really want to stress ‘no alcohol, no tobacco,’ according to Dr. McNally, chief of gastroenterology at Evans Army Hospital in Fort Carson, Colo.

Therapeutic endoscopic cholangiopancreatography is the preferred treatment when gallstones are the cause of acute pancreatitis. That’s fairly straightforward. But pinning down the etiology of the 20% of cases of acute pancreatitis not due to alcohol or gallstones can be challenging. There is a grab bag of potential causes, for which Dr. McNally offered the mnemonic GET SMASH’D. It stands for Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion bites, Hyperlipidemia, and Drugs.

When no other cause for an episode of acute pancreatitis can be identified, it becomes important to perform a medications reconciliation to learn if the patient has been on any of 38 drugs incriminated as probable causes of drug-induced pancreatitis. Many of these agents are widely prescribed, including several statins, tamixofen, trimethoprim/sulfamethoxazole, valproate, and metronidazole.

"If you don’t check their medications against this list, they’re going to be right back in with recurrent pancreatitis," the gastroenterologist advised.

One-quarter to one-third of patients who have had acute pancreatitis will develop exocrine and/or endocrine dysfunction over time.

"If it’s severe pancreatitis, the rate is almost 100%. So you need to look for it. A fecal elastase test 2-3 months after discharge is totally appropriate to see if a patient has fat malabsorption. Check for vitamin D and B12 deficiency as well," Dr. McNally suggested.

Genetic testing is just on the verge of being incorporated into pancreatitis management.

"We’ll be doing genetic tests within the next 5 years on all patients who come in with acute pancreatitis to figure out if they’re in that 10% that will go on to have chronic pancreatitis. And if you have a gene mutation assay that’s positive in a patient with alcoholic pancreatitis, you’ll need to tell them, ‘There’s no way you can drink again,’ " according to Dr. McNally.

He reported having no financial conflicts.

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