Rising Cases of Acute Pancreatitis in Kashmir

Over the past decade, hospitalization rates for acute pancreatitis (AP) have significantly increased in the Kashmiri population, primarily due to gallstone (GS)-related cases. This rise is linked to lifestyle changes, including poor dietary habits, lack of exercise, and a sedentary lifestyle, leading to higher rates of obesity, diabetes, and non-alcoholic fatty liver disease (NAFLD).

Acute pancreatitis is a serious condition where the pancreas, a small organ behind the stomach, becomes inflamed over a short period. The pancreas plays a crucial role in digesting food and regulating blood sugar levels through hormones like insulin and glucagon.

AP is characterized by severe upper abdominal pain that often radiates to the back, accompanied by vomiting and elevated blood levels of enzymes such as amylase and lipase. Most AP cases improve within a week, but about 20% can become severe, leading to prolonged hospital stays, infections, and high treatment costs. Mortality in severe cases ranges from 10% to 20%, often due to multiorgan failure.

However, AP can largely be prevented by managing the risk factors that cause it. Given the high morbidity and mortality associated with severe AP, it is crucial to raise public awareness about the condition and adopt preventive measures to curb its increasing incidence.

Major causes of AP and Risk factors

The major causes of AP includes GS related AP, excessive consumption of alcohol,high blood lipid levels (hypertriglyceridemia), intestinal parasites like Ascaris lumbricoides in endemic areas and various drugs. The associated risk factors include smoking, obesity, high blood lipid levels, diabetes and certain genetic predispositions.The incidence of AP has increased worldwide and is one of the leading causes of gastrointestinal related hospital admissions.

The increased incidence is related to increased incidence of GS pancreatitis (GSP) involving elderly population with higher body mass index and obesity.Alcohol associated AP accounts for the highest proportion of AP in India involving younger male population followed by GS related AP.

Changing spectrum of AP in Kashmiri population:                                         

The hospitalization rate for acute pancreatitis (AP) in the Kashmiri population has steadily increased in recent years. Gallstones and pancreatic biliary ascariasis are the leading causes of AP in both adults and children. A study from SKIMS, published in the Indian Journal of Gastroenterology, highlighted a rise in AP-related hospital admissions from 5.6% in 2015 to 10.3% in 2019, nearly doubling in five years.

This increase is primarily due to gallstone pancreatitis (GSP), which rose from 31% to 52.4% during this period. Meanwhile, cases of Ascaris-related AP have significantly declined, likely due to better socioeconomic conditions, improved hygiene, and increased awareness about deworming.

The study also noted that asymptomatic gallstones, particularly multiple small ones (<5mm), account for 87.7% of GSP cases, often presenting as AP for the first time. This suggests that asymptomatic gallstones can still lead to severe AP, advocating for prophylactic cholecystectomy (gallbladder removal) in such cases, even though it's not currently recommended for asymptomatic gallstones.

The rising incidence of GSP is likely linked to lifestyle changes, including high-calorie diets, sedentary habits, and lack of exercise, leading to increased rates of obesity, diabetes, and non-alcoholic fatty liver disease (NAFLD).

These conditions are significant risk factors for gallstone formation. Additionally, smoking, a known risk factor for AP, is prevalent in Jammu and Kashmir, with over 20% of the population using tobacco. However, alcohol-related AP remains low in the region compared to other Indian states. Obesity remains a strong risk factor for AP, contributing to higher rates of gallstones, hypertriglyceridemia, and diabetes.

Prevention of Acute Pancreatitis

There is no specific treatment for AP once it has occurred and about 20% of patients who get AP may get recurrent AP unless the cause and risk factors are not taken care of. Lifestyle changes which reduce the risk factors involved will reduce the risk of AP. This involves awareness in the general population about AP,its causes and the risk factors.

Lifestyle modifications

Cessation of smoking and alcohol abstinence can lower the risk of AP by 50% and 20% respectively.The risk of AP is lowered by 25% if one maintains the body weight by keeping body mass index (BMI) between 18-25 Kg/m2.This can be achieved by regular exercise and by taking healthy balanced diet.

Dietary changes

Saturated fat intake should be limited to less than 10% of your total fat consumption. Saturated fats are found in red meat and dairy products like butter, cream, cheese, yogurt, whole milk, and in coconut and palm oils—all of which raise triglyceride and cholesterol levels. Instead, opt for lean meats and skinless poultry, which are lower in fat. The remainder of your fat intake should come from monounsaturated and polyunsaturated fats (omega-3 and omega-6 fatty acids), which help lower bad cholesterol (LDL) and triglycerides. Sources include plant-based oils like olive, sunflower, and soybean oil, as well as fish oil, almonds, peanuts, and walnuts.

A diet rich in vegetables, fruits, and high-fiber foods is essential. Incorporate whole grains like oats, brown rice, wheat, corn, and millets to reduce triglyceride and cholesterol levels. Obesity, high cholesterol, and high triglycerides are significant risk factors for gallstone formation. Diabetics should maintain strict control of blood sugar and lipid levels. Medications known to cause acute pancreatitis (AP) should only be used if essential and prescribed by a physician.

If you experience recurrent upper abdominal pain, an ultrasound is advisable to check for gallstones. Patients with symptomatic or asymptomatic multiple small gallstones should consider cholecystectomy (gallbladder removal) to prevent severe AP. For symptomatic gallstones, laparoscopic cholecystectomy can be done within 72 hours or 8-12 weeks, depending on the situation. In mild AP, it should be performed within two weeks, while in severe cases, it should be done after inflammation subsides, ideally within eight weeks, to prevent a second episode of AP. Timely cholecystectomy is crucial to avoid severe complications associated with gallstone-related AP.

Key points in prevention of AP

Stop smoking and alcohol consumption.

Regular exercise and use balanced diet

Eat fresh fruit and vegetables regularly.

Use whole grains like oats, brown rice

Take less Saturated fat

Include mono or polyunsaturated fats.

Prefer lean meat and skinless poultry

Look for Gallstones if you are getting recurrent pain upper abdomen

Timely Cholecystectomy in symptomatic GS.

Prophylactic cholecystectomy in asymptomatic multiple small GS

Regular deworming and Hygiene

By: Prof (Dr) Jaswinder Singh

Author is professor at Department of Gastroenterology,  SKIMS -Soura