IStock Photo 7730761 © rjzinger

In 323 BC, after a two-day drinking binge in Babylon with his friend Medius of Larissa, Alexander the Great developed fevers, vomiting, and severe abdominal pain—symptoms consistent with pancreatitis.

Over the next two weeks, Alexander’s condition worsened. By the sixth day, his physicians described jaundice. The following week, they wrote about his cold extremities, deteriorating mental state, respiratory failure, and, finally, death on day 14. Historians have many different hypotheses for what caused Alexander’s demise (poisoning is most popular), but the course his physicians described could certainly have been acute pancreatitis.

Alexander was only 33 years old when he died—a bit young for a pancreatitis-related death. Nowadays, in the United States, the odds a person 15-44 will die from pancreatitis in a year are 1 in 269,400, close to the odds a person will be injured by a tornado in a year (1 in 297,100). People 65 or older are at significantly greater risk, with 1 in 18,600 odds of dying from pancreatitis in a year—about the same as the odds a person in the US will be murdered in a year (1 in 18,690). Overall, acute pancreatitis causes death in about 2% of affected patients, but the disease varies greatly in severity.

Acute pancreatitis is an inflammatory process in the pancreas, the organ that manufactures the enzymes necessary for digesting food in the small intestine. When these enzymes become activated inside the pancreas (before they are released into the intestine), the pancreas can actually digest itself. This causes damage, or even death (necrosis), to the pancreatic tissue, and releases pancreatic enzymes into the bloodstream. In response, the body produces other inflammatory chemicals, called cytokines, which can trigger a cascade of systemic problems.

The precise causes of pancreatitis are only partially understood. Alcohol intake, especially binge drinking, accounts for approximately 40% of cases, but the exact mechanism by which alcohol damages the pancreas is still unknown. About 35% of cases are attributable to gallstones, which is somewhat easier to explain. Under normal circumstances, the pancreas squirts its digestive enzymes through the pancreatic duct into the common bile duct before it empties into the small intestine. If a stone passes out of the gallbladder and gets stuck temporarily in the common bile duct, it can block the pancreatic enzymes from entering. Consequently, they flow backwards into the pancreas. The list of causes for the other 25% of cases is long: high triglycerides, medications, trauma, viruses, parasites, idiopathic (the fancy medical term for “unknown”), and scorpion venom (a medical-school-trivia favorite).

No matter the cause, pancreatitis presents as severe abdominal pain usually accompanied by nausea and vomiting. Blood tests show significant elevation of the pancreatic enzymes amylase and lipase. A CT scan of the abdomen can also be useful for diagnosis, and is often necessary in order to detect complications.

Fortunately, 80-85% of acute pancreatitis cases are considered “mild,” but even many of these require inpatient care. The odds a person will be hospitalized for pancreatitis in a year are 1 in 1,060(the disease accounts for about 330,000 hospitalizations in the United States each year). Most patients with pancreatitis need careful monitoring, anti-nausea medication, IV pain medication, and lots of IV fluid. They generally recover within 5-7 days.

It is a different story for the 15-20% of patients with severe acute pancreatitis. Almost all of them require a prolonged stay in the intensive care unit. As more of the pancreas is destroyed and the systemic process worsens, acute pancreatitis can rapidly lead to severe dehydration, mental status changes, and eventually multi-system organ failure. The prognosis is even bleaker if the necrotic pancreas becomes infected. Then, surgery is often required to remove the dead tissue. Even with surgery, as many as 17-28% of patients with severe acute pancreatitis will die.

Although the mortality rate of acute pancreatitis is still quite high 2,300 years later, it does leave you wondering: what if Babylon had had a good ICU?