The pancreas lies crosswise behind the stomach and has two jobs: it produces digestive enzymes for fat, protein and carbohydrate (the exocrine part) and the hormones insulin and glucagon for blood sugar (the endocrine part). If the organ fails, both are lost.¹,²
Normally the enzymes are released as inactive precursors and only switched on in the small bowel. In pancreatitis they become active while still inside the organ and digest its own tissue — from mild swelling through to areas of dead tissue.
Why the organ is so vulnerable. Unlike the liver, the pancreas can barely regenerate — tissue that has been lost is replaced by scar tissue. That is why chronic inflammation leaves permanent losses behind, while a mild acute episode often leaves nothing at all.
2. Acute or chronic: the difference
The two forms sound similar but behave completely differently — in how they run, how they are treated and what they mean day to day.¹
Feature
Acute pancreatitis
Chronic pancreatitis
Onset & setting
Sudden, within hours; usually in hospital
Creeping over years, often in flare-ups; managed as an outpatient
Leading complaint
Very severe upper abdominal pain
Recurring pain, easing off only late on
Trigger
Gallstones, alcohol
Alcohol, smoking, genetics
Consequences
Usually full recovery; severe courses are possible
Permanent loss of digestion and of insulin production
Table scrolls to the right
Repeated acute episodes — above all where alcohol or smoking continue — can turn into chronic pancreatitis. Looking for the cause after the first episode is therefore not a formality.¹
3. Symptoms and consequences
In the acute form pain is the leading symptom: severe, persistent, starting in the upper abdomen and typically radiating round into the back like a belt. Leaning forward often eases it, lying flat makes it worse. Nausea, vomiting and fever frequently come with it.⁴
Emergency: do not wait it out. Severe, persistent upper abdominal pain radiating into the back — especially with vomiting, fever, jaundice or a rigid abdomen — needs assessing immediately; with the most severe pain, breathlessness or circulatory collapse, call 112 (emergency services in Germany). Severe courses can be life-threatening.
In the chronic form the picture shifts from pain towards loss of function:
Pain — dull, deep in the upper abdomen, often after eating; late on it eases while the digestive problems increase.
Fatty stools (steatorrhoea) — bulky, pale grey, greasy stools that are hard to flush away: the sign that fat is no longer being digested. Along with bloating, diarrhoea and unintended weight loss.
Blood sugar problems — if the insulin-producing cells are affected as well, a particular kind of diabetes develops (section 9).
The exocrine weakness only shows itself once a large part of enzyme production has been lost — fatty stools are therefore not an early sign, but they are a very treatable one.¹,³
4. Causes: gallstones, alcohol — and medicines
Gallstones: a stone in the shared final stretch of the ducts dams up the pancreatic juice — the most common cause of the acute form, and the one most easily put right.
Alcohol and smoking: a single acute binge as well as years of drinking can trigger pancreatitis; in the chronic form alcohol is the most important risk factor, and smoking acts independently of it (Medications and alcohol).
Other triggers: markedly raised triglycerides (see Lipid metabolism disorder), ERCP, injuries, raised calcium, autoimmune processes, genetic variants. In a proportion of cases the cause remains unclear.
Medicine-induced pancreatitis is rare but easily missed. A connection has been described for diuretics (thiazides, furosemide), azathioprine, mesalazine, valproate and oestrogen preparations — the evidence often rests on individual case reports.¹,³
What is known about weight-loss injections and diabetes medicines. The product information for the GLP-1 receptor agonists — semaglutide among them — lists acute pancreatitis as a rare side effect; whether the class raises the risk is still being investigated. With severe, persistent upper abdominal pain while taking such a preparation, treatment is usually interrupted and the cause investigated — but do not stop anything permanently on your own, and take your medication list with you.
5. Diagnosis: blood values, ultrasound, stool test
The acute form is recognised from typical symptoms, a raised enzyme level and imaging; with the chronic form, measuring the loss of function is added.¹,²
Lipase in the blood: the most important value when an acute episode is suspected — how high it is, though, says nothing about how severe the illness is (Understanding blood values).
Imaging: ultrasound first, above all to look for stones; CT, MRCP and endoscopic ultrasound in addition.
Elastase-1 in the stool: the standard test for exocrine weakness. Alongside it HbA1c, weight over time, fat-soluble vitamins such as vitamin D and, over a longer course, bone density.
What has to be ruled out includes biliary colic, a perforated stomach ulcer, a heart attack and other causes of abdominal pain. The liver is often examined at the same time, for example for fatty liver.
6. Treating acute pancreatitis
Acute pancreatitis is as a rule treated in hospital — because it is in the first few days that it is decided whether the course stays mild or turns severe. Most cases heal; severe courses with dead tissue are less common but serious.¹
Acute phaseStabilise and remove the cause
Fluids, pain relief, early feeding
Controlled fluid replacement through a vein is regarded as the most important measure of the early phase, together with adequate pain relief. The long period of fasting that used to be standard is out of date: with a mild course, oral feeding is resumed early.
Clearing the bile ducts
If a stone is stuck in the bile duct, it is removed endoscopically (ERCP); with mild pancreatitis the gallbladder is usually removed surgically soon afterwards. If a medicine is suspected of being involved, the preparation is reviewed medically and changed if necessary — never as a step you take yourself.
Antibiotics are not given routinely, only where an infection has been demonstrated. Digestive enzymes are not standard in the acute phase — they only come into play once the body permanently produces too few of its own.
7. Treating chronic pancreatitis
On current understanding the chronic form cannot be reversed. Three things are treated: pain, loss of function and progression. Treatment decisions always rest with the treating practice.¹,³
Stop the cause: giving up alcohol and stopping smoking are the only measures shown to influence the course (section 10).
Treat the pain: step by step, following a medical plan — with a strategy from the outset for avoiding dependence on strong painkillers.
Replace digestion, make up deficiencies: enzyme preparations with meals, plus vitamins, minerals, dietary advice and blood sugar checks.
Procedures where needed: endoscopic or surgical treatment for narrowed ducts, stones or cysts.
Painkillers: nothing on your own initiative. Neither taking NSAIDs such as ibuprofen long term nor increasing opioids on your own is a good idea — the first are hard on the stomach and kidneys, the second lead into dependence. If the dose no longer covers the pain, that is a reason for an appointment. On stopping in an orderly way: Stopping medications.
Enzymes, painkillers, vitamins — four times a day
brite brings your plan together and shows what you took and when.
If the pancreas delivers too few digestive enzymes, they are replaced from outside. The preparation is called pancreatin and contains lipase, amylase and proteases in gastro-resistant micropellets, so that stomach acid does not destroy them. The dose is set medically in lipase units — according to the fat content of the meal and according to how weight and stools develop.¹,³ The sticking point is rarely the substance itself but the way it is used: an enzyme taken at the wrong moment no longer meets the food.
With the meal, not before it and not after it — the usual approach is part at the start and the rest during the meal, so that enzymes and food mix. Half an hour beforehand, or only after the dessert, and the effect is lost; see Medications before or after eating.
The amount follows the meal — a fatty main meal needs more than a snack; a milky coffee counts too. The dose levels are set by your practice.
Do not chew them, do not stir them into anything hot — the gastro-resistant coating is the whole trick. If a capsule has to be opened, the product information says to do so into a cold, slightly acidic food such as apple purée. See also How to take medications.
When things do not improve despite the enzymes
What you notice
Common explanation
What gets discussed
Fatty stools persist, weight falls
Dose too low, or too few calories
Adjusting the lipase units, dietary advice
The enzymes only partly work
Wrong timing — all of them before or after the meal
Splitting them between the start and the course of the meal
Hardly any effect despite correct use
Too much stomach acid inactivates the enzymes
An acid blocker such as pantoprazole can be considered
Table scrolls to the right
Eating low-fat is not the answer. Anyone eating very little fat takes in too little energy and too few fat-soluble vitamins. Today’s approach is the other way round — eat normally and match the enzyme dose to the meal.
9. Type 3c diabetes and deficiencies
If the inflammation destroys the insulin-producing cells as well, a form of diabetes develops that is neither type 1 nor type 2: pancreatogenic diabetes, often called “type 3c”. The decisive point is that it is not only insulin that is missing but also glucagon, the hormone that raises blood sugar.¹,³ The consequence: blood sugar swings more widely and slips more easily into a hypo, because the emergency mechanism is gone. Many people need insulin early — the basics are in the article Diabetes.
If fat is not digested, the fat-soluble vitamins A, D, E and K are missing as well. This goes unnoticed for a long time and then shows up as tiredness, difficulty seeing at night, a tendency to bleed or falling bone density. A lack of vitamin D together with being underweight, alcohol and smoking is a risky mixture for osteoporosis.
What should be checked regularly. Weight over time, HbA1c, fat-soluble vitamins, full blood count and, over a longer course, bone density. Take your medication list to every appointment — including food supplements.
10. Alcohol and smoking: the most powerful lever
No tablet influences the course of chronic pancreatitis the way these two decisions do.¹
Giving up alcohol: with alcohol-related pancreatitis, complete abstinence is recommended — not “less”, but none. That reduces the number of flare-ups and slows progression; it is advised with other causes too.
Stopping smoking: smoking is an independent risk factor for progression and for pancreatic cancer — and it is often forgotten in the conversation. With both, do not rely on willpower alone: addiction counselling and stop-smoking programmes are well-established routes.
Keeping pancreatic cancer in mind. Years of chronic pancreatitis raise the risk of it. That is no reason to live in fear, but it is a reason to take changing symptoms seriously: rapidly increasing weight loss, new jaundice or a kind of pain you do not recognise all need checking promptly.
11. Everyday life with chronic pancreatitis
Several small meals instead of two large ones — that takes the strain off your digestion and makes the enzyme dosing easier to handle. And keep the capsules everywhere you might need them: coat pocket, car, workplace. A meal without enzymes is the most common reason for a bad day.
And a word about the mind: chronic pain and a daily life that revolves around food leave nobody untouched. Exhaustion and low mood deserve the same attention as the fatty stools.
The right enzyme dose with every meal — without having to think about it
Reminders at your mealtimes and a record for your next appointment.
What is typical is very severe, persistent pain in the upper abdomen that often radiates round into the back like a belt and eases when you lean forward. Nausea, vomiting and a bloated abdomen frequently come with it. It can only be identified reliably by a doctor, with blood values and ultrasound — and that means straight away.
As a rule, yes. It is in the first few days that it is decided whether the course stays mild or turns severe, and that can only be judged under observation. Fluids through a vein, pain relief and the search for the cause are standard; a severe course can be life-threatening.
With alcohol-related pancreatitis, complete abstinence is recommended, not merely cutting down. That reduces the number of flare-ups and slows progression. With other causes too, professional bodies mostly advise abstinence; if you find that difficult, addiction counselling can help.
With the meal: part right at the start, the rest while you eat, so that enzymes and food mix. Well before the meal or only afterwards and they largely miss their purpose. Fatty snacks between meals need a dose as well — the amount is set by your practice.
Typical pointers are fatty stools that persist, marked bloating, diarrhoea and a weight that keeps falling. Before the dose is raised, it is worth checking the timing and the way the capsules are taken — the more common source of error. Adjusting the dose belongs in medical hands.
Strict fat restriction is now regarded as out of date. Anyone eating very little fat takes in too little energy and too few fat-soluble vitamins and goes on losing weight. The current approach: eat normally and match the enzyme dose to the fat content; dietary advice is recommended.
Yes, but rarely. A connection has been described for certain diuretics, azathioprine, mesalazine, valproate and oestrogen preparations, among others; for GLP-1 receptor agonists, pancreatitis is listed in the product information as a rare side effect and the connection is still being investigated. Do not stop anything on your own — take your medication list along for the assessment.
Because the same organ also makes insulin and glucagon. If tissue is lost through chronic inflammation, both hormones are missing — this is called pancreatogenic diabetes, or type 3c. Because glucagon, which raises blood sugar, is missing too, blood sugar swings more widely and hypos occur more easily.
German S3 guideline on pancreatitis (DGVS, AWMF reg. no. 021-003) — German source. awmf.org
Gesundheitsinformation.de, German Institute for Quality and Efficiency in Health Care (IQWiG): Inflammation of the pancreas. Accessed 2026 — German source. gesundheitsinformation.de
gesund.bund.de, the national health portal of the German Federal Ministry of Health: Inflammation of the pancreas (pancreatitis). Accessed 2026 — German source. gesund.bund.de
Medical disclaimer: This article is for general information and does not replace medical advice, diagnosis or treatment. Severe, persistent upper abdominal pain radiating into the back is an emergency and needs immediate medical assessment — with the most severe pain, breathlessness or circulatory weakness, call 112 (emergency services in Germany). Do not change the dose of enzyme preparations or painkillers on your own, and do not stop a medicine you suspect without speaking to your practice. The choice of medicine and its dose is always decided individually by the treating practice. Last updated: August 2026.
