Introduction

Salmonella infection, also referred to as salmonellosis, is a bacterial disease which affects the intestinal tract.¹ It usually occurs by consuming contaminated food or water.¹ Pancreatitis is a condition that develops when our pancreas is inflamed.²

Although Salmonella infection is not a major cause of pancreatitis, an association between this disease and pancreatitis has been reported ³. There are many species of salmonella that cause salmonella infection, and Salmonella typhi has been reported as the main cause of pancreatitis.³ Salmonella typhi-related pancreatitis usually presents as biochemical pancreatitis.⁴ 

This article aims to present an overview of both conditions, including cases, symptoms, diagnosis, and treatment. We will also explore the association between salmonella infection and pancreatitis and the management approaches for a patient who has acute pancreatitis caused by Salmonella infection.

Salmonella infection

Transmission and infection process

Salmonella is one of the most common foodborne pathogens and is a global health concern.⁵ How do so many people become infected with Salmonella?

Both human and animal intestines are home to Salmonella bacteria. There are several ways that people might become infected with salmonella. This includes drinking water that is contaminated or consuming contaminated food and contact with diseased animals, their excrement, or their surroundings.⁶ Animals are a major source of contaminated food. These sources include beef, poultry, shellfish, milk, and eggs. However, any meal can get infected, including certain unwashed fruits and vegetables.⁷

Pathophysiology

Salmonella can survive in the harsh and acidic environment of your stomach once it reaches the stomach by eating infected food. After entering the small and large intestines, these bacteria begin to produce toxins by invading your intestinal lining. This invasion triggers the body’s immune response, causing the release of chemicals known as proinflammatory cytokines, which can lead to inflammation. This usually results in symptoms like diarrhoea. In severe situations, the inflammation may result in ulceration, breaking down and destroying the intestine’s lining. Moreover, they can also spread to organs other than the gut, thereby leading to more severe illnesses.⁸

Symptoms and diagnosis

Frequent symptoms of Salmonella infection include fever, cramping in the stomach, diarrhoea, chills, headaches, nausea, and vomiting.^{8, 6}

Once infected, symptoms often appear from 6 hours to 6 days later and remain for four to seven days. On the other hand, some individuals feel symptoms for weeks following an infection, while others do not.⁶

To diagnose this condition, usually a laboratory test is done using your bodily fluids, tissues, or faeces, which can identify the presence of Salmonella bacteria.⁶

Treatment

Treatment of this condition depends on your symptoms, age, and overall health. It will also rely on the seriousness of the infection.⁷ 

Most people can recover from a Salmonella infection without the need for antibiotics in four to seven days. People infected with Salmonella should drink extra water to prevent dehydration while their diarrhoea lasts.⁶

Treatment with antibiotics is advised for severe cases and for individuals suffering from serious illnesses, those with weak immune systems and health issues, those over 65 years, and infants.⁶ 

Pancreatitis

There are two types of pancreatitis: acute (sudden and severe inflammation) and chronic (long-lasting and recurrent inflammation), and Salmonella infection can lead to acute pancreatitis.^{9, 3} The disease can range greatly in severity, from a mild condition requiring minimal treatment to a severe, complex condition with a high rate of morbidity and death.¹⁰

Causes and risk factors 

The most frequent causes of acute pancreatitis are hypertriglyceridemia, alcoholism, and gallstones.

Other reasons for pancreatitis include:

• Surgery or injuries to the abdomen
• Higher blood levels of triglycerides
• Very elevated blood calcium levels 
• Some medications, including steroids, thiazide diuretics, and oestrogens
• Diseases like salmonella, hepatitis A or B, or the mumps
• Fibrosis, cystic and tumours
• Certain genetic defects
• Pancreatic congenital anomalies
• Pancreatic trauma
• Smoking cigarettes²

Pathophysiology

Pancreatitis happens when the pancreas gets damaged and inflamed. This could happen when digestive enzymes, like trypsin, become active too early inside your pancreas rather than in the digestive tract. The cause of this early activation may be blockages or issues with pancreatic calcium levels.

Digestion-related enzymes are produced by unique cells in the pancreas known as acinar cells. These enzymes are usually inert until they get to the intestines. But if they become active too soon, they begin to break down the pancreas, which may be quite harmful. This damage releases harmful molecules that attract  neutrophils (immune cells), which leads to inflammation¹⁰

Symptoms 

Common symptoms of pancreatitis include:

• Severe abdominal discomfort that might radiate to your chest or back
• Nausea
• Vomiting
• Accelerated heart rate
• Fever
• Feeling swollen and uncomfortable in your upper abdomen
• Accumulation of fluid in your abdomen
• Reduced blood pressure²

Diagnosis

Diagnosis involves a healthcare provider asking about your symptoms, and medical history, and performing a physical examination. If you have acute pancreatitis, your stomach will feel very tender.

Your healthcare provider may use blood, stool, and urine tests, along with imaging techniques such as abdominal X-ray, ultrasound, endoscopic ultrasound, ERCP (endoscopic retrograde cholangiopancreatography), CT scan, and MRCP (magnetic resonance cholangiopancreatography) to diagnose your condition.²

Treatment

Typically, the treatment for pancreatitis includes

• Hospitalisation for administering IV fluids to prevent dehydration
• Taking pain medicine to relieve abdominal pain
• Taking antibiotics
• Following a clear liquid or low-fat diet (for mild conditions) or fasting with the potential use of a feeding tube (for severe conditions). 
• Additional interventions may involve a nasogastric tube for vomiting, ERCP to address bile duct issues, or surgery to remove gallstones or the gallbladder²

The link between salmonella infection and pancreatitis

Mechanism of action

The mechanism by which Salmonella infection leads to pancreatitis is not fully elucidated.

One hypothesis is that the increased intestinal inflammation caused by Salmonella infection may lead to heightened intestines' permeability, allowing lipase (digestive enzyme) to be absorbed into the bloodstream at higher levels. This may contribute to the development of pancreatitis by exposing the pancreas to these enzymes in excess amounts.

There is also evidence that Salmonella bacteria can be found in bile fluid and gallstones. These bacteria might travel through the bile ducts and directly infect the pancreas, leading to inflammation and pancreatitis.¹¹

However, further research is needed to gain a deeper understanding of the pathophysiology of Salmonella-induced pancreatitis and its clinical implications.

Case studies and clinical evidence

While severe pancreatitis has been documented in a small number of cases, mild pancreatitis seems to be more common.

In the reported cases of acute pancreatitis due to Salmonella typhi, the main symptoms presented by people included periumbilical pain, abdominal pain, vomiting, fever, diarrhoea, headache, epistaxis (nosebleeds), and stool anomalies. In all these cases, bacteria were isolated from stool and blood samples. Antibiotic therapy was the mainstay of treatment in all cases. Common antibiotics used included chloramphenicol, ampicillin, sulbactam, cefixime, and meropenem. With adequate antibiotic medication in addition to symptomatic medical care, the prognosis was good in all cases, and the patient had a favourable outcome.³

Managing pancreatitis due to salmonella infection

Since Salmonella-induced pancreatitis is usually moderate in severity, symptomatic medical treatment suffices in most cases. Treatment for infectious acute pancreatitis due to salmonella infection is similar to that for acute pancreatitis caused by other factors. For proper treatment, an accurate diagnosis of acute pancreatitis is crucial. This involves ruling out other conditions, including gallstones, alcohol abuse, hypercalcemia, and hypertriglyceridemia. 

If you experience severe stomach pain and febrile diarrhoea, there is a likelihood of acute Salmonella pancreatitis. Doctors may look for symptoms such as intense epigastric pain and fever. Additionally, lipasemia (elevated levels of lipase enzymes) and the presence of bacteria like Salmonella typhi, identified through blood and stool cultures, can help diagnose correctly. Proper diagnosis and appropriate treatment, including rehydration, pain relief, and antibiotics, are essential for recovery.³

Preventive measures

To prevent salmonellosis, practising good hygiene is crucial. This includes:

• Wash your hands thoroughly after using the bathroom, handling food, or touching animals
• Ensuring that food preparation areas are kept clean and sanitised
• Avoid consuming unpasteurised foods and undercooked meats
• Being cautious when handling animals with diarrhoea¹²

FAQs

What organs are affected by Salmonella?

Salmonella can affect the gastrointestinal system (including the stomach and digestive tract), and depending on the species, various organs like the spleen, gallbladder, liver, bones, and meninges can be affected⁸. Salmonella strains can occasionally result in infections in the blood, bones, joints, urine, or the nervous system (brain and spinal fluid), which can lead to serious illness.⁶

What kind of infection causes pancreatitis?

Other than salmonella species, pathogens like Legionella, Leptospira, and Mycoplasma spp. Fungi like PCP, Aspergillus, and Cryptococcus and  viruses including the varicella-zoster virus, mumps, Coxsackie virus, CMV, acute HIV, hepatitis B, and SARS-coronavirus-2 can cause acute pancreatitis.¹³

Summary

• Salmonella infection is a condition that affects the intestinal tract and is caused by salmonella bacteria. This condition is spread through contaminated food and water
• Salmonella infection can lead to pancreatitis if not properly treated
• Specifically, pancreatitis has been linked to Salmonella typhi through mechanisms such as increased intestinal permeability and direct bile duct infection
• Accurate diagnosis of pancreatitis due to salmonella infection is crucial for proper treatment, which usually includes antibiotic intake
• To lower the risk of salmonellosis and its possible consequences, including pancreatitis, preventative measures such as adequate cleanliness and safe food handling are crucial