Dr. VP Bhalla, MS FICS (USA), FACS (USA)
Director, Centre for Digestive and Liver Diseases.
Consultant, GI Onco Surgery.
Head, Gastrointestinal Surgery Team.
BLK Super Speciality Hospital, New Delhi
The pancreas is a complex gland found deep within the upper abdomen lying across the back bone. The gland is composed of different cells which produce substances used by the body to control blood sugar levels and help in the digestion of fats and proteins. Hence the appearance of abnormal blood sugar levels as in diabetes mellitus, and the passage of foul smelling stools and loss of weight are all important features of pancreatic disease. Some patients with Pancreatitis and Pancreatic Cancer can also suffer from back ache. The combination of unexplained weight loss and back ache in a middle aged or elderly patient could well be due to a Pancreatic Cancer and this must always be looked for and excluded.
Diseases of the Pancreas are not so common. They are often difficult to diagnose. Investigations and treatment options for pancreatic disorders are technology intensive and expensive. The clinical, financial and social consequences of diseases of the pancreas are probably as significant as diseases of more ‘emotive’ human organs like the heart and the brain. However unlike heart and brain diseases, pancreatic diseases are not the subject of common discussion. Subsequently when faced with terms like Acute Pancreatitis, Chronic Pancreatitis, Pancreatic cancer and Pseudo cyst of pancreas patients, their attendants neither understand the problem at hand nor comprehend what lies ahead.
Presenting features of pancreatic disorders
Some features of pancreatic diseases have been mentioned in the introductory paragraph.Pancreatic disease can also present as jaundice or yellow discoloration of the eyes. In a population where jaundice is most often due to infections of the liver – Infective Viral Hepatitis, it is not so readily understood that jaundice can sometimes also be due to an obstruction to the flow of bile from the liver due to gall stones or cancer of the Pancreas.
Perhaps the most common presentation of pancreatic disease is pain. Your doctor tries clinically to define the character of the pain to make a bedside working diagnosis on which immediate treatment can be started and tests ordered to confirm the clinical suspicion. What starts as a mild pain in the upper abdomen accompanied by repeated vomiting often preceded by alcohol intake can progress rapidly, sometimes within hours, to a life threatening illness involving many other body systems as it happens in Acute Pancreatitis.
This issue will discuss Acute Pancreatitis. Other Pancreatic diseases will appear in subsequent articles.
Pancreatitis is swelling or inflammation of the Pancreas. It can be acute or chronic. By convention,Acute Pancreatitis when it resolves does so without any residual structural or functional deficiency of the pancreas. In contrast Chronic Pancreatitis is marked by a progressive destruction of the gland substance which slowly leads to a deterioration of gland function. These conventions are dynamic and doctors strive to constantly debate and refine them.
Acute Pancreatitis the subject of this article is a distinct entity with its own peculiar causes, severity of presentation, management problems and complications.
The most common causes of Acute Pancreatitis are gall stones and alcohol intake.Blunt and sometimes penetrating abdominal trauma can also cause acute Pancreatitis as also viral infections like mumps. Sometimes the cause is not apparent and doctors like to use the term ‘idiopathic’ for these cases. It is important to know the cause, for a good way to prevent future attacks of Pancreatitis is to treat the underlying cause. This may mean doing a cholecystectomy-removing the gall bladder where stones are produced and stopping alcohol intake.
The presentation can be quite dramatic and pain in the upper abdomen radiating to the back accompanied by vomiting is the common way in which the disease starts. There are various grades of severity of the disease ranging from a mild attack to a very severe life threatening illness. Hence the terms Mild Acute Pancreatitis and Severe Acute Pancreatitis. Fortunately the majority of patients have mild attacks which settle down with simple symptomatic treatment over a few days.
In about 10% of patients the disease progresses relentlessly and is potentially fatal. Mortality rates for severe acute pancreatitis vary from 20-40%.Doctors will try to determine the severity by studying objective parameters which guide them in determining the seriousness of the attack. These are called severity scores. The higher the severity score the worse the prognosis.
Severe acute pancreatitis is associated with pancreatic necrosis. Pancreatic necrosis refers to dead pancreatic tissue within the inflamed pancreas. A CT scan is a very effective investigation to pick up necrosis of the pancreas. Necrosis is a progressive phenomena and more than one CT scan may be required during the course of the illness.
Easily available blood and urine tests to measure levels of pancreatic enzymes are enough to confirm the diagnosis of Acute Pancreatitis.A CT scan is helpful in establishing the diagnosis in doubtful cases and indicates the extent of necrosis. As the disease progresses and as ‘toxins’ released in the body during acute pancreatitis effects other organ systems, a syndrome of multi system organ involvement develops. Extensive and repeated tests are now required to monitor the various involved systems.
The treatment is intensive support. The initial aim of management is intravenous fluid replacement often in litres and special antibiotics which can penetrate pancreatic necrosis and prevent infection from reaching the dead necrotic pancreatic tissue. These special antibiotics are expensive and as they may have to be used for extended periods, they can add substantially to cost of management. This effort at infection prevention is particularly important for it is the infection which causes complications of pancreatitis which can be fatal and which may necessitate high risk surgical operations.
As other systems get involved they all need intensive support of the highest order. Such support systems are now widely available but costs spiral as more systems need support. The use of the ICU, expensive drugs and the involvement of consultants of various specialties, the occasional high risk operations all add to treatment costs.
In spite of all recent, read costly, advancements in the management of Acute Pancreatitis the mortality rates for Acute Pancreatitis, particularly for the severe variety, remain depressingly high. While the mild attack usually subsides and resolves completely in a matter of days, the severe attack can run a fulminant course for weeks.
Occasionally surgery may be required to deal with infective complications within and in structures surrounding the dead necrotic and now infected pancreatic tissue. The patient already battered for days and weeks by the disease, is a poor surgical candidate when he develops a complication which requires an operation. The results of operations in this given setting are therefore understandably poor.
The best results for treating this dangerous disease will come from centers which have a special interest in diseases of the pancreas and which frequently and routinely treat such patients in an intensive care setting manned by teams of Intensivists Gastroenterologists and Gastrointestinal Surgeons experienced in handling patients with Acute Pancreatitis.
The ferocity of the severe attack and the huge costs involved in public and private hospitals coupled with the reluctance of attending doctors to commit to a favorable outcome in the initial days and weeks of the disease as it goes from one complication to the other can catch the supporting family and attendants completely off guard. The fear associated with a loved one doing poorly despite all the care being provided is only compounded by a lack of general knowledge about acute pancreatitis.
In spite of all recent read costly advances in the treatment of acute pancreatitis, mortality rates for Severe Acute Pancreatitis remain high. The real challenge for doctors must be not only in treating acute pancreatitis but also in constantly counseling and educating the patients relatives, attendants and the public in general about acute pancreatitis to enable them to cope better with the situation.
The best results of treatment will come from High Dependency Units manned by experts specially trained to treat patients of Acute Pancreatitis.