pancreatitis

the pancreas
pancreatitis
causes of pancreatitis
symptoms and diagnosis
drug treatment
surgical treatment
diet
drugs used in this condition
when to consult your doctor
further reading


the pancreas

The pancreas is a thin, flat, long organ placed horizontally deep in the abdomen, a little above the level of the umbilicus. In shape it resembles the wooden spatula often used in the kitchen for use on non-stick pans. The pancreas has two functions. Firstly, it produces pancreatic juice which contains enzymes that digest food. The enzymes are poured by the pancreatic tissue into the duct of the pancreas, and from there they are discharged into the intestines. In the absence of these enzymes, digestion is adversely affected. Secondly, the pancreas produces insulin, which regulates blood sugar levels. If the pancreas is not working properly, the patient can develop diabetes.

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pancreatitis

Pancreatitis is an inflammation of the pancreas. Pancreatitis occurs because some of its digestive enzymes leak between the pancreatic cells instead of flowing into the pancreatic duct. Here they begin to digest the cells themselves, and can cause immense harm. Inflammation continues unchecked, and the toxins of inflammation can generate oxidants, which further damage the pancreatic tissue. When pancreatitis develops, the pancreas initially enlarges in size and fills with water and other fluids. With time the damaged pancreas either heals or develops a collection of water around it (pseudocyst) or a collection of pus around it (abscess).

The pancreas also contains protective enzymes called antiproteases. With the help of these antiproteases, the pancreas may regress to normal. Sometimes, unfortunately, the damage may continue till much of the pancreas is destroyed.

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causes of pancreatitis

Pancreatitis can be caused by many factors. One of the major causes of pancreatitis is alcohol intake. Another common cause of pancreatitis is stones in the gall bladder. Some drugs and some viral infections can also cause pancreatitis.
Alcohol. Alcohol intake is one of the commonest causes of pancreatitis. Alcohol increases the pressure in the intestines, causing flow of activated pancreatic juice back from the pancreatic duct into the tissues. Alcohol, which is a toxin, is detoxified in the liver into acetaldehyde. Acetaldehyde is harmful to the pancreatic cells, and can cause them to function abnormally and discharge their juices into the wrong places. Alcohol worsens pancreatitis in another way. The protective antiproteases are also affected by alcohol, so that the damage is much more.
Gallstones. The gall bladder, a small organ situated on the undersurface of the liver, contains a digestive secretion called bile. Bile flows into the intestines through a tube called the bile duct. The bile duct is situated very close to the pancreatic duct, and in many persons actually joins the pancreatic duct so that both ducts enter the intestine by one common opening. In the bile the dissolved salts sometimes precipitate to form solid deposits, usually called gall stones. These gall stones can travel down the bile duct into the intestine. During passage they can irritate the pancreatic duct, causing increased pressure within it and setting off a chain of events that results in pancreatitis.

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symptoms and diagnosis

Pancreatitis presents with abdominal pain. The pain is in the mid-abdomen and can spread to the rest of the abdomen and the back. Pain is typically very severe and lasts for days. It is often confused with the pain of an ulcer, kidney stones or appendicitis. The patient can become very ill, with a fall in the blood pressure and life-threatening changes in the blood. Vomiting, fall in blood pressure and a rise in the pulse rate usually occur. Fever may be present.
In pancreatitis the enzymes that leak into the tissues also enter the blood. To diagnose pancreatitis a search is made for the presence of these enzymes in the blood. The easiest to measure of all the enzymes is the starch-digesting enzyme, amylase. Levels of amylase are increased often by 10 times in the blood in patients who have pancreatitis. Since the effects of pancreatitis occur all over the body, several blood tests and X-rays are needed to determine which organs are affected. An ultrasound test can usually diagnose pancreatitis, but for an accurate diagnosis as well as for assessment of the extent of damage, a CT scan is required.

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medical treatment

The best method of treatment is by giving rest to the pancreas. This is done by restricting food intake, and often a tube is passed from the nose into the stomach to suck out the contents of the stomach and intestines. Symptomatic control is by adequate doses of painkillers. Intravenous fluids are administered, and in most cases antibiotics are needed as well to prevent or minimize infection. Newer drugs such as somatostatin have shown promise in decreasing pancreatic enzyme production, thus allowing rest and healing.

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surgical treatment

If the damage to the pancreas has been marked, and the patient is not recovering, surgery may be needed. An operation is needed in the following cases:
a.the patient has developed a complication such as pus around the pancreas, or a large pseudocyst. Surgery is performed to remove pus, or to find an outlet for collected fluid in the pseudocyst.
b. the patient is gradually worsening in spite of best treatment. These patients may have recurrent passage of small gallstone particles causing repeated stress on the pancreas, and preventing. healing. Surgery is done to remove the gall bladder, thus removing this possible cause of pancreatitis.
c. the patient's diagnosis is unclear, in spite of all investigations. Some patients have a burst or other dangerous intestinal lesion, but the symptoms resemble those of pancreatitis. If the diagnosis is in doubt, it is better to operate and be sure. Operating in pancreatitis does not do the pancreas any harm, but a curable lesion of some other organ should not be missed. If an intestinal lesion is found, it is treated appropriately.
Results of treatment. In mild pancreatitis the patient may recover in two or three weeks, but in severe cases recovery may be much more prolonged. Complications such as abscess or pseudocyst can occur. A few patients develop vomiting of blood. At least 10% of patients with pancreatitis will not survive.

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diet

The main aim of treatment in acute pancreatitis is provide rest to the pancreas. This is effective only when the pancreas does not need to digest food. Initially the patient is not allowed any food by mouth. After 2 days or more, depending on the severitiy of the attack, the patient is allowed oral fluids, and then solids. Of the nutrients, water stimulates the pancreas the least, and fats the most. Therefore the sequence of nutrients is as follows: first water, then carbohydrates (sugars, starch), then proteins, and lastly fats. Fat-containing foods are allowed after 2-6 weeks. In the early days the patient will be allowed glucose water. 2-3 days later fat-free milk, boiled vegetables, some cereals and pulses can be give. Fried foods, butter, cream etc are fat-containing foods and are allowed only much later.

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drugs used in this condition

Intravenous fluids: dextrose, saline, Ringer's lactate and others
Painkillers: diclofenac, tramadol, pentazocine, pethidine and others
Antibiotics: these may vary
Drugs to prevent ulcers in the stomach: ranitidine (a very safe drug)
Drugs to minimize formation of pancreatic juice: somatostatin

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when to consult your doctor

Severe pain in the abdomen is always in indication for visiting your doctor. Pancreatitis is not a condition one can diagnose on ones own, unless the setting is very classical (such as severe upper abdominal pain in the presence of known gall stones or after an alcoholic binge)

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Further reading

http://www.limit.ac.uk/Pancreas/acute.htm about 1200 words, actually a very informative site
http://www.healthanswers.com/adam/top/view.asp?filename=001144.htm&rdir# brief account of pancreatitis, about 350 words
http://ca.yahoo.com/Health/Diseases_and_Conditions/Pancreatit lots of text, some information
http://ourworld.compuserve.com/homepages/psnjimarmour/ lots of pages, patients of pancreatitis should get answers to most of their questions
http://www.zen.co.uk/home/page/ppsg/ a support group for patients who have pancreatitis

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Author

Dr Suneet Sood, MBBS (AIIMS), MS (AIIMS), MAMS, is a practising surgeon attached to Dharamshila Cancer Hospital, Sir Ganga Ram Hospital and to Noida Medicare Center. Formerly Professor of Surgery, Himalayan Institute of Medical Sciences, Dehradun, Dr Sood has a special interest in gastrointestinal surgery. He has had an active academic career, has published several papers in national and international journals, and is the Editor (with Dr Anurag Krishna) of a widely acclaimed book titled Surgical Diseases in Tropical Countries.
Contact Nos: 2486788, 9811052966, suneetsood@vsnl.com


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Last revised: May 12, 2000