Benign Pancreatic Diseases

 

Acute Pancreatitis:

 

What is meant by ‘benign’?

  • It is an acute inflammatory process of the pancreas caused by gallstones in the majority of cases, followed by alcohol. Other possible causes includes: hyperlipedemia, medications, trauma and post surgical and endoscopic procedures

 

How do gallstones cause pancreatitis?

  • The bile duct carries the bile from the liver and gallbladder down to the duodenum. The lower part of the bile duct has a valve which regulate the bile secretion into the duodenum. This valve is located in front of the pancreas sometimes it does also regulate the pancreatic secretions. If a stone migrates from the gallbladder to the bile duct it may get stuck at the level of the valve and block both the bile and pancreatic juice secretions. This may activate the pancreatic enzymes causing pancreatic inflammation (pancreatitis)

 

How does alcohol cause pancreatitis ?

  • It is unclear how exactly alcohol cause pancreatits but there are few theories; it is suggested that it occurs due to the direct toxic effect of alcohol on the pancreas, it is also thought that alcohol can affect the viscosity of the pancreatic juice and hence its discharge.

 

What medications can cause pancreatitis?

  • Few medications can be involved including; azathioprine, estrogens, furosemide, pentamidine, thiazide diuretics and valproic acid

 

What are the syemptoms?

  • Sudden severe abdominal pain. Pain usually begins in the upper abdomen and radiates s to your back. This can be associated to nausea and vomiting, fever, swelling of the abdomen, rapid pulse, high or low blood pressure, shock, feelings of faintness, and jaundice (a yellowing of the skin or whites of eyes).

 

What is the difference between Mild and sever acute pancreatitis?

  • Mild pancreatitis is self limiting and dose not cause any systemic or local complications. Systemic complications are dysfunction of one of more organs such as the lung, heart, kidney and liver. Local complications include the death of the pancreatic tissue or part of it (necrosis), formation of pancreatic abscess and the formation of pancreatic pseudocysts,

 

How are complications treated?

  • Systemic complications and organ failure requires good organ support, usually patient are looked after in high dependency care till the show signs of improvement. Pancreatic necorsis does not require any treatment as long as it is not infected . in case of infection this need surgical removal. Pancreatic pseudocysts may resolve spontaneously, if they don't , they can cause symptoms such as pain and pressure on other organs. In these case they can be drained either endocopically or by a surgical operation. How to avoid having further attacks It is important to try to identify the cause of pancreatitis . If it was caused by gallstones , the a laparoscopic cholecystectomy should be performed. Otherwise, alcohol should be stopped if it was caused by alcohol , or medications should be changed if it was drugs related.

 

Chronic Pancreatitis :

It is a long standing inflammatory process which involves the pancreatic tissue, leading to progressive, permanent changes in its structure and therefore its function.

 

What is it caused by?

  • The most common cause is excessive alcohol intake over a long period of time, it is been observed that the majority of patients have consumed an average of 150g/day for an average of 10 years. Autoimmune pancreatitis is a newly recognised cause, other rare causes such as drugs ( anti-inflammatory, steroids), related chronic pancreatitis and hereditary pancreatitis are recognised.

 

What are the symptoms?

  • The most common symptom leading to the diagnosis is abdominal pain, it typically originates in the central abdomen and radiates to the back. Steatorrhea ( pasty, offensive smelling, soft stool caused by non absorbed fat) is another important symptom. Steatorrhea ( malabsorbtion) and pain ( patients tend to eat less to avoid pain) lead to significant weight loss.

 

How is the diagnosis made?

  • The diagnosis is usually based on a combination of clinical picture, radiological exams, blood tests and stool analysis. Diagnosis of chronic pancreatitis can be difficult and a carful assessment is needed to ensure a correct diagnosis is made.

 

What is the treatment?

  • Obviously the first step is to avoid the precipitating factor. In alcohol related pancreatitis a complete avoidance of alcohol is essential to avoid pain attacks and progression of disease. Pain control is the most important issue to mange to improve patients symptoms and quality of life. This may require specialist advice from the pain management team. Special attention should also be paid to the nutritional aspect. This is done by improving patients oral intake, both quantity and quality of diet. Also improving the absorption by adding the correct doses of pancreatic enzyme supplements to patients regular treatment. Last but not least is the management of diabetes which is often found in patients with chronic pancreatitis due to the pancreatic damage. This will need treatment with tablets or Insulin depending of its severity.

 

Would patients need surgery?

  • Surgery for chronic pancreatitis is not uncommon, this is normally required in advance stages where pain is difficult to control, in cases where bile duct is compressed leading to jaundice or in cases where the pancreatic duct is clearly obstructed by calcification. In some case surgical treatment is important to avoid further progression of disease.

 

What dose surgery involve?

  • There are different described surgical procedures for the management of this disease ( Beger's, Frey, Puestow procedures). Surgery may involve removing the head of the pancreas, preserving the duodenum to a separate loop of bowel. In other cases the pancreatic duct is opened and joined to the small bowel to permit free drainage. The choice of the surgical procedure depends on the radiological picture (the pancreas which is mostly involved, the presence and location of stones, the size of the gland), the surgical expertise and judgment of the surgeon.