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Monday, November 9, 2009

Pancreatitis, what pancreatitis?

I was warded for 6 days at Hospital Kuala Krai and was discharged on Hari Raya eve. I had to fast for 5 days and five nights? Not really, on the third day I was allowed to consumed plain water, on the forth day - beverages and on the fifth - soft diet.

It was damn painful, I thought I was going to die. After day one, when I recovered , the specialist told me that I will be ok, he explained that he had “cut” of my “engine (no food in the stomach)” and will do so until I recovered and able to do so. If I survived the first day. I will survive, according to him 10 per cent die – before they can even put the “engine” off .

I survived on 6 bottles of common salt and dextrose drips per day, throughout my days in the hospital. I could take plain water - but only very little on the third day, I had diarrhea on that day. I thought this was what I had when I received my therapy in Telipot. It can’t be appendicitis. If Doc Aziz is still around, I could have asked him in person.

I met Yu Nah’s tapper at the Hospital, her menantu was there, he had a motorbike accident.

I was discharged at night and had to ask a doctor to help me take the prescription for me. When he handed me the pills, I had to ask, why are there 2 painkillers. This was his answer, the Tranadol is for your stomach but when you take them it was give you a headache and that’s when you need Paracetamol, both on PRN. Damned modern medicine! no wonder they gave them this definition, “a doctor is someone who gives you pills and at the end the pills kill you". 

Below is a note on the subject from a Doctor, now practicing in the States and from my alma mater .

On a professional topic for a change!

Acute pancreatitis is an inflammation of the exocrine part of the pancreas (that organ abutting the backbone behind the stomach and what the chefs refer to as sweetbread). The pancreas has two functions. The exocrine part produces enzymes needed for digesting fat and protein; the other, the endocrine, produces insulin needed for regulating our sugar metabolism.

When the organ is inflamed, the cell wall becomes leaky and all those enzymes start to leak out and begin digesting your insides, hence the pain and damage. You are literally being digested or destroyed internally by your own enzymes!

Chronic pancreatitis is where the condition is chronic (that is over weeks, months or years). The mechanism and consequences are very different leading many to think that it is an entirely different clinical entity with different causes.

In America (West generally) the main causes of acute pancreatitis are alcohol and gallstones. Nobody knows what causes gallstones, and not all gallstones cause acute pancreatitis. Beyond the two, then we have rare causes, like hyperparathyroidism (hyperactivity of a small gland in the neck anatomically associated with but different from the thyroid gland), drugs, scorpion bites, and other "rare brids."

A Malay friend here had acute pancreatitis a few years ago and his doctors insisted that he was a "closet alcoholic." Knowing the friend well I suggested to him to suggest to his doctors to investigate for possible hyperparathyroidism. Indeed that was he had, and he had surgery that effectively cured the condition as well prevent further possible complications caused by the hyperparathyroidism (like kidney stones).

when I have a patient with acute pancreatitis, the immediate treatment is to maintain his metabolic stability; hence intravenous fluids, pain medications, antibiotics, etc. and give the pancreas a rest. So no eating for a few days. This will resolve most cases. Once that is resolved then investigate for the 'root cause" using CAT scans, ultrasounds, and ERCP (endoscopic examination). If a cause is found, then of course deal with it appropriately.

If no obvious cause, then seek the rare birds as mentioned above. Review the medications you are taking to make sure it is not a contributing factor.

Most acute pancreatitis will resolve. Nonetheless it is a serious disease and when there are complications (like necrotizing pancreatitis; necrotizing means death of tissues), then it is an even more serious and can be lethal. Generally you would require to be in ICU.

In my brief surgical practice in Malaysia I saw many cases of pancreatitis that have "weird" or rare causes including one caused by lupus, another caused by severe malnutrition, another a complication of kidney transplant, and a few of unknown causes that we lumped simply as "tropical pancreatitis."

Once you recover form acute pancreatitis the damage is such that you may have difficulty digesting foods especially those with high fat content; so avoid nasi lemak, rich rendang, kacang goreng. Alcohol is an absolute contraindication. We may not realize it but alcohol comes in many forms apart from the familiar ones in the bottle you get in the bar. Many cough syrups have alcohol base and they can trigger a pancreatitis attack if you so have been made predisposed by a previous attack.

Lastly, if the tissue damage is severe enough to affect the endocrine portion of the pancreas, then you may develop diabetes.

Transplant of both the exocrine and endocrine portions of the pancreas is now clinically feasible and done.

I trust this is helpful.
M. Bakri Musa, M.D.

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