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Monday, January 30, 2006
ACUTE PANCREATITIS
ACUTE PANCREATITIS:
Symptoms:
Abdominal pain: Diffuse throughout the entire upper abdomen. May be localized in the midepigastrum and LUQ or RUQ. Radiation to the back. Pain reaches maximum intensity within 10-20 min and may appear like a perforated ulcer. Pain is moderate to severe. Can be unbearable and refractory to PO narcotics. Steady and boring. Little fluctuation in pain. No relief by change of position of bed.
Nausea and vomiting: Frequent. May be severe and last several hours. May turn into dry heaves. Vomiting does not relieve the intensity of the pain. Even with gallstone pancreatitis, there is no temporal relationship between eating and the onset of pain.
Physical Exam:
Vitals: HR may be ( to 100 to 150. BP may start high and then go lower as there is third spacing. Temp: may be normal and then rise to 101 to 103.
Respiration: May be shallow if there inflammatory exudate on the diaphragm. Limited diaphragmatic excursion if abd causes splinting of the abdomen. Dullness to percussion due to pleural effusion.
Abdomen: Tenderness in upper abdomen. Guarding, percussion tenderness. Distention of abdomen. Rarely rigid. Grey Turner sign: ecchymoses in one or both flanks. Cullen sign: ecchymoses of the periumbilical region due to pancreatic exudate
Lab diagnosis:
Amylase: Reflects leakage of pancreatic isoamylase into the systemic circulation. ( 75% of acute pancreatitis. Remains ( for 5 to 10 days. Usually 3x Nl. Limitations: Amylase not ( in all cases of pancreatitis.
Lack of specificity: Acute pancreatitis, pancreatic carcinoma, acute cholecystitis, common bile duct obstruction, perforation of viscous, intestinal ischemia, intestinal obstruction ,acute appendicitis, renal insufficiency, and many more.
Lipase: ( in pancreatitis to 3x normal. Normal is 20-250. More specific. Almost all lipase originates from the pancreas.
Limitations:
( Renal insufficiency: Lipase ( only when creatinine clearance is < 20 ml/min. Lipase level is usually 2x normal.
( Acute intra-abdominal conditions: Usually less than 3x normal.
Standard blood tests:
( ( WBC, serum glucose, AST, ALT, Alk phos, and serum bilirubin.
( Biliary vs. alcoholic pancreatitis: ALT > 150 96% specific for gallstone pancreatitis. However, sensitivity was only 48%. Therefore a level of < 150 does not exclude gallstone pancreatitis
Radiologic features:
Survey film: Anterior displacement of the stomach. Ileus of one or more loops of jejunum (called the sentinel loop), or any of the small intestine. Colon cutoff sign: Inflammation from head of pancreas that spreads to the proximal transverse colon that leads to spasm of this area and dilatation of the ascending colon. Possible calcified gallstones.
Chest radiography: limited diaphragmatic excursion, pulmonary infiltrates, or pleural effusion.
Barium Studies: Replaced by CT
Ultrasound: Presence of gallstone. Dilated CBD. Enlargement of pancreas
CT: Most common technique for evaluation of acute pancreatitis. The indications are:
( If mesenteric infarction or perforated ulcer cannot be excluded.
( Staging pancreatitis
( Defining the complications.
MRI: Same information as CT. Not currently used.
Differential Diagnosis:
Biliary Colic
Perforated hollow viscus
Mesenteric ischemia
Closed loop intestinal obstruction
Inferior wall MI
Dissecting aneurysm
Ectopic pregnancy
Predisposing conditions:
Gallstones: Responsible for 30 to 75% of all cases of acute pancreatitis. Caused by lodging of gallstone in the ampulla of vater. Pathogenesis remains undetermined. Thought to be obstruction of pancreatic outflow rather than regurgitation of bile into the pancreas. Others cases are caused by stones too small to image.
Alcohol: 30% of cases. Mechanism is unclear.
Hyperlipidemia: 4% of cases. Most occur in pts with uncontrolled DM and a Hx of hypertriglyceridemia. Typically pts will need levels greater than 1000. Levels between 500 and 1000 may occasionally cause pancreatitis.
Hereditary pancreatitis: Autosomal dominant with variable penetrance. Need identification of at least two family members. Episodes begin in childhood.
Hyperparathyroidism and Hypercalcemia: 0.5% of cases. Mechanism unclear.
Structural abnormalities:
Medications:
( Immunosuppressive agents
( Sulfonamides
( Abx: Metronidazole, tetracycline, and nitrofurantoin
( Valproic acid
( Corticosteroids
( Furosemide
( Estrogens
( Aldomet
( Pentamidine
( Octreotide
( Didanosine
Infectious agents:
( Viral: Coxsackie B, EBV, CMV, varicella, and Hep A, Hep B, Hep C.
( Bacterial: Tb, leptospirosis, brucellosis.
( Candida albicans
( Parasitic: C. Sinensis and ascaris.
Other: Vascular dz, ERCP, post-operative, pancreatic trauma, cystic fibrosis, pregnancy, and miscellaneous.
Classification by Ranson criteria:
These are signs that have prognostic significance. The criteria on admission are measures of the intensity of local inflammation. The other 6 reflect the development of systemic complications and the harmful effects of third spacing fluid. The higher the number of Ranson criteria a pt has the more severe the pancreatitis. A large study showed that a ranson score of 1.6 correlated with mild pancreatitis, 2.4 with severe pancreatitis, and 5.6 with lethal pancreatitis.
On admission:
Age > 55
WBC > 16,000
Glucose > 200
AST >250
LDH > 350
During first 48 hrs
1) Hct ( of > 10: a measure of hemoconcentration
2) BUN ( of >5: reflects renal failure
3) Ca <8: loss of nonionized calcium associated w/loss of serum albumin, fat saponification, and complex cascade ( calciuria.
4) Pa O2 < 60: respiratory failure
5) Base deficit > 4: metabolic acidosis and shock
6) Fluid sequestration > 6 L: difference between amount of fluids administered IV vs. losses from urine and NGT.
These criteria are good only for the first 48 hrs. These criteria are most useful to exclude severe disease. The overall sensitivity for the criteria is 57 to 85%, specificity is 68 to 85%, the positive predictive value is 50% and negative predictive value of 90%.
Medical Management:
Fluid Resuscitation: Large amounts of fluid are lost secondary to exudation of blood and plasma protein into the retro peritoneal space. There is also ( the formation and release of kinin peptides ( vasodilatation and ( vascular permeability. Fluid resuscitation prevents hypotension and renal insufficiency. Requirements may be in excess of 6 L per day and can exceed 10L to maintain adequate vol. Swan-Ganz may be helpful in determining adequacy of fluid resuscitation. Colloid should be used if albumin is < 2 g/l. If Hct ( to 25 then PRBC should be used to maintain Hct at 30.
Respiratory care: Major problems are atelectasis, pneumonia, pleural effusions, CHF and fatigue. ARDS may also develop. O2 should be measured constantly and given if needed. ARDS occurs on 2nd to 7th day of illness.
Cardiovascular care: ( in cardiac index and ( in peripheral vascular resistance. IV use of dopamine can help maintain systemic blood pressure.
Relief of pain: PCA MSO4 is preferred over Meperidine.
Nutritional support: TPN for 3 to 6 weeks. Switch to oral feedings if abdominal pain and tenderness have lessened, organ dysfunction improved, and pt is hungry. Start with small feedings.
Local Complications
1. Pancreatic inflammatory mass (phlegmon).
2. Pancreatic infection of necrotic tissue
3. Pancreatic abscess (bacterial infection)
4. Pancreatic pseudocyst (collection of fluid and debris which, in contrast to true cysts, do not have epithelial lining)
5. Pancreatic ascites (leak of pancreatic duct)
6. Involvement of adjacent organs by necrotizing pancreatitis
Systemic Complications
1) Pulmonary: Hypoxia and ARDS can occur due to ( surfactant due to circulating phospholipases, alveolar capillary leak.
2) Cardiovascular: ( intravascular vol or shock may occur due to "third spacing" of fluid into edematous retroperitoneal space. Kallikrein activation and bradykinin production can cause ( capillary permeability, vasodilation, and hypotension.
3) Hematologic: Circulating trypsin activates thrombin and plasmin with resulting DIC. ( Hct may occur due to retroperitoneal bleeding.
4) Gastrointestinal: GI bleeding may occur due to pancreatic inflammation affected the stomach, duodenum, or peri-pancreatic blood vessels, or due to gastric varices resultant from splenic vein thrombosis. Nausea and vomiting may occur due to ileus of small bowel adjacent to pancreatic inflammation.
5) Renal: Impaired kidney function due to hypoperfusion of the kidneys from ( intravascular volume.
6) Metabolic: Hypocalcemia may occur due to precipitation of Ca in fatty soaps in the retroperitoneum (saponification of Ca by fatty acids in areas of fat necrosis), ( serum albumin, and/or ( PTH secretion.
7) CNS (psychosis)
8) Fat necrosis. Occurs in pancreas and in other sites, such as subcutaneous tissue. Related to release of lipase and phospholipase.
9) Endocrine. Hyperglycemia may occur if insulin production is impaired. Need to have 90% destroyed before get problem.
10) Fevers. Related to pancreatic inflammation and cytokine release.
11) Ascites: fluid leaking from pancreas. ( amylase and lipase.
12) Pseudocyts: Not true cysts. Still dealing with residual and fluid collection. About 6 weeks. Some will resolve on their own. Some need more active treatment.
CHRONIC PANCREATITIS
Chronic inflammatory process of the pancreas which generally manifests as pain and/or malabsorption. It can cause exocrine and endocrine insufficiency, especially when >90% of pancreatic function impaired.
Etiology
*****Alcohol >80%****
Idiopathic
Cystic Fibrosis: cause of occult pancreatitis.
Hereditary
Protein malnutrition
Pathophysiology
Uncertain. Associated with ( precipitation of protein (inspissated enzymes) w/in ducts ( duct obstruction, dilation, fibrosis, and calcification. Induced stone formation w/in ducts in pancreas.
Recurrent pancreatitis ( Chronic pancreatic changes.
Alcohol toxic to pancreas. Disrupts normal defenses against autodigestion.
Abnormal trypsin resistance to trypsin degradation.
Clinical Features
1) Epigastric pain: constant or intermittent. Etiology of pain unclear, but may be related to pancreatic duct/tissue HTN (actual stretching) or to peri-pancreatic nerve damage.
2) Steatorrhea occurs when >90% of gland ceases to function. If from pancreatic. Do they see oil drops in stool. Has to be pancreatic insufficiency. Maldigestion.
3) DM:
4) Protein maldigestion is less common than fat maldigestion.
5) Malabsorption of fat soluble vitamins (ADEK) and vitamin B12 may occur. Vitamin B12 deficiency occurs because B12 binds to non-intrinsic factor proteins which must be cleaved by pancreatic enzymes to allow binding to intrinsic factor for absorption.
Diagnostic Evaluation
Unfortunately no clinical "gold standard" exists. Pancreatic biopsy is generally not performed for fear of inducing acute pancreatitis. Severe cases are easy to diagnose with pancreatic calcifications on xray, steatorrhea, and diabetes mellitus.
Anatomic Imaging Studies
( Abd radiograph ( calcification in severe cases.
( Ultrasound (trans-abdominal or endoscopic) - shows calcification, thickening pancreatic duct wall, dilated and irregular pancreatic duct, and lobular appearance
( CT scan - shows calcifications and a dilated pancreatic duct
( ERCP - shows dilated and irregular pancreatic duct with strictures, possible stones, and dilated side branches.
Functional Studies
1. Qualitative and quantitative fecal fat: > 7 gm in 24 hrs will confim diagnosis.
2. Secretin stimulation test.: release of pancreatic enzymes and release of bicarb.
3. Bentiromide test.
Management
1. *****Avoid alcohol *****
2. Long-term narcotic pain medication is often required.
3. Tricyclic antidepressants can help raise sensory pain threshold.
4. Surgical or endoscopic treatment may help if there is a focal pancreatic duct stricture.
5. Oral ingestion of pancreatic enzymes results in negative feedback to the pancreas, decreases enzyme secretion, improves steatorrhea, and may improve pain in mild-moderate severity cases.
6 Octreotide may have a role in selected cases.
HEREDITARY PANCREATITIS
Autosomal dominant disease with 80% penetrance.
Symptoms: begin before age 20. Epigastric pain and ( pancreatic enzymes. Symptoms may be mild, or may appear as acute or chronic pancreatitis.
Abd radiographs ( calcification in approximately 50% of pts.
There is ( risk of pancreatic cancer ( ~ 40% risk by age 70.
Mutation in the cationic trypsinogen gene on Ch 7 ( abnormality in the trypsinogen molecule which inhibits degradation by trypsin in a feed-back ioop. Under normal circumstances, there is a low level of trypsinogen autoactivation in the pancreas. Any activated trypsin within the pancreas is inhibited by trypsin inhibitor. However if there is excessive trypsin activation which exceeds the amount of trypsin inhibitor, then trypsin can feedback on itself and hydrolyze trypsin to prevent activating the cascade of pancreatic enzymes. In patients with hereditary pancreatitis, activated trypsin will not be inactivated, and therefore will lead to generalized digestive enzyme activation leading to pancreatitis.
Symptoms:
Abdominal pain: Diffuse throughout the entire upper abdomen. May be localized in the midepigastrum and LUQ or RUQ. Radiation to the back. Pain reaches maximum intensity within 10-20 min and may appear like a perforated ulcer. Pain is moderate to severe. Can be unbearable and refractory to PO narcotics. Steady and boring. Little fluctuation in pain. No relief by change of position of bed.
Nausea and vomiting: Frequent. May be severe and last several hours. May turn into dry heaves. Vomiting does not relieve the intensity of the pain. Even with gallstone pancreatitis, there is no temporal relationship between eating and the onset of pain.
Physical Exam:
Vitals: HR may be ( to 100 to 150. BP may start high and then go lower as there is third spacing. Temp: may be normal and then rise to 101 to 103.
Respiration: May be shallow if there inflammatory exudate on the diaphragm. Limited diaphragmatic excursion if abd causes splinting of the abdomen. Dullness to percussion due to pleural effusion.
Abdomen: Tenderness in upper abdomen. Guarding, percussion tenderness. Distention of abdomen. Rarely rigid. Grey Turner sign: ecchymoses in one or both flanks. Cullen sign: ecchymoses of the periumbilical region due to pancreatic exudate
Lab diagnosis:
Amylase: Reflects leakage of pancreatic isoamylase into the systemic circulation. ( 75% of acute pancreatitis. Remains ( for 5 to 10 days. Usually 3x Nl. Limitations: Amylase not ( in all cases of pancreatitis.
Lack of specificity: Acute pancreatitis, pancreatic carcinoma, acute cholecystitis, common bile duct obstruction, perforation of viscous, intestinal ischemia, intestinal obstruction ,acute appendicitis, renal insufficiency, and many more.
Lipase: ( in pancreatitis to 3x normal. Normal is 20-250. More specific. Almost all lipase originates from the pancreas.
Limitations:
( Renal insufficiency: Lipase ( only when creatinine clearance is < 20 ml/min. Lipase level is usually 2x normal.
( Acute intra-abdominal conditions: Usually less than 3x normal.
Standard blood tests:
( ( WBC, serum glucose, AST, ALT, Alk phos, and serum bilirubin.
( Biliary vs. alcoholic pancreatitis: ALT > 150 96% specific for gallstone pancreatitis. However, sensitivity was only 48%. Therefore a level of < 150 does not exclude gallstone pancreatitis
Radiologic features:
Survey film: Anterior displacement of the stomach. Ileus of one or more loops of jejunum (called the sentinel loop), or any of the small intestine. Colon cutoff sign: Inflammation from head of pancreas that spreads to the proximal transverse colon that leads to spasm of this area and dilatation of the ascending colon. Possible calcified gallstones.
Chest radiography: limited diaphragmatic excursion, pulmonary infiltrates, or pleural effusion.
Barium Studies: Replaced by CT
Ultrasound: Presence of gallstone. Dilated CBD. Enlargement of pancreas
CT: Most common technique for evaluation of acute pancreatitis. The indications are:
( If mesenteric infarction or perforated ulcer cannot be excluded.
( Staging pancreatitis
( Defining the complications.
MRI: Same information as CT. Not currently used.
Differential Diagnosis:
Biliary Colic
Perforated hollow viscus
Mesenteric ischemia
Closed loop intestinal obstruction
Inferior wall MI
Dissecting aneurysm
Ectopic pregnancy
Predisposing conditions:
Gallstones: Responsible for 30 to 75% of all cases of acute pancreatitis. Caused by lodging of gallstone in the ampulla of vater. Pathogenesis remains undetermined. Thought to be obstruction of pancreatic outflow rather than regurgitation of bile into the pancreas. Others cases are caused by stones too small to image.
Alcohol: 30% of cases. Mechanism is unclear.
Hyperlipidemia: 4% of cases. Most occur in pts with uncontrolled DM and a Hx of hypertriglyceridemia. Typically pts will need levels greater than 1000. Levels between 500 and 1000 may occasionally cause pancreatitis.
Hereditary pancreatitis: Autosomal dominant with variable penetrance. Need identification of at least two family members. Episodes begin in childhood.
Hyperparathyroidism and Hypercalcemia: 0.5% of cases. Mechanism unclear.
Structural abnormalities:
Medications:
( Immunosuppressive agents
( Sulfonamides
( Abx: Metronidazole, tetracycline, and nitrofurantoin
( Valproic acid
( Corticosteroids
( Furosemide
( Estrogens
( Aldomet
( Pentamidine
( Octreotide
( Didanosine
Infectious agents:
( Viral: Coxsackie B, EBV, CMV, varicella, and Hep A, Hep B, Hep C.
( Bacterial: Tb, leptospirosis, brucellosis.
( Candida albicans
( Parasitic: C. Sinensis and ascaris.
Other: Vascular dz, ERCP, post-operative, pancreatic trauma, cystic fibrosis, pregnancy, and miscellaneous.
Classification by Ranson criteria:
These are signs that have prognostic significance. The criteria on admission are measures of the intensity of local inflammation. The other 6 reflect the development of systemic complications and the harmful effects of third spacing fluid. The higher the number of Ranson criteria a pt has the more severe the pancreatitis. A large study showed that a ranson score of 1.6 correlated with mild pancreatitis, 2.4 with severe pancreatitis, and 5.6 with lethal pancreatitis.
On admission:
Age > 55
WBC > 16,000
Glucose > 200
AST >250
LDH > 350
During first 48 hrs
1) Hct ( of > 10: a measure of hemoconcentration
2) BUN ( of >5: reflects renal failure
3) Ca <8: loss of nonionized calcium associated w/loss of serum albumin, fat saponification, and complex cascade ( calciuria.
4) Pa O2 < 60: respiratory failure
5) Base deficit > 4: metabolic acidosis and shock
6) Fluid sequestration > 6 L: difference between amount of fluids administered IV vs. losses from urine and NGT.
These criteria are good only for the first 48 hrs. These criteria are most useful to exclude severe disease. The overall sensitivity for the criteria is 57 to 85%, specificity is 68 to 85%, the positive predictive value is 50% and negative predictive value of 90%.
Medical Management:
Fluid Resuscitation: Large amounts of fluid are lost secondary to exudation of blood and plasma protein into the retro peritoneal space. There is also ( the formation and release of kinin peptides ( vasodilatation and ( vascular permeability. Fluid resuscitation prevents hypotension and renal insufficiency. Requirements may be in excess of 6 L per day and can exceed 10L to maintain adequate vol. Swan-Ganz may be helpful in determining adequacy of fluid resuscitation. Colloid should be used if albumin is < 2 g/l. If Hct ( to 25 then PRBC should be used to maintain Hct at 30.
Respiratory care: Major problems are atelectasis, pneumonia, pleural effusions, CHF and fatigue. ARDS may also develop. O2 should be measured constantly and given if needed. ARDS occurs on 2nd to 7th day of illness.
Cardiovascular care: ( in cardiac index and ( in peripheral vascular resistance. IV use of dopamine can help maintain systemic blood pressure.
Relief of pain: PCA MSO4 is preferred over Meperidine.
Nutritional support: TPN for 3 to 6 weeks. Switch to oral feedings if abdominal pain and tenderness have lessened, organ dysfunction improved, and pt is hungry. Start with small feedings.
Local Complications
1. Pancreatic inflammatory mass (phlegmon).
2. Pancreatic infection of necrotic tissue
3. Pancreatic abscess (bacterial infection)
4. Pancreatic pseudocyst (collection of fluid and debris which, in contrast to true cysts, do not have epithelial lining)
5. Pancreatic ascites (leak of pancreatic duct)
6. Involvement of adjacent organs by necrotizing pancreatitis
Systemic Complications
1) Pulmonary: Hypoxia and ARDS can occur due to ( surfactant due to circulating phospholipases, alveolar capillary leak.
2) Cardiovascular: ( intravascular vol or shock may occur due to "third spacing" of fluid into edematous retroperitoneal space. Kallikrein activation and bradykinin production can cause ( capillary permeability, vasodilation, and hypotension.
3) Hematologic: Circulating trypsin activates thrombin and plasmin with resulting DIC. ( Hct may occur due to retroperitoneal bleeding.
4) Gastrointestinal: GI bleeding may occur due to pancreatic inflammation affected the stomach, duodenum, or peri-pancreatic blood vessels, or due to gastric varices resultant from splenic vein thrombosis. Nausea and vomiting may occur due to ileus of small bowel adjacent to pancreatic inflammation.
5) Renal: Impaired kidney function due to hypoperfusion of the kidneys from ( intravascular volume.
6) Metabolic: Hypocalcemia may occur due to precipitation of Ca in fatty soaps in the retroperitoneum (saponification of Ca by fatty acids in areas of fat necrosis), ( serum albumin, and/or ( PTH secretion.
7) CNS (psychosis)
8) Fat necrosis. Occurs in pancreas and in other sites, such as subcutaneous tissue. Related to release of lipase and phospholipase.
9) Endocrine. Hyperglycemia may occur if insulin production is impaired. Need to have 90% destroyed before get problem.
10) Fevers. Related to pancreatic inflammation and cytokine release.
11) Ascites: fluid leaking from pancreas. ( amylase and lipase.
12) Pseudocyts: Not true cysts. Still dealing with residual and fluid collection. About 6 weeks. Some will resolve on their own. Some need more active treatment.
CHRONIC PANCREATITIS
Chronic inflammatory process of the pancreas which generally manifests as pain and/or malabsorption. It can cause exocrine and endocrine insufficiency, especially when >90% of pancreatic function impaired.
Etiology
*****Alcohol >80%****
Idiopathic
Cystic Fibrosis: cause of occult pancreatitis.
Hereditary
Protein malnutrition
Pathophysiology
Uncertain. Associated with ( precipitation of protein (inspissated enzymes) w/in ducts ( duct obstruction, dilation, fibrosis, and calcification. Induced stone formation w/in ducts in pancreas.
Recurrent pancreatitis ( Chronic pancreatic changes.
Alcohol toxic to pancreas. Disrupts normal defenses against autodigestion.
Abnormal trypsin resistance to trypsin degradation.
Clinical Features
1) Epigastric pain: constant or intermittent. Etiology of pain unclear, but may be related to pancreatic duct/tissue HTN (actual stretching) or to peri-pancreatic nerve damage.
2) Steatorrhea occurs when >90% of gland ceases to function. If from pancreatic. Do they see oil drops in stool. Has to be pancreatic insufficiency. Maldigestion.
3) DM:
4) Protein maldigestion is less common than fat maldigestion.
5) Malabsorption of fat soluble vitamins (ADEK) and vitamin B12 may occur. Vitamin B12 deficiency occurs because B12 binds to non-intrinsic factor proteins which must be cleaved by pancreatic enzymes to allow binding to intrinsic factor for absorption.
Diagnostic Evaluation
Unfortunately no clinical "gold standard" exists. Pancreatic biopsy is generally not performed for fear of inducing acute pancreatitis. Severe cases are easy to diagnose with pancreatic calcifications on xray, steatorrhea, and diabetes mellitus.
Anatomic Imaging Studies
( Abd radiograph ( calcification in severe cases.
( Ultrasound (trans-abdominal or endoscopic) - shows calcification, thickening pancreatic duct wall, dilated and irregular pancreatic duct, and lobular appearance
( CT scan - shows calcifications and a dilated pancreatic duct
( ERCP - shows dilated and irregular pancreatic duct with strictures, possible stones, and dilated side branches.
Functional Studies
1. Qualitative and quantitative fecal fat: > 7 gm in 24 hrs will confim diagnosis.
2. Secretin stimulation test.: release of pancreatic enzymes and release of bicarb.
3. Bentiromide test.
Management
1. *****Avoid alcohol *****
2. Long-term narcotic pain medication is often required.
3. Tricyclic antidepressants can help raise sensory pain threshold.
4. Surgical or endoscopic treatment may help if there is a focal pancreatic duct stricture.
5. Oral ingestion of pancreatic enzymes results in negative feedback to the pancreas, decreases enzyme secretion, improves steatorrhea, and may improve pain in mild-moderate severity cases.
6 Octreotide may have a role in selected cases.
HEREDITARY PANCREATITIS
Autosomal dominant disease with 80% penetrance.
Symptoms: begin before age 20. Epigastric pain and ( pancreatic enzymes. Symptoms may be mild, or may appear as acute or chronic pancreatitis.
Abd radiographs ( calcification in approximately 50% of pts.
There is ( risk of pancreatic cancer ( ~ 40% risk by age 70.
Mutation in the cationic trypsinogen gene on Ch 7 ( abnormality in the trypsinogen molecule which inhibits degradation by trypsin in a feed-back ioop. Under normal circumstances, there is a low level of trypsinogen autoactivation in the pancreas. Any activated trypsin within the pancreas is inhibited by trypsin inhibitor. However if there is excessive trypsin activation which exceeds the amount of trypsin inhibitor, then trypsin can feedback on itself and hydrolyze trypsin to prevent activating the cascade of pancreatic enzymes. In patients with hereditary pancreatitis, activated trypsin will not be inactivated, and therefore will lead to generalized digestive enzyme activation leading to pancreatitis.
Friday, January 13, 2006
Transitional Diets posted by Robin H
Robin H found this for transitional diets for Pancreatitis
PANCREATITIS MESSAGE BOARD
Posted by cj on December 30, 2005 at 18:53:09:
I just couldn’t get the daily example of diet to space right, so it was just choices off the lists below.
Transitional Diets for Pancreatitis
When you are discharged home from the hospital, you will be starting off with a diet that is easier for your body to tolerate and will not stimulate your pancreas too much.
Gradually, you will be allowed more and more food, and will transition finally to a low-fat regular diet that you can stay on almost indefinitely to minimize pain and abdominal symptoms.
Start off with the clear liquid diet (1), then when you tolerate this without pain, nausea, vomiting or diarrhea, advance to the full liquid diet (2). When you tolerate this, advance to the low-residue low-fat diet (3). Finally, you can graduate to the regular low-fat diet (4).
This transition should be slow to avoid any problems with worsening pain or Pancreatitis symptoms. A rough rule of thumb is to complete the transition from clear liquid to solid, but a low-fat diet, within 1 week. Please remember that the pancreas is more prone to react to fatty (heavy) food and food that stays within the stomach for a long time. Therefore, a liquid diet or a low-fat diet is better tolerated than a solid, regular or high-fat diet.
The following pages will give you some guidance on what to avoid and what to choose during your transition. The last page gives a sample menu for each stage of the diet.
If you have diabetes or are prone to high blood sugars, follow the asterix (*) for extra instructions on how to balance the carbohydrates in your diet.
1. Clear Liquid Diet
The clear liquid diet is used only very short term, for example, 2 to 3 days, for when you are initially starting to eat. This is a very limited diet with only the following items. When you are feeling better, and have minimal abdominal pain, no nausea, vomiting or diarrhea, move on to the Full Liquid Diet (2).Juices*Broth, Clear soups Gelatin (Jell-O),*Sorbet*
Popsicles*, Fruit ices*, 7-up or Sprite*, Sports drinks such as Gatorade*
* if you have diabetes or are prone to high blood sugars, have at least two but not more than three 4-oz portions of these carbohydrate containing clear liquids at each meal. You can have unlimited diet gelatin (diet Jell-O), Diet 7-up or Diet Sprite, or diet fruit ices in addition.
2. Full Liquid Diet
When you are ready to add to the Clear Liquid Diet, add the following items to your diet, and continue to have everything allowed on the Clear Liquid Diet. Make sure you try to eat at least 3 times a day to try to meet your nutritional requirements. You should not follow this diet for more than 2 weeks as it is not fully nutritionally adequate. When you tolerate this diet, move on to the low-residue, low-fat diet.
Milk*Smooth yogurt with no fruit chunks*, Broth soup, Cream soup*, Pudding*, Custard*, Low-fat Ice cream*, Boost or Ensure*, Fruit smoothies*, Rice milk*, Soy milk*
* if you have diabetes or are prone to high blood sugars, have at least two but not more than three 4-oz portions of these carbohydrate containing clear liquids at each meal. You can have unlimited diet gelatin (diet Jell-O), Diet 7-up or Diet Sprite, or diet fruit ices in addition.
3. Low Residue (Low-Fiber), Low-Fat Diet
A low-residue or low-fiber, low-fat diet avoids most foods with a lot of fiber and fat. Try to consume white breads, white rice, and not too many raw fruits or vegetables. Avoid fatty foods. This will allow you to transition to a regular low-fat diet more easily, and minimize pain and other symptoms such as nausea, vomiting and diarrhea. This diet is balanced and can be followed for weeks.
L Foods to AVOID:
Whole grain and whole wheat breads , Rye breads with seeds ,Nuts and seeds , Granola and granola bars , Dried fruit , Coconut , Raw fruits , Raw vegetables
Salads:
Gas-producing vegetables: Broccoli, Brussels sprouts, Cabbage, Cauliflower Sauerkraut, Onions, Vegetables with seeds:, Eggplant. Tomatoes Fried meats , Tough meats , Sausages , Bologna , Peanut butter , Beans , Jams and preserves , Fried potatoes/french fries , Wild or brown rice , Whole wheat pasta , Ice cream , Cream , Butter , Pudding , Coffee , Gravy , Mayonnaise
J Foods to EAT:
White breadSourdough breadEnglish muffins, Pancakes and waffles, Canned fruit (moderation), Crackers, Cream of wheat, Oatmeal, Soft cooked vegetables: Asparagus tip, Carrots, Beets, Green beans, Spinach, Summer squash, Zucchini, Mushrooms, Soft fruits (limit 2 per day): , Melon, peach, banana, or skinless, Tender lean meats, Skinless chicken, Fish, Turkey, ground turkey, Jelly, Honey, Mashed potatoes , Baked potatoes no skin, Boiled potatoes, White rice, noodles, Pasta (not whole wheat), w-fat milk (if tolerated)Lactaid milk, yogurt, Angel food cake, Fruit juices, soy milk, Lite mayonnaise
4. Low-Fat Diet
A low fat diet is the recommended diet to follow almost indefinitely when you have Pancreatitis. Try to follow a low-fat diet consistently, eating no more than 50 grams of fat per day. A low-fat diet is a balanced, healthy way to eat
L Foods to AVOID:
Croissants , Donuts, muffins , Nuts and nut butters , Granola and granola bars Cakes, cookies , Oily crackers (e.g. Ritz) , Bacon and eggs , Cream soups , Salad dressings , Croutons , Bacon bits , Sour cream , Sesame and other seeds , Fried meats , Fatty meats , Sausages , Cheeseburger , Bologna, hot dogs , Peanut butter Cheese , Mayonnaise , Fried potatoes/french fries , Scalloped potatoes , Pasta with cream sauce , Ice cream, Cream , Fried noodles, Pudding , Pound cake, cakes with icing , Cookies
J Foods to EAT:
White or wheat bread, Sourdough bread, rye bread, English muffins, pancakes, waffles, Corn flakes, rice crispies, cereal bars, Fresh fruit, dried fruit, juices, Dry crackers, e.g. soda, graham, water, Cream of wheat, oatmeal, , Vegetable soups, broth based soups , Salads, vegetables, fat-free dressings, Vinegars, Garbanzo beans, Plain yogurt, nonfat sour cream, Pretzels, Skinless chicken , Lean meats, Ham, roast beef, roast turkey slices, Turkey burger, no cheese, “Smart Dogs” and other soy products, Turkey, ground turkey, Jams and Jelly, Mustard, ketchup, lite mayo, Mashed potatoes with no butter, Baked potatoes, boiled potato, Pasta with tomato based sauce, Sorbet, sherbet, low-fat frozen yogurt, Low-fat desserts , Noodles in soup, Nonfat or low-fat milk or yogurt, Angel food cake, All fruits
FREQUENTLY ASKED QUESTIONS ON PANCREATITIS DIET
1. What kind of diet do I have to follow for life?
The kind of diet that is best for someone with chronic Pancreatitis is a diet that is low in fat, low in sugar, and moderate in protein. That means, most of your diet will consist of fruits and vegetables, lean meats, skinless chicken and turkey, fish, potatoes, rice and pasta, and low-fat dairy products and soy. This is similar to the diet recommended for patients with heart disease, so you can look in bookstores for cookbooks for heart-healthy diets, and you can choose items on restaurant menus that are intended for heart-healthy diets.
2. Can I follow a low-carbohydrate, Atkins-type diet if I have Pancreatitis and want to lose weight?
A low-carbohydrate, Atkins-type diet will probably have too much meat and fat for a person with Pancreatitis to follow. However, it is important for a person with Pancreatitis to eat enough protein. The best is to be moderate in your protein intake and try to avoid fatty meats and fatty food preparation techniques such as frying and sautéing.
In general, it is not advised to follow an Atkins-type diet if you have Pancreatitis. If you wish to lose weight, cut down on foods with a lot of calories, such a juices, sweets, baked goods, heavy sauces, and reduce your portion sizes of rice, bread, pasta, and potatoes. Don’t cut them out entirely, as they are low-fat foods. Eat more vegetables. Make sure you eat breakfast (this actually helps with weight loss). Make sure you do some exercise daily or every other day for at least 30 minutes. It can be walking or any activity you enjoy and can do consistently.
3. How much protein do I need per day?
Most adults need about 6 oz of fish, chicken, turkey, or lean meat every day. You can divide this into 3 oz at lunch and 3 oz at dinner, or 2 oz at lunch and 4 oz at dinner. A 3 oz portion is the size of a deck of cards. A 4 oz portion is about the size of a woman’s palm. A slice of turkey or chicken is about 1 oz, so a sandwich with 2 slices is about 2 oz of protein food.
Eating enough protein is important. Don’t cut out all protein foods.
4. What if I’m vegetarian?
If you are vegetarian, you need to obtain your protein from beans, soy products, eggs, and dairy products. Try not to use cheese and nuts for protein, as they come with a lot of fat also. Instead, purchase a low-fat vegetarian cookbook and make items such as bean chili, tofu stir-fries (with a minimum of vegetable oil), and other such vegetarian recipes. Low-fat milk, eggs, yogurt and cottage cheese are also acceptable sources of protein.
5. What are some things I can snack on?
Low-fat snacks include fresh fruit, fruited yogurt, low-fat crackers, cereal and milk, liteJell-O, toast and jam, or bagel.
6. Should I avoid sugar?
If you have high blood sugars, you may need to be on a diabetic diet. It is best, then, to avoid sugar as much as possible, but also be aware of your portion sizes for starchy foods such as rice, potato, pasta, bread, cereal, and noodles. Keep your portions sizes to ½ to 1 cup per meal, and only have one of these starchy items per meal. Eat more vegetables instead.
If you don’t currently have high blood sugars, you can have some foods with sugar, and use small amounts of sugar in foods and beverages, but be moderate. The reason for this is that the pancreas is responsible for making insulin, the hormone that helps the body utilize sugar, so if your pancreas is stressed, it may be stressed further if you constantly eat a high sugar diet. Use sugar and sweets in moderation.
PANCREATITIS MESSAGE BOARD
Posted by cj on December 30, 2005 at 18:53:09:
I just couldn’t get the daily example of diet to space right, so it was just choices off the lists below.
Transitional Diets for Pancreatitis
When you are discharged home from the hospital, you will be starting off with a diet that is easier for your body to tolerate and will not stimulate your pancreas too much.
Gradually, you will be allowed more and more food, and will transition finally to a low-fat regular diet that you can stay on almost indefinitely to minimize pain and abdominal symptoms.
Start off with the clear liquid diet (1), then when you tolerate this without pain, nausea, vomiting or diarrhea, advance to the full liquid diet (2). When you tolerate this, advance to the low-residue low-fat diet (3). Finally, you can graduate to the regular low-fat diet (4).
This transition should be slow to avoid any problems with worsening pain or Pancreatitis symptoms. A rough rule of thumb is to complete the transition from clear liquid to solid, but a low-fat diet, within 1 week. Please remember that the pancreas is more prone to react to fatty (heavy) food and food that stays within the stomach for a long time. Therefore, a liquid diet or a low-fat diet is better tolerated than a solid, regular or high-fat diet.
The following pages will give you some guidance on what to avoid and what to choose during your transition. The last page gives a sample menu for each stage of the diet.
If you have diabetes or are prone to high blood sugars, follow the asterix (*) for extra instructions on how to balance the carbohydrates in your diet.
1. Clear Liquid Diet
The clear liquid diet is used only very short term, for example, 2 to 3 days, for when you are initially starting to eat. This is a very limited diet with only the following items. When you are feeling better, and have minimal abdominal pain, no nausea, vomiting or diarrhea, move on to the Full Liquid Diet (2).Juices*Broth, Clear soups Gelatin (Jell-O),*Sorbet*
Popsicles*, Fruit ices*, 7-up or Sprite*, Sports drinks such as Gatorade*
* if you have diabetes or are prone to high blood sugars, have at least two but not more than three 4-oz portions of these carbohydrate containing clear liquids at each meal. You can have unlimited diet gelatin (diet Jell-O), Diet 7-up or Diet Sprite, or diet fruit ices in addition.
2. Full Liquid Diet
When you are ready to add to the Clear Liquid Diet, add the following items to your diet, and continue to have everything allowed on the Clear Liquid Diet. Make sure you try to eat at least 3 times a day to try to meet your nutritional requirements. You should not follow this diet for more than 2 weeks as it is not fully nutritionally adequate. When you tolerate this diet, move on to the low-residue, low-fat diet.
Milk*Smooth yogurt with no fruit chunks*, Broth soup, Cream soup*, Pudding*, Custard*, Low-fat Ice cream*, Boost or Ensure*, Fruit smoothies*, Rice milk*, Soy milk*
* if you have diabetes or are prone to high blood sugars, have at least two but not more than three 4-oz portions of these carbohydrate containing clear liquids at each meal. You can have unlimited diet gelatin (diet Jell-O), Diet 7-up or Diet Sprite, or diet fruit ices in addition.
3. Low Residue (Low-Fiber), Low-Fat Diet
A low-residue or low-fiber, low-fat diet avoids most foods with a lot of fiber and fat. Try to consume white breads, white rice, and not too many raw fruits or vegetables. Avoid fatty foods. This will allow you to transition to a regular low-fat diet more easily, and minimize pain and other symptoms such as nausea, vomiting and diarrhea. This diet is balanced and can be followed for weeks.
L Foods to AVOID:
Whole grain and whole wheat breads , Rye breads with seeds ,Nuts and seeds , Granola and granola bars , Dried fruit , Coconut , Raw fruits , Raw vegetables
Salads:
Gas-producing vegetables: Broccoli, Brussels sprouts, Cabbage, Cauliflower Sauerkraut, Onions, Vegetables with seeds:, Eggplant. Tomatoes Fried meats , Tough meats , Sausages , Bologna , Peanut butter , Beans , Jams and preserves , Fried potatoes/french fries , Wild or brown rice , Whole wheat pasta , Ice cream , Cream , Butter , Pudding , Coffee , Gravy , Mayonnaise
J Foods to EAT:
White breadSourdough breadEnglish muffins, Pancakes and waffles, Canned fruit (moderation), Crackers, Cream of wheat, Oatmeal, Soft cooked vegetables: Asparagus tip, Carrots, Beets, Green beans, Spinach, Summer squash, Zucchini, Mushrooms, Soft fruits (limit 2 per day): , Melon, peach, banana, or skinless, Tender lean meats, Skinless chicken, Fish, Turkey, ground turkey, Jelly, Honey, Mashed potatoes , Baked potatoes no skin, Boiled potatoes, White rice, noodles, Pasta (not whole wheat), w-fat milk (if tolerated)Lactaid milk, yogurt, Angel food cake, Fruit juices, soy milk, Lite mayonnaise
4. Low-Fat Diet
A low fat diet is the recommended diet to follow almost indefinitely when you have Pancreatitis. Try to follow a low-fat diet consistently, eating no more than 50 grams of fat per day. A low-fat diet is a balanced, healthy way to eat
L Foods to AVOID:
Croissants , Donuts, muffins , Nuts and nut butters , Granola and granola bars Cakes, cookies , Oily crackers (e.g. Ritz) , Bacon and eggs , Cream soups , Salad dressings , Croutons , Bacon bits , Sour cream , Sesame and other seeds , Fried meats , Fatty meats , Sausages , Cheeseburger , Bologna, hot dogs , Peanut butter Cheese , Mayonnaise , Fried potatoes/french fries , Scalloped potatoes , Pasta with cream sauce , Ice cream, Cream , Fried noodles, Pudding , Pound cake, cakes with icing , Cookies
J Foods to EAT:
White or wheat bread, Sourdough bread, rye bread, English muffins, pancakes, waffles, Corn flakes, rice crispies, cereal bars, Fresh fruit, dried fruit, juices, Dry crackers, e.g. soda, graham, water, Cream of wheat, oatmeal, , Vegetable soups, broth based soups , Salads, vegetables, fat-free dressings, Vinegars, Garbanzo beans, Plain yogurt, nonfat sour cream, Pretzels, Skinless chicken , Lean meats, Ham, roast beef, roast turkey slices, Turkey burger, no cheese, “Smart Dogs” and other soy products, Turkey, ground turkey, Jams and Jelly, Mustard, ketchup, lite mayo, Mashed potatoes with no butter, Baked potatoes, boiled potato, Pasta with tomato based sauce, Sorbet, sherbet, low-fat frozen yogurt, Low-fat desserts , Noodles in soup, Nonfat or low-fat milk or yogurt, Angel food cake, All fruits
FREQUENTLY ASKED QUESTIONS ON PANCREATITIS DIET
1. What kind of diet do I have to follow for life?
The kind of diet that is best for someone with chronic Pancreatitis is a diet that is low in fat, low in sugar, and moderate in protein. That means, most of your diet will consist of fruits and vegetables, lean meats, skinless chicken and turkey, fish, potatoes, rice and pasta, and low-fat dairy products and soy. This is similar to the diet recommended for patients with heart disease, so you can look in bookstores for cookbooks for heart-healthy diets, and you can choose items on restaurant menus that are intended for heart-healthy diets.
2. Can I follow a low-carbohydrate, Atkins-type diet if I have Pancreatitis and want to lose weight?
A low-carbohydrate, Atkins-type diet will probably have too much meat and fat for a person with Pancreatitis to follow. However, it is important for a person with Pancreatitis to eat enough protein. The best is to be moderate in your protein intake and try to avoid fatty meats and fatty food preparation techniques such as frying and sautéing.
In general, it is not advised to follow an Atkins-type diet if you have Pancreatitis. If you wish to lose weight, cut down on foods with a lot of calories, such a juices, sweets, baked goods, heavy sauces, and reduce your portion sizes of rice, bread, pasta, and potatoes. Don’t cut them out entirely, as they are low-fat foods. Eat more vegetables. Make sure you eat breakfast (this actually helps with weight loss). Make sure you do some exercise daily or every other day for at least 30 minutes. It can be walking or any activity you enjoy and can do consistently.
3. How much protein do I need per day?
Most adults need about 6 oz of fish, chicken, turkey, or lean meat every day. You can divide this into 3 oz at lunch and 3 oz at dinner, or 2 oz at lunch and 4 oz at dinner. A 3 oz portion is the size of a deck of cards. A 4 oz portion is about the size of a woman’s palm. A slice of turkey or chicken is about 1 oz, so a sandwich with 2 slices is about 2 oz of protein food.
Eating enough protein is important. Don’t cut out all protein foods.
4. What if I’m vegetarian?
If you are vegetarian, you need to obtain your protein from beans, soy products, eggs, and dairy products. Try not to use cheese and nuts for protein, as they come with a lot of fat also. Instead, purchase a low-fat vegetarian cookbook and make items such as bean chili, tofu stir-fries (with a minimum of vegetable oil), and other such vegetarian recipes. Low-fat milk, eggs, yogurt and cottage cheese are also acceptable sources of protein.
5. What are some things I can snack on?
Low-fat snacks include fresh fruit, fruited yogurt, low-fat crackers, cereal and milk, liteJell-O, toast and jam, or bagel.
6. Should I avoid sugar?
If you have high blood sugars, you may need to be on a diabetic diet. It is best, then, to avoid sugar as much as possible, but also be aware of your portion sizes for starchy foods such as rice, potato, pasta, bread, cereal, and noodles. Keep your portions sizes to ½ to 1 cup per meal, and only have one of these starchy items per meal. Eat more vegetables instead.
If you don’t currently have high blood sugars, you can have some foods with sugar, and use small amounts of sugar in foods and beverages, but be moderate. The reason for this is that the pancreas is responsible for making insulin, the hormone that helps the body utilize sugar, so if your pancreas is stressed, it may be stressed further if you constantly eat a high sugar diet. Use sugar and sweets in moderation.
Newbie Post 0
Newbie 0: Define the diseases, Acute vs. Chronic
PANCREATITIS MESSAGE BOARD
Posted by Chuck on September 28, 2004 at 11:29:17:
Chronic Pancreatitis versus Acute Pancreatitis.
Let's start with definitions since they are vastly different diseases. Acute Pancreatitis is defined as an inflammation of the pancreas. That's all. Chronic Pancreatitis is a progressive, incurable disease defined as permanent structural damage to the pancreas. Pretty simplistic definitions aren't they? Too bad that with definitions so broad they still cannot diagnose them quickly and easily.
Acute Pancreatitis can be caused by excess (and activated) pancreatic enzymes within the pancreas, alcohol abuse, blunt force trauma, pancreatic duct obstruction or even medications. It can manifest itself as acute (temporary) abdominal pain, nausea, diarrhea and fever. It can sometimes be determined by elevated serum levels of the pancreatic enzymes, amylase (unreliable measure) and lipase (more reliable than serum amylase but may be useless after 24-48 hours after initial onset). Acute Pancreatitis is very dangerous since high amylase and lipase levels may compromise the heart, lungs, liver, spleen and kidneys.
Acute Pancreatitis may show up as "subclinical", small relatively minor inconveniences like a daily case of diarrhea after lunch or a particular burning under your ribcage after dinner. It can range all the way up to life threatening, debilitating, severe attacks which require hospitalization. Most Acute Pancreatitis patients make a complete recovery within a few days to a week of their attack and will never have another one if the main antagonist (alcohol, drugs, obstructions, etc.) is removed from the patients life.
Chronic Pancreatitis is an enigma to most. It is a very rare disease and only occurs in 8.5 out of 100,000 population (.0085%) in the US. The mechanism of pain and dysfunction is not understood by today's medicine. There are no generally accepted diagnostic or treatment methods. Every Doctor has his/her own "favorite" out of a limited number of studies done. As a result successes are few even when success is defined as slowing the deterioration of the organ or giving temporary relief from the pain.
While Acute Pancreatitis attacks can and sometimes do cause Chronic Pancreatitis the disease are as different as night and day.
Chuck
PANCREATITIS MESSAGE BOARD
Posted by Chuck on September 28, 2004 at 11:29:17:
Chronic Pancreatitis versus Acute Pancreatitis.
Let's start with definitions since they are vastly different diseases. Acute Pancreatitis is defined as an inflammation of the pancreas. That's all. Chronic Pancreatitis is a progressive, incurable disease defined as permanent structural damage to the pancreas. Pretty simplistic definitions aren't they? Too bad that with definitions so broad they still cannot diagnose them quickly and easily.
Acute Pancreatitis can be caused by excess (and activated) pancreatic enzymes within the pancreas, alcohol abuse, blunt force trauma, pancreatic duct obstruction or even medications. It can manifest itself as acute (temporary) abdominal pain, nausea, diarrhea and fever. It can sometimes be determined by elevated serum levels of the pancreatic enzymes, amylase (unreliable measure) and lipase (more reliable than serum amylase but may be useless after 24-48 hours after initial onset). Acute Pancreatitis is very dangerous since high amylase and lipase levels may compromise the heart, lungs, liver, spleen and kidneys.
Acute Pancreatitis may show up as "subclinical", small relatively minor inconveniences like a daily case of diarrhea after lunch or a particular burning under your ribcage after dinner. It can range all the way up to life threatening, debilitating, severe attacks which require hospitalization. Most Acute Pancreatitis patients make a complete recovery within a few days to a week of their attack and will never have another one if the main antagonist (alcohol, drugs, obstructions, etc.) is removed from the patients life.
Chronic Pancreatitis is an enigma to most. It is a very rare disease and only occurs in 8.5 out of 100,000 population (.0085%) in the US. The mechanism of pain and dysfunction is not understood by today's medicine. There are no generally accepted diagnostic or treatment methods. Every Doctor has his/her own "favorite" out of a limited number of studies done. As a result successes are few even when success is defined as slowing the deterioration of the organ or giving temporary relief from the pain.
While Acute Pancreatitis attacks can and sometimes do cause Chronic Pancreatitis the disease are as different as night and day.
Chuck
Newbie Post 1
Newbie 1: What is Chronic Pancreatitis?
PANCREATITIS MESSAGE BOARD
Posted by Chuck on September 28, 2004 at 11:30:13:
This is the second of a series of messages that I repost occasionally as we get new people. I hope they are of some help.
In normal conversation the Docs I worked with throw around a few terms that have no specific definable borderlines. Chronic Pancreatitis by definition is the result of unrecoverable structural damage to the pancreas. Period. Nothing fancier than that. So you can imagine what Doctors, who are supposed to be scientists, do when presented with such a broad definition as that. What tissue defines structure? Is it exocrine or endocrine structure? Where does it have to be damaged? How much damage?
Early Chronic Pancreatitis is what they use when they don't know how much damage there is but you show several of the symptoms. This is usually only used until they determine what is really wrong. The mistake many patients make is to let them get away with this definition. Make them define the type of damage that has been or is being done.
Damage to the pancreas can be diffuse, focused or annular. Diffuse or sclerosing damage is the hardest for the Docs to deal with because they can't point at something and go "A-HA". Since there is no single point of failure it is usually written off as "idiopathic" or no known cause. The deterioration is unpredictable in speed but the progress is steady and frequently accelerating. The pain from this form is just as steady and unrelenting. It can be mild or severe but since it never stops or even slows down it is simply mind numbing. Depression is extremely common among these patients due to the unrelenting nature of the chronic pain
Focused damage to the pancreas is almost never labeled idiopathic. There will almost always be an obstruction or defect at the root cause. Obstructions can be a stone, tumor, stricture or malfunctioning valve (SOD). Defects that can be at the core of focused damage include Pancreas Divisum, blood flow restrictions and several very rare conditions. Unless the root cause is fixed/removed the deterioration is usually very rapid and excruciatingly painful. The pain tends to come in peaks and valleys. The longer the obstruction remains in place, the more damage is done, the higher the baseline level of pain becomes. Surgery is very often determined to be an answer for patients with focused damage. If the surgery is early enough then it is highly successful and the patient may never show another symptom. The later in the deterioration it is done, the lower the odds of success.
Damage known as Annular Pancreas is very rare. In this type the damage basically forms in a ring. As the ring dies and becomes larger it can cut off or strangle sections of the exocrine pancreas behind it. This can go unnoticed until it is too late. You can end up losing a huge amount or all of the pancreas very rapidly. The pain usually doesn't become severe until it is very advanced. A very complicated surgery is almost always required. Many times a Whipple is the only answer if there is any hope of being pain free and insulin independent.
You'll hear the docs throw around the terms mild, early, severe and end-stage casually. Doctors that throw around the term mild should probably be fired. How can you have irrecoverable damage to a critical organ and have it be "mild"?
The best way I can tell to categorize CP is by defining early as the stage you're in before they figure out how much damage has really been caused and what the root is. Middle stage is while all of the symptoms are manageable by diet/lifestyle changes or medication and you can still function in your normal life completely. This doesn't mean you are not going to have acute attacks or flare-ups. It just means that your day to day life can go on with little modification.
Severe CP begins when medication is unable to control one or more of the symptoms on a regular basis. Your life has a severe impact as you are unable to perform to the degree you had in the past. Severe CP is more a state of symptoms than it is a measurement of quantity of damage.
End-stage is just what it sounds like. The structure of your pancreas has deteriorated to the point of near or complete exocrine dysfunction. Pain is disabling and enzyme supplements are required for even the smallest amount of food. At this point it is possible that the damage has caused irreparable harm to the Islets of Langerhans. Islet cells produce insulin into small pools in the Isles where it is picked up into the blood stream. If the damage has compromised the blood flow or has caused too many of the cells or pool locations to become non-functional then diabetes can occur. Doctors will bring up a complete pancreatectomy for pain control if there is little hope for retention of insulin independence.
There is a stage that may be the medical equivalent of an Urban Legend. Burnout is the stage where all exocrine cells have been destroyed by the disease. Since there is no more to deteriorate, the pain stops. Enzyme supplements are required but they probably have been a requirement on the table of the CP patient for a long time anyway. Although there is some argument internationally the Doctors here believe it is highly likely that diabetes will result. Still, there is that ray of hope to cling to.
"Pain free and insulin independent" is the last dream of the CP patient.
I was told by my Surgeon not to have the Total Pancreatectomy that my GI Doctor had recommended. When a Surgeon tells you not to get cut you have to listen. The fact that he is the Head of the Surgery Department AND the Islet Transplantation Center at one of the top medical schools in the country gives him instant credibility. He also was the Doctor who performed the Whipple Procedure on me.
He said that we are within 5-10 years of some remarkable breakthroughs in Endocrinology and Transplantation that may change our perceptions completely. That was in 1999 and there are several still on the horizon. Geneticists are rapidly closing in on raising pigs with no genetic rejection markers. Your immune system would not recognize it as a foreign body when transplanted. This would give us a virtually unlimited supply of hearts, livers, pancreii and kidneys available for transplantation without the harsh life with anti-rejection drugs.
There are also promising technique modifications in the works for harvesting a larger number of Islets from a pancreas during a Pancreatectomy with Islet Cell Auto Transplant. That might make more of the procedures fully successful.
Living without a pancreas is no picnic and Dr. Brunicardi would have to be convinced that there was no hope before he would take out a non-cancerous pancreas.
Anytime a Doctor starts taking about cutting the first thing to ask is which surgery the doc has in mind. There are only a few choices. There are endoscopic procedures done under the auspices of an ERCP. They can open up the sphincters by cutting them with a wire lead or placing stents or both. All of the other procedures are open surgeries.
There is a Puestow procedure which basically is used for ductal problems. They filet the pancreas and sew it directly into the duodenum so the pancreas secretes directly into the small intestine. There is very little tissue that is discarded in the process.
The other commonly available surgery is the Whipple procedure. This is very major surgery. There are a million options on this one. Questions to be determined are how much will be removed, which part will be taken and how many Whipples has the doc done. There are also differing techniques. My surgeon used a technique he helped refine when he was at UCLA. He has actually done hundreds of them. He saved both my pylorus and the duodenum. He removed my gall bladder, 3/4 of my pancreas and 1/2 of my stomach. There is another variant called a Beger Procedure that reduces recovery time even more as it saves more if not all of the stomach along with the pylorus and duodenum. This is a relatively new procedure in the US but has been used in Germany for quite a while.
The complications of these surgeries can be bleeding, infection or fistula (leakage). The location and number of drains (Jackson-Pratt) to remove leakage has a definite impact on the time it takes to recover. I was out of the hospital in less than 2 weeks and had my single drain removed after 3 weeks. Recovery is completely based upon the skill of the surgeon and what he/she finds once you're opened up.
There is an experimental surgery that is available in very few locations with the most notable being the University of Minnesota Fairview Hospital. The Total Pancreatectomy with Islet Cell Autotransplant removes the pancreas, smushes it up and turns it into slurry, isolates the insulin producing Beta cells and injects them into the portal vein where they take up residence in the liver. The Beta cells will hopefully continue to produce insulin and will be absorbed into the bloodstream just as if they were still in their original place. The harvesting process can sometimes be very inefficient. There is no way the surgeons can tell you ahead of time if they will be able to harvest the 300,000 islet cells that are necessary to have full insulin function. Also if the nerve root has been damaged by the deterioration of the pancreas the pain may not go away with the pancreas. There is a very real possibility that you could go through this $125,000 operation and be a brittle diabetic who still has intractable pain. That is why most insurance companies still do not cover the procedure.
There are a few variations of these surgeries such as a distal Pancreatectomy where they remove the tail of the pancreas and leave the head. This is a relatively easy surgery for the surgeon since there are no blood supply issues. It is simply removing diseased or necrotic tissue. Recovery is usually very quick. I don't want anyone to think I am trivializing this surgery. It is still major surgery of the Alimentary and Endocrine Systems of the body. It is just that complications are few and recovery is fast. The outcome is usually that the patient becomes a type 1 diabetic (insulin dependent).
There is another surgery that is once again pretty major. It is basically opening you up and surgically cutting open the pancreas to widen the end of the ducts and the sphincters so that the pancreas will drain better. The pancreas doesn't like to be fooled with like this and the initial result is severe acute Pancreatitis. Once the attack is controlled the flow should be back to what a non afflicted person considers normal. The biggest complications come when the duct forms scar tissue and/or re-stenoses. That makes the first surgery moot and leaves you in the position of needing a Whipple because of the damage done.
Occasionally, when the pancreas cells rapidly die off in massive numbers they cannot be sloughed out fast enough. Instead of being passed out of the pancreas along with bile and enzymes they collect in what for all extents and purposes is a balloon of tissue called a pseudocyst. Usually these containers of necrotic tissue dissipate on their own. If they do not then surgery is required.
There are two main types of intervention to pseudocysts. The first is minimally invasive. Guided by an Endoscopic Ultrasound (EUS) they guide a fine needle into the pseudocyst and drain it with a syringe. This is called fine needle aspiration. I have never heard of anyone having a pseudocyst of any large size, say 7 cm or larger, successfully drained by fine needle aspiration.
Once a pseudocyst starts to get to a point of danger, either from compromising other organs or fear of rupturing, then more drastic methods must be used. A drain is placed surgically to remove the fluid into either the stomach or small intestine. In extremely rare cases it is drained into the pancreas or the large intestine. Regardless it is not fun either way. Pseudocysts are very painful, upsetting and dangerous.
If it sounds like pancreatic surgery is all desperate measures for desperate people then you probably understand perfectly. From an ERCP to the Whipple or even a complete Pancreatectomy it is all done because we so very desperately want the pain and the nausea and the pain and the diarrhea and oh, yeah, the pain to just stop.
Hopefully, this gives you a little bit to talk to your surgeon about. I can't help in any way to steer you to one or the other. Each has it's own justification. Just have the doc tell you why or why not on each.
Chuck
PANCREATITIS MESSAGE BOARD
Posted by Chuck on September 28, 2004 at 11:30:13:
This is the second of a series of messages that I repost occasionally as we get new people. I hope they are of some help.
In normal conversation the Docs I worked with throw around a few terms that have no specific definable borderlines. Chronic Pancreatitis by definition is the result of unrecoverable structural damage to the pancreas. Period. Nothing fancier than that. So you can imagine what Doctors, who are supposed to be scientists, do when presented with such a broad definition as that. What tissue defines structure? Is it exocrine or endocrine structure? Where does it have to be damaged? How much damage?
Early Chronic Pancreatitis is what they use when they don't know how much damage there is but you show several of the symptoms. This is usually only used until they determine what is really wrong. The mistake many patients make is to let them get away with this definition. Make them define the type of damage that has been or is being done.
Damage to the pancreas can be diffuse, focused or annular. Diffuse or sclerosing damage is the hardest for the Docs to deal with because they can't point at something and go "A-HA". Since there is no single point of failure it is usually written off as "idiopathic" or no known cause. The deterioration is unpredictable in speed but the progress is steady and frequently accelerating. The pain from this form is just as steady and unrelenting. It can be mild or severe but since it never stops or even slows down it is simply mind numbing. Depression is extremely common among these patients due to the unrelenting nature of the chronic pain
Focused damage to the pancreas is almost never labeled idiopathic. There will almost always be an obstruction or defect at the root cause. Obstructions can be a stone, tumor, stricture or malfunctioning valve (SOD). Defects that can be at the core of focused damage include Pancreas Divisum, blood flow restrictions and several very rare conditions. Unless the root cause is fixed/removed the deterioration is usually very rapid and excruciatingly painful. The pain tends to come in peaks and valleys. The longer the obstruction remains in place, the more damage is done, the higher the baseline level of pain becomes. Surgery is very often determined to be an answer for patients with focused damage. If the surgery is early enough then it is highly successful and the patient may never show another symptom. The later in the deterioration it is done, the lower the odds of success.
Damage known as Annular Pancreas is very rare. In this type the damage basically forms in a ring. As the ring dies and becomes larger it can cut off or strangle sections of the exocrine pancreas behind it. This can go unnoticed until it is too late. You can end up losing a huge amount or all of the pancreas very rapidly. The pain usually doesn't become severe until it is very advanced. A very complicated surgery is almost always required. Many times a Whipple is the only answer if there is any hope of being pain free and insulin independent.
You'll hear the docs throw around the terms mild, early, severe and end-stage casually. Doctors that throw around the term mild should probably be fired. How can you have irrecoverable damage to a critical organ and have it be "mild"?
The best way I can tell to categorize CP is by defining early as the stage you're in before they figure out how much damage has really been caused and what the root is. Middle stage is while all of the symptoms are manageable by diet/lifestyle changes or medication and you can still function in your normal life completely. This doesn't mean you are not going to have acute attacks or flare-ups. It just means that your day to day life can go on with little modification.
Severe CP begins when medication is unable to control one or more of the symptoms on a regular basis. Your life has a severe impact as you are unable to perform to the degree you had in the past. Severe CP is more a state of symptoms than it is a measurement of quantity of damage.
End-stage is just what it sounds like. The structure of your pancreas has deteriorated to the point of near or complete exocrine dysfunction. Pain is disabling and enzyme supplements are required for even the smallest amount of food. At this point it is possible that the damage has caused irreparable harm to the Islets of Langerhans. Islet cells produce insulin into small pools in the Isles where it is picked up into the blood stream. If the damage has compromised the blood flow or has caused too many of the cells or pool locations to become non-functional then diabetes can occur. Doctors will bring up a complete pancreatectomy for pain control if there is little hope for retention of insulin independence.
There is a stage that may be the medical equivalent of an Urban Legend. Burnout is the stage where all exocrine cells have been destroyed by the disease. Since there is no more to deteriorate, the pain stops. Enzyme supplements are required but they probably have been a requirement on the table of the CP patient for a long time anyway. Although there is some argument internationally the Doctors here believe it is highly likely that diabetes will result. Still, there is that ray of hope to cling to.
"Pain free and insulin independent" is the last dream of the CP patient.
I was told by my Surgeon not to have the Total Pancreatectomy that my GI Doctor had recommended. When a Surgeon tells you not to get cut you have to listen. The fact that he is the Head of the Surgery Department AND the Islet Transplantation Center at one of the top medical schools in the country gives him instant credibility. He also was the Doctor who performed the Whipple Procedure on me.
He said that we are within 5-10 years of some remarkable breakthroughs in Endocrinology and Transplantation that may change our perceptions completely. That was in 1999 and there are several still on the horizon. Geneticists are rapidly closing in on raising pigs with no genetic rejection markers. Your immune system would not recognize it as a foreign body when transplanted. This would give us a virtually unlimited supply of hearts, livers, pancreii and kidneys available for transplantation without the harsh life with anti-rejection drugs.
There are also promising technique modifications in the works for harvesting a larger number of Islets from a pancreas during a Pancreatectomy with Islet Cell Auto Transplant. That might make more of the procedures fully successful.
Living without a pancreas is no picnic and Dr. Brunicardi would have to be convinced that there was no hope before he would take out a non-cancerous pancreas.
Anytime a Doctor starts taking about cutting the first thing to ask is which surgery the doc has in mind. There are only a few choices. There are endoscopic procedures done under the auspices of an ERCP. They can open up the sphincters by cutting them with a wire lead or placing stents or both. All of the other procedures are open surgeries.
There is a Puestow procedure which basically is used for ductal problems. They filet the pancreas and sew it directly into the duodenum so the pancreas secretes directly into the small intestine. There is very little tissue that is discarded in the process.
The other commonly available surgery is the Whipple procedure. This is very major surgery. There are a million options on this one. Questions to be determined are how much will be removed, which part will be taken and how many Whipples has the doc done. There are also differing techniques. My surgeon used a technique he helped refine when he was at UCLA. He has actually done hundreds of them. He saved both my pylorus and the duodenum. He removed my gall bladder, 3/4 of my pancreas and 1/2 of my stomach. There is another variant called a Beger Procedure that reduces recovery time even more as it saves more if not all of the stomach along with the pylorus and duodenum. This is a relatively new procedure in the US but has been used in Germany for quite a while.
The complications of these surgeries can be bleeding, infection or fistula (leakage). The location and number of drains (Jackson-Pratt) to remove leakage has a definite impact on the time it takes to recover. I was out of the hospital in less than 2 weeks and had my single drain removed after 3 weeks. Recovery is completely based upon the skill of the surgeon and what he/she finds once you're opened up.
There is an experimental surgery that is available in very few locations with the most notable being the University of Minnesota Fairview Hospital. The Total Pancreatectomy with Islet Cell Autotransplant removes the pancreas, smushes it up and turns it into slurry, isolates the insulin producing Beta cells and injects them into the portal vein where they take up residence in the liver. The Beta cells will hopefully continue to produce insulin and will be absorbed into the bloodstream just as if they were still in their original place. The harvesting process can sometimes be very inefficient. There is no way the surgeons can tell you ahead of time if they will be able to harvest the 300,000 islet cells that are necessary to have full insulin function. Also if the nerve root has been damaged by the deterioration of the pancreas the pain may not go away with the pancreas. There is a very real possibility that you could go through this $125,000 operation and be a brittle diabetic who still has intractable pain. That is why most insurance companies still do not cover the procedure.
There are a few variations of these surgeries such as a distal Pancreatectomy where they remove the tail of the pancreas and leave the head. This is a relatively easy surgery for the surgeon since there are no blood supply issues. It is simply removing diseased or necrotic tissue. Recovery is usually very quick. I don't want anyone to think I am trivializing this surgery. It is still major surgery of the Alimentary and Endocrine Systems of the body. It is just that complications are few and recovery is fast. The outcome is usually that the patient becomes a type 1 diabetic (insulin dependent).
There is another surgery that is once again pretty major. It is basically opening you up and surgically cutting open the pancreas to widen the end of the ducts and the sphincters so that the pancreas will drain better. The pancreas doesn't like to be fooled with like this and the initial result is severe acute Pancreatitis. Once the attack is controlled the flow should be back to what a non afflicted person considers normal. The biggest complications come when the duct forms scar tissue and/or re-stenoses. That makes the first surgery moot and leaves you in the position of needing a Whipple because of the damage done.
Occasionally, when the pancreas cells rapidly die off in massive numbers they cannot be sloughed out fast enough. Instead of being passed out of the pancreas along with bile and enzymes they collect in what for all extents and purposes is a balloon of tissue called a pseudocyst. Usually these containers of necrotic tissue dissipate on their own. If they do not then surgery is required.
There are two main types of intervention to pseudocysts. The first is minimally invasive. Guided by an Endoscopic Ultrasound (EUS) they guide a fine needle into the pseudocyst and drain it with a syringe. This is called fine needle aspiration. I have never heard of anyone having a pseudocyst of any large size, say 7 cm or larger, successfully drained by fine needle aspiration.
Once a pseudocyst starts to get to a point of danger, either from compromising other organs or fear of rupturing, then more drastic methods must be used. A drain is placed surgically to remove the fluid into either the stomach or small intestine. In extremely rare cases it is drained into the pancreas or the large intestine. Regardless it is not fun either way. Pseudocysts are very painful, upsetting and dangerous.
If it sounds like pancreatic surgery is all desperate measures for desperate people then you probably understand perfectly. From an ERCP to the Whipple or even a complete Pancreatectomy it is all done because we so very desperately want the pain and the nausea and the pain and the diarrhea and oh, yeah, the pain to just stop.
Hopefully, this gives you a little bit to talk to your surgeon about. I can't help in any way to steer you to one or the other. Each has it's own justification. Just have the doc tell you why or why not on each.
Chuck
Newbie Post 2
Newbie 2: How do I live with this accursed disease?
PANCREATITIS MESSAGE BOARD
Posted by Chuck on September 28, 2004 at 11:31:08:
I would love to give you good news about Chronic Pancreatitis but I can't. Today it is still an incurable progressive disease. Doctors can give you prescriptions to help give you some relief from individual symptoms. The big key to the future of CP patients are NO ALCOHOL WHATSOEVER, low fat diet, keep triglycerides down if possible, get good GI & Pain Management docs, take your enzyme supplements religiously (I mean all the time, every time, not to pray over them altough I think that would also help sometimes) and don't try to be brave and tough out your pain - take your pain meds whenever you have pain, period (if you have pain all the time DO NOT miss a dose at all). Let someone else worry about addiction. You worry about covering your pain.
Let's face it. Our quality of life is totally dependent upon our conformance to these principals and the quality of our doctors. If you have a Doctor (with a Capital "D") that has great knowledge of pancreatobiliary diseases and compassion for your condition and admit when he/she is over his/her head and will call for help when needed you will probably have a better quality of life than if you have one of the thousands of doctors (small "d") that either are ignorant, arrogant or apathetic (some can fit into all 3 categories). We refer to these people as DINKs (Doctors In Need of Knowledge).
We highly recommend keeping a food and event diary. This journal can help you find your triggers and limits. Sometimes this disease can be fickle and hurt you one day for something that was fine the week before but as a general rule what hurts us once has a tendency to hurt us again. The diary can remind you of what you did or ate before each attack. You can also keep your questions for the doctor in it. Then make sure you take your journal with you to every appointment.
Hang around here for a while. You are among friends who know exactly what you are going through. We welcome you with open arms. Feel free to ask any questions you want. You would be very surpised at some of the topics we get into. Some are funny, some are gross but we are very much like a family here so anything goes.
Chuck
PANCREATITIS MESSAGE BOARD
Posted by Chuck on September 28, 2004 at 11:31:08:
I would love to give you good news about Chronic Pancreatitis but I can't. Today it is still an incurable progressive disease. Doctors can give you prescriptions to help give you some relief from individual symptoms. The big key to the future of CP patients are NO ALCOHOL WHATSOEVER, low fat diet, keep triglycerides down if possible, get good GI & Pain Management docs, take your enzyme supplements religiously (I mean all the time, every time, not to pray over them altough I think that would also help sometimes) and don't try to be brave and tough out your pain - take your pain meds whenever you have pain, period (if you have pain all the time DO NOT miss a dose at all). Let someone else worry about addiction. You worry about covering your pain.
Let's face it. Our quality of life is totally dependent upon our conformance to these principals and the quality of our doctors. If you have a Doctor (with a Capital "D") that has great knowledge of pancreatobiliary diseases and compassion for your condition and admit when he/she is over his/her head and will call for help when needed you will probably have a better quality of life than if you have one of the thousands of doctors (small "d") that either are ignorant, arrogant or apathetic (some can fit into all 3 categories). We refer to these people as DINKs (Doctors In Need of Knowledge).
We highly recommend keeping a food and event diary. This journal can help you find your triggers and limits. Sometimes this disease can be fickle and hurt you one day for something that was fine the week before but as a general rule what hurts us once has a tendency to hurt us again. The diary can remind you of what you did or ate before each attack. You can also keep your questions for the doctor in it. Then make sure you take your journal with you to every appointment.
Hang around here for a while. You are among friends who know exactly what you are going through. We welcome you with open arms. Feel free to ask any questions you want. You would be very surpised at some of the topics we get into. Some are funny, some are gross but we are very much like a family here so anything goes.
Chuck
Newbie Post 3
MESSAGE BOARD.
Newbie 3: Grieve for your lost health and lifestyle
PANCREATITIS MESSAGE BOARD
Posted by Chuck on September 28, 2004 at 11:32:36:
We all have to go through the 5 stages of grief many times in our lives. One of the most important for us is to grieve for our lost lives and lost health. A diagnosis of Chronic Pancreatitis takes away so many things from our lives. The most critical of them is hope. We need to grieve for the loss of our "life as we know it".
Five Stages of Grief
The first stage is denial
Upon hearing the diagnosis, the patient reacts with a shocked, "No, not me." According to Dr.Kubler-Ross, this is a healthy stage, and permits the patient and the family to develop other defenses.
Next comes anger or resentment
"Why me?" is the question asked now. "Why my child?" Blame, directed against the doctor, nurses and God often is a part of this stage. This outcry should be accepted, unjudged.
The third stage is bargaining
"Yes me, but-" "If you'll just let me/him/her be well, God, I'll . . ." This Dr. Kubler-Ross calls a period of temporary truce.
The fourth stage is depression
Now the person says, "Yes, me," with the courage to admit that it is happening; this acknowledgment brings depression. (Note: The family often goes through all the stages, along with the patient.)
Finally comes acceptance
A time of facing serious illness or death calmly. This is often a difficult time for the family, since the patient tends to withdraw, to be silent.
Chuck
Newbie 3: Grieve for your lost health and lifestyle
PANCREATITIS MESSAGE BOARD
Posted by Chuck on September 28, 2004 at 11:32:36:
We all have to go through the 5 stages of grief many times in our lives. One of the most important for us is to grieve for our lost lives and lost health. A diagnosis of Chronic Pancreatitis takes away so many things from our lives. The most critical of them is hope. We need to grieve for the loss of our "life as we know it".
Five Stages of Grief
The first stage is denial
Upon hearing the diagnosis, the patient reacts with a shocked, "No, not me." According to Dr.Kubler-Ross, this is a healthy stage, and permits the patient and the family to develop other defenses.
Next comes anger or resentment
"Why me?" is the question asked now. "Why my child?" Blame, directed against the doctor, nurses and God often is a part of this stage. This outcry should be accepted, unjudged.
The third stage is bargaining
"Yes me, but-" "If you'll just let me/him/her be well, God, I'll . . ." This Dr. Kubler-Ross calls a period of temporary truce.
The fourth stage is depression
Now the person says, "Yes, me," with the courage to admit that it is happening; this acknowledgment brings depression. (Note: The family often goes through all the stages, along with the patient.)
Finally comes acceptance
A time of facing serious illness or death calmly. This is often a difficult time for the family, since the patient tends to withdraw, to be silent.
Chuck
Newbie Post 4
Newbie 4: How to successfully navigate the ER
PANCREATITIS MESSAGE BOARD
Posted by Chuck on September 28, 2004 at 11:33:42:
Regularly, CP patients are turned away from Emergency Rooms because their serum amylase/lipase numbers are not elevated. The DINKs (Doctors In Need of Knowledge) are unaware that Amylase can return to WNL (Within Normal Limits) in as quickly as 12 hours after onset (or less in the case of Sphincter of Oddi Dysfunction) of an acute attack. Even the slower to react serum lipase levels can return to WNL in 24-48 hours.
Basically an acute attack is a chemical burn on the inside of your pancreas. Does a burn stop hurting when the flame is removed from the skin? If you had spilled Sodium Hydroxide (NaOH - a very strong base reagent) on your skin would they pat you on the head, give you a Tylenol and snicker behind your back as they sent you home untreated? Of course not but that is exactly what they do regularly for CP patients who have an equally painful chemical irritation to their pancreas.
I suggest carrying a letter with you explaining to the ER DINK exactly what your situation is. Make sure you carry a list of all medications, your insurance information and all the contact info for your GI Doctor.
Here is what I carry. I suggest you come up with one as well
[Personal contact information] [List of Medications, Dosages & Why taken]
[Insurance information]
[GI Doctor name address and phone number]
If you have been given this letter it is because I have landed in your Emergency Room. I am not a junkie or a drug seeker. I suffer from severe Chronic Pancreatitis. I am on pain medication 24x7. All of my medications are listed above. Chronic Pancreatitis leaves me fighting without cessation the worst imaginable pain. If I am here it is because the medications I have are not enough to make me tolerate the pain.
Since I suffer from Chronic Pancreatitis it is possible for me to be suffering from an Pancreatitis flare up without having extreme elevations of my pancreatic enzymes (amylase and lipase). Please contact my Gastroenterologist, [enter your GI docs name and telephone number here] if you have any questions about my condition.
[Enter your GI doctors instructions here]
For me an Chronic Pancreatitis flare up usually presents itself as uncontrolled nausea including repeated vomiting and extreme upper abdominal pain presenting itself as a high level (5-7) of constant pain with surges of breathtaking pain (8-9).
As a warning, I am a very "tough stick" when it comes to finding a vein for an IV. Pancreatitis and the huge number of IV’s I have had in my life have ruined my veins. Most of the IV’s that are put in the ER blow out within hours. If I am to be admitted I request that you put in a central line.
I carry this letter because many people with Pancreatitis are sent home without treatment from Emergency Rooms because some tests return WNL. Many Doctors, interns and med students are not knowledgeable of Acute or Chronic Pancreatitis and jump to the conclusion that the patient is seeking drugs or even just attention. I understand there are only 5-10 cases of Pancreatitis that show up each year per 100,000 population and only 2.72 cases of Chronic Pancreatitis are discovered. I know that you do not see many people with my condition and you see many more drug seekers than Pancreatitis sufferers. Please understand that my pain and other symptoms are real and I do indeed need treatment, even if it is only IV fluids and pain medication.
Thank you for your understanding.
PANCREATITIS MESSAGE BOARD
Posted by Chuck on September 28, 2004 at 11:33:42:
Regularly, CP patients are turned away from Emergency Rooms because their serum amylase/lipase numbers are not elevated. The DINKs (Doctors In Need of Knowledge) are unaware that Amylase can return to WNL (Within Normal Limits) in as quickly as 12 hours after onset (or less in the case of Sphincter of Oddi Dysfunction) of an acute attack. Even the slower to react serum lipase levels can return to WNL in 24-48 hours.
Basically an acute attack is a chemical burn on the inside of your pancreas. Does a burn stop hurting when the flame is removed from the skin? If you had spilled Sodium Hydroxide (NaOH - a very strong base reagent) on your skin would they pat you on the head, give you a Tylenol and snicker behind your back as they sent you home untreated? Of course not but that is exactly what they do regularly for CP patients who have an equally painful chemical irritation to their pancreas.
I suggest carrying a letter with you explaining to the ER DINK exactly what your situation is. Make sure you carry a list of all medications, your insurance information and all the contact info for your GI Doctor.
Here is what I carry. I suggest you come up with one as well
[Personal contact information] [List of Medications, Dosages & Why taken]
[Insurance information]
[GI Doctor name address and phone number]
If you have been given this letter it is because I have landed in your Emergency Room. I am not a junkie or a drug seeker. I suffer from severe Chronic Pancreatitis. I am on pain medication 24x7. All of my medications are listed above. Chronic Pancreatitis leaves me fighting without cessation the worst imaginable pain. If I am here it is because the medications I have are not enough to make me tolerate the pain.
Since I suffer from Chronic Pancreatitis it is possible for me to be suffering from an Pancreatitis flare up without having extreme elevations of my pancreatic enzymes (amylase and lipase). Please contact my Gastroenterologist, [enter your GI docs name and telephone number here] if you have any questions about my condition.
[Enter your GI doctors instructions here]
For me an Chronic Pancreatitis flare up usually presents itself as uncontrolled nausea including repeated vomiting and extreme upper abdominal pain presenting itself as a high level (5-7) of constant pain with surges of breathtaking pain (8-9).
As a warning, I am a very "tough stick" when it comes to finding a vein for an IV. Pancreatitis and the huge number of IV’s I have had in my life have ruined my veins. Most of the IV’s that are put in the ER blow out within hours. If I am to be admitted I request that you put in a central line.
I carry this letter because many people with Pancreatitis are sent home without treatment from Emergency Rooms because some tests return WNL. Many Doctors, interns and med students are not knowledgeable of Acute or Chronic Pancreatitis and jump to the conclusion that the patient is seeking drugs or even just attention. I understand there are only 5-10 cases of Pancreatitis that show up each year per 100,000 population and only 2.72 cases of Chronic Pancreatitis are discovered. I know that you do not see many people with my condition and you see many more drug seekers than Pancreatitis sufferers. Please understand that my pain and other symptoms are real and I do indeed need treatment, even if it is only IV fluids and pain medication.
Thank you for your understanding.
Newbie Post 5
Newbie 5: NEVER, EVER self diagnose
PANCREATITIS MESSAGE BOARD
Posted by Chuck on September 28, 2004 at 11:34:32:
Last of all for the usual disclaimer.
As the boards resident amateur biologist I do have to warn you about self diagnosis. For every symptom we can come up with there are literally hundreds of possible causes. We tend to hone in on a single symptom until we find one that fits. A doctor can't get away with that. Our research can however help push the docs into action. It can help get them to test you for certain diseases/syndromes. We have to be careful and believe them with healthy skepticism when they tell us no. We must accept a no answer but it must be just a step in finding a true diagnosis. There has to be more to it than just no. Accept it but push for a diagnosis.
The doctors have an old worn out saying "If you hear hoof beats think horses not zebras". It basically means to look for the most common of causes of the symptoms before seeking out the rarer ones. Chronic Pancreatitis is extremely rare. The last reports we have seen put the incidence in the United States at about 8.5 patients per 100,000 population. That is why most doctors see few if any cases of Chronic Pancreatitis in their careers.
IMHO you have to let the process work out to it's final end. You just need to make sure the docs don't stop the process short. Don't accept a default diagnosis. Make sure you get a definitive one.
This even extends to new symptoms as they arise. CP patients have leaned to live with pain that would have others writhing on the floor. As such we tend to downplay new symptoms as they show up. We rationalize that it is a normal part of the disease and just live with it. This is a passive form of self diagnosis.
Make sure when you get new issues that you let your doctor/Doctor know about it. That one symptom may be the key to discovering why you continue to have flare ups or attacks.
Chuck
PANCREATITIS MESSAGE BOARD
Posted by Chuck on September 28, 2004 at 11:34:32:
Last of all for the usual disclaimer.
As the boards resident amateur biologist I do have to warn you about self diagnosis. For every symptom we can come up with there are literally hundreds of possible causes. We tend to hone in on a single symptom until we find one that fits. A doctor can't get away with that. Our research can however help push the docs into action. It can help get them to test you for certain diseases/syndromes. We have to be careful and believe them with healthy skepticism when they tell us no. We must accept a no answer but it must be just a step in finding a true diagnosis. There has to be more to it than just no. Accept it but push for a diagnosis.
The doctors have an old worn out saying "If you hear hoof beats think horses not zebras". It basically means to look for the most common of causes of the symptoms before seeking out the rarer ones. Chronic Pancreatitis is extremely rare. The last reports we have seen put the incidence in the United States at about 8.5 patients per 100,000 population. That is why most doctors see few if any cases of Chronic Pancreatitis in their careers.
IMHO you have to let the process work out to it's final end. You just need to make sure the docs don't stop the process short. Don't accept a default diagnosis. Make sure you get a definitive one.
This even extends to new symptoms as they arise. CP patients have leaned to live with pain that would have others writhing on the floor. As such we tend to downplay new symptoms as they show up. We rationalize that it is a normal part of the disease and just live with it. This is a passive form of self diagnosis.
Make sure when you get new issues that you let your doctor/Doctor know about it. That one symptom may be the key to discovering why you continue to have flare ups or attacks.
Chuck
Symptoms for newbies
Symptoms for newbie’s
PANCREATITIS MESSAGE BOARD
Posted by cj on September 27, 2004 at 21:45:47:
Do you all remember when we all figured out we all had the same referred shoulder pains? or some other symptom? I was chatting with a lady at the salon I work at and her hub might also be suffering from panc or maybe gallbladder. She brought up the right hand shoulder pain, and also the horrendous sweats. I can remember when we found and when others find this site and are like OMG i'm not alone!! we all have similar symptoms be it from, acute panc/chronic panc/alcoholic panc/idiopathic panc/ panc caused by meds/viruses ECT! scary how more and more people are showing up with this disease. I sent her this link and hope she shows up and can read and see if maybe hub has same issues. I know how nice everyone is and will help out.
PANCREATITIS MESSAGE BOARD
Posted by cj on September 27, 2004 at 21:45:47:
Do you all remember when we all figured out we all had the same referred shoulder pains? or some other symptom? I was chatting with a lady at the salon I work at and her hub might also be suffering from panc or maybe gallbladder. She brought up the right hand shoulder pain, and also the horrendous sweats. I can remember when we found and when others find this site and are like OMG i'm not alone!! we all have similar symptoms be it from, acute panc/chronic panc/alcoholic panc/idiopathic panc/ panc caused by meds/viruses ECT! scary how more and more people are showing up with this disease. I sent her this link and hope she shows up and can read and see if maybe hub has same issues. I know how nice everyone is and will help out.
A Letter to Normals
A Letter to Normals from a Person With Chronic Pain
Having chronic pain means many things change, and a lot of them are
invisible. Unlike having cancer or being hurt in an accident, most
people do not understand even a little about chronic pain and its
effects, and of those that think they know, many are actually
misinformed.
In the spirit of informing those who wish to understand:
These are the things that I would like you to understand about me
before you judge me.
Please understand that being sick doesn't mean I'm not still a human
being. I have to spend most of my day in considerable pain and
exhaustion, and if you visit, sometimes I probably don't seem like
much fun to be with, but I'm still me, stuck inside this body. I
still worry about work, my family, my friends, and most of the time,
I'd still like to hear you talk about yours, too.
Please understand the difference between "happy" and "healthy". When
you've got the flu, you probably feel miserable with it, but I've
been sick for years. I can't be miserable all the time. In fact, I
work hard at not being miserable. So, if you're talking to me and I
sound happy, it means I'm happy. that's all. It doesn't mean that
I'm not in a lot of pain, or extremely tired, or that I'm getting
better, or any of those things. Please don't say, "Oh, you're
sounding better!" or "But you look so healthy!" I am merely coping.
I am sounding happy and trying to look normal. If you want to
comment on that, you're welcome.
Please understand that being able to stand up for ten minutes
doesn't necessarily mean that I can stand up for twenty minutes, or
an hour. Just because I managed to stand up for thirty minutes
yesterday doesn't mean that I can do the same today. With a lot of
diseases you're either paralyzed, or you can move. With this one, it
gets more confusing everyday. It can be like a yo-yo. I never know
from day to day, how I am going to feel when I wake up. In most
cases, I never know from minute to minute. That is one of the
hardest and most frustrating components of chronic pain.
Please repeat the above paragraph
substituting, "sitting", "walking", "thinking", "concentrating", "bei
ng sociable" and so on, it applies to everything. That's what
chronic pain does to you.
Please understand that chronic pain is variable. It's quite possible
(for many, it's common) that one day I am able to walk to the park
and back, while the next day I'll have trouble getting to the next
room. Please don't attack me when I'm ill by saying, "But you did it
before!" or "Oh, come on, I know you can do this!" If you want me to
do something, then ask if I can. In a similar vein, I may need to
cancel a previous commitment at the last minute. If this happens,
please do not take it personally. If you are able, please try to
always remember how very lucky you are, to be physically able to do
all of the things that you can do.
Please understand that "getting out and doing things" does not make
me feel better, and can often make me seriously worse. You don't
know what I go through or how I suffer in my own private time.
Telling me that I need to exercise, or do some things to "get my
mind off of it", may frustrate me to tears, and is not correct. if I
was capable of doing some things any or all of the time, don't you
know that I would? I am working with my doctors and I am doing what
I am supposed to do. Another statement that hurts is, "You just need
to push yourself more, try harder". Obviously, chronic pain can deal
with the whole body, or be localized to specific areas. Sometimes
participating in a single activity for a short or a long period of
time can cause more damage and physical pain than you could ever
imagine. Not to mention the recovery time, which can be intense. You
can't always read it on my face or in my body language. Also,
chronic pain may cause secondary depression (wouldn't you get
depressed and down if you were hurting constantly for months or
years?), but it is not created by depression.
Please understand that if I say I have to sit down,lie down, stay in
bed, or take these pills now, that probably means that I do have to
do it right now, it can't be put off or forgotten just because I'm
somewhere, or I'm right in the middle of doing something. Chronic
pain does not forgive, nor does it wait for anyone.
If you want to suggest a cure to me, please don't. It's not because
I don't appreciate the thought, and it's not because I don't want to
get well. Lord knows that isn't true. In all likelihood, if you've
heard of it or tried it, so have I. In some cases, I have been made
sicker, not better. This can involve side effects or allergic
reactions, as is the case with herbal remedies. It also includes
failure, which in and of itself can make me feel even lower. If
there were something that cured, or even helped people with my form
of chronic pain, then we'd know about it. There is worldwide
networking (both on and off the Internet) between people with
chronic pain. If something worked, we would KNOW. It's definitely
not for lack of trying. If, after reading this, you still feel the
need to suggest a cure, then so be it. I may take what you said and
discuss it with my doctor.
If I seem touchy, it's probably because I am. It's not how I try to
be. As a matter of fact, I try very hard to be normal. I hope you
will try to understand. I have been, and am still, going through a
lot. Chronic pain is hard for you to understand unless you have had
it. It wreaks havoc on the body and the mind. It is exhausting and
exasperating. Almost all the time, I know that I am doing my best to
cope with this, and live my life to the best of my ability. I ask
you to bear with me, and accept me as I am. I know that you cannot
literally understand my situation unless you have been in my shoes,
but as much as is possible, I am asking you to try to be
understanding in general.
In many ways I depend on you, people who are not sick. I need you to
visit me when I am too sick to go out. Sometimes I need you help me
with the shopping, the cooking or the cleaning. I may need you to
take me to the doctor, or to the store. You are my link to
the "normalcy" of life. You can help me to keep in touch with the
parts of life that I miss and fully intend to undertake again, just
as soon as I am able.
I know that I asked a lot from you, and I do thank you for
listening. It really does mean a lot.
Adapted from a work by Bek Oberin
Having chronic pain means many things change, and a lot of them are
invisible. Unlike having cancer or being hurt in an accident, most
people do not understand even a little about chronic pain and its
effects, and of those that think they know, many are actually
misinformed.
In the spirit of informing those who wish to understand:
These are the things that I would like you to understand about me
before you judge me.
Please understand that being sick doesn't mean I'm not still a human
being. I have to spend most of my day in considerable pain and
exhaustion, and if you visit, sometimes I probably don't seem like
much fun to be with, but I'm still me, stuck inside this body. I
still worry about work, my family, my friends, and most of the time,
I'd still like to hear you talk about yours, too.
Please understand the difference between "happy" and "healthy". When
you've got the flu, you probably feel miserable with it, but I've
been sick for years. I can't be miserable all the time. In fact, I
work hard at not being miserable. So, if you're talking to me and I
sound happy, it means I'm happy. that's all. It doesn't mean that
I'm not in a lot of pain, or extremely tired, or that I'm getting
better, or any of those things. Please don't say, "Oh, you're
sounding better!" or "But you look so healthy!" I am merely coping.
I am sounding happy and trying to look normal. If you want to
comment on that, you're welcome.
Please understand that being able to stand up for ten minutes
doesn't necessarily mean that I can stand up for twenty minutes, or
an hour. Just because I managed to stand up for thirty minutes
yesterday doesn't mean that I can do the same today. With a lot of
diseases you're either paralyzed, or you can move. With this one, it
gets more confusing everyday. It can be like a yo-yo. I never know
from day to day, how I am going to feel when I wake up. In most
cases, I never know from minute to minute. That is one of the
hardest and most frustrating components of chronic pain.
Please repeat the above paragraph
substituting, "sitting", "walking", "thinking", "concentrating", "bei
ng sociable" and so on, it applies to everything. That's what
chronic pain does to you.
Please understand that chronic pain is variable. It's quite possible
(for many, it's common) that one day I am able to walk to the park
and back, while the next day I'll have trouble getting to the next
room. Please don't attack me when I'm ill by saying, "But you did it
before!" or "Oh, come on, I know you can do this!" If you want me to
do something, then ask if I can. In a similar vein, I may need to
cancel a previous commitment at the last minute. If this happens,
please do not take it personally. If you are able, please try to
always remember how very lucky you are, to be physically able to do
all of the things that you can do.
Please understand that "getting out and doing things" does not make
me feel better, and can often make me seriously worse. You don't
know what I go through or how I suffer in my own private time.
Telling me that I need to exercise, or do some things to "get my
mind off of it", may frustrate me to tears, and is not correct. if I
was capable of doing some things any or all of the time, don't you
know that I would? I am working with my doctors and I am doing what
I am supposed to do. Another statement that hurts is, "You just need
to push yourself more, try harder". Obviously, chronic pain can deal
with the whole body, or be localized to specific areas. Sometimes
participating in a single activity for a short or a long period of
time can cause more damage and physical pain than you could ever
imagine. Not to mention the recovery time, which can be intense. You
can't always read it on my face or in my body language. Also,
chronic pain may cause secondary depression (wouldn't you get
depressed and down if you were hurting constantly for months or
years?), but it is not created by depression.
Please understand that if I say I have to sit down,lie down, stay in
bed, or take these pills now, that probably means that I do have to
do it right now, it can't be put off or forgotten just because I'm
somewhere, or I'm right in the middle of doing something. Chronic
pain does not forgive, nor does it wait for anyone.
If you want to suggest a cure to me, please don't. It's not because
I don't appreciate the thought, and it's not because I don't want to
get well. Lord knows that isn't true. In all likelihood, if you've
heard of it or tried it, so have I. In some cases, I have been made
sicker, not better. This can involve side effects or allergic
reactions, as is the case with herbal remedies. It also includes
failure, which in and of itself can make me feel even lower. If
there were something that cured, or even helped people with my form
of chronic pain, then we'd know about it. There is worldwide
networking (both on and off the Internet) between people with
chronic pain. If something worked, we would KNOW. It's definitely
not for lack of trying. If, after reading this, you still feel the
need to suggest a cure, then so be it. I may take what you said and
discuss it with my doctor.
If I seem touchy, it's probably because I am. It's not how I try to
be. As a matter of fact, I try very hard to be normal. I hope you
will try to understand. I have been, and am still, going through a
lot. Chronic pain is hard for you to understand unless you have had
it. It wreaks havoc on the body and the mind. It is exhausting and
exasperating. Almost all the time, I know that I am doing my best to
cope with this, and live my life to the best of my ability. I ask
you to bear with me, and accept me as I am. I know that you cannot
literally understand my situation unless you have been in my shoes,
but as much as is possible, I am asking you to try to be
understanding in general.
In many ways I depend on you, people who are not sick. I need you to
visit me when I am too sick to go out. Sometimes I need you help me
with the shopping, the cooking or the cleaning. I may need you to
take me to the doctor, or to the store. You are my link to
the "normalcy" of life. You can help me to keep in touch with the
parts of life that I miss and fully intend to undertake again, just
as soon as I am able.
I know that I asked a lot from you, and I do thank you for
listening. It really does mean a lot.
Adapted from a work by Bek Oberin
Thursday, January 05, 2006
Welcome to the PMB Blog
This blog is here as a resource for anyone wanting to know more about pancreatitis and the way it affects people. We intend to make it a resource that anyone can use and all are welcome. If there is any information that you would like added to the blog then drop us a line. So welcome and feel free to have a visit with the Pancreatitis Message Board.
This blog is here as a resource for anyone wanting to know more about pancreatitis and the way it affects people. We intend to make it a resource that anyone can use and all are welcome. If there is any information that you would like added to the blog then drop us a line. So welcome and feel free to have a visit with the Pancreatitis Message Board.
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