Diseases Of The Pancreas

Acute Pancreatitis

Acute Pancreatitis is an inflammation of the pancreas of sudden onset that is short-lived and usually resolves over a period of time. It is most commonly caused by alcohol abuse or gallstones. It is characterized by the sudden onset of severe upper abdominal and back pain and is diagnosed by elevated serum amylase and/or lipase levels. Most attacks are clinically mild and resolve with supportive care over a period of 7-10 days, but in 20% of patients, this disease can run a severe course that is prolonged and life-threatening. Early detection of severe acute pancreatitis and referral to a centre equipped to handle these patients is vital. Severe pancreatitis is associated with areas of pancreatic cell death(necrosis). When pancreatic necrosis becomes infected, patients are likely to require radiological or surgical drainage of infected collections. Surgical drainage, when necessary, is often performed laparoscopically nowadays.

Chronic Pancreatitis

Chronic pancreatitis is a progressive illness that causes scarring, calcification, and atrophy of the pancreas over many years. It commonly causes repeated attacks of severe upper abdominal pain, along with progressive loss of pancreatic function. The latter may result in diabetes mellitus and, less commonly, in diarrhoea and weight loss. Patients with this disease are at an increased risk of pancreatic cancer. The most common cause for this disease is alcohol abuse, but it can occur as a consequence of severe acute pancreatitis or as a sequelae of major abdominal trauma. The exact cause is undetermined and may be genetic in the majority of patients. Treatment is aimed at preventing and controlling abdominal pain. It involves a combination of radiological, endoscopic, and surgical procedures that need to be individualized depending on the patient’s symptoms and the specific changes induced by the disease on the anatomy of the patient’s pancreas. Surgical intervention usually involves duodenum-preserving resection of the head of the pancreas with drainage of the pancreatic duct (Frey’s Procedure)

Pancreatic Carcinoma

The symptoms of pancreatic cancer depend on which part of the pancreas the tumour arises from. Tumours in the head of the pancreas produce symptoms relatively early by compressing the adjacent bile duct or duodenum, causing jaundice and vomiting/bleeding, respectively. Tumours arising from the body or tail of the pancreas usually do not produce symptoms until the tumour has grown to a very large size, although the patient may experience non-specific symptoms like tiredness or loss of appetite and weight. Diagnosis of this disease is usually by CT scan, MRI scan, or, in difficult cases, by Endoscopic Ultrasound. Unfortunately, many patients with pancreatic cancer, whether from the head, body, or tail of the pancreas, have advanced disease at the time of diagnosis. Surgical resection of the tumour by pancreaticoduodenectomy or distal pancreatectomy, depending on the location of the tumour, provides the best chance for cure, even when this requires resection of the portal vein, which runs through the pancreas. Pancreaticoduodenectomy is a major operation that needs to be performed by an experienced team of doctors to get good results. Distal pancreatectomy is often possible laparoscopically. Patients benefit from chemotherapy after the operation.

When the disease is very advanced at diagnosis, surgery may not be possible, in which case the cancer will need treatment using chemotherapy and biological agents. In borderline cases, such treatment may permit surgery at a later date.

Autoimmune Pancreatitis

Autoimmune pancreatitis (AIP) is a chronic inflammation. It is believed that it is caused by the body’s immune system attacking the pancreas. It can mimic pancreatic cancer, causing jaundice, abdominal pain, and weight loss. Diagnosing it can be difficult because its symptoms are similar to those of pancreatic cancer. Accurate diagnosis is crucial because AIP responds well to steroid therapy, while pancreatic cancer requires different treatment approaches. There are two subtypes of AIP that are now recognized, type 1 and type 2.

Diabetes and Pancreatitis

Diabetes and pancreatitis are closely linked. Diabetes often develops as a consequence of pancreatitis, particularly chronic pancreatitis. Conversely, poorly managed diabetes can also increase the risk of developing pancreatitis, especially acute pancreatitis

How Diabetes and Pancreatitis are Connected: 

Pancreatitis Leading to Diabetes: 

1. Chronic Pancreatitis: Long-term inflammation and scarring of the pancreas can damage or destroy the insulin-producing cells in the pancreas, leading to a type of diabetes called Type 3c diabetes. 
2. Acute Pancreatitis: Even a single episode of acute pancreatitis can sometimes cause temporary or even permanent diabetes. 

Diabetes Increasing Risk of Pancreatitis: 

Poorly managed blood sugar levels, obesity, high triglyceride levels, and excessive alcohol consumption are risk factors for both diabetes and pancreatitis, potentially increasing the likelihood of developing pancreatitis in diabetic individuals.

Hereditary Pancreatitis

Hereditary pancreatitis is a genetic disorder that leads to repeated inflammation of the pancreas. Often starting in childhood, it is characterized by episodes of acute pancreatitis that can progress to chronic pancreatitis. The condition results from genetic mutations.

Familial Pancreatitis

Familial pancreatitis refers to families where the occurrence of pancreatitis is higher than what would be expected by chance. Familial pancreatitis is diagnosed when two or more close family members have idiopathic pancreatitis without any known obstructive or environmental cause. Your healthcare provider may inquire about your lifestyle, medications, and personal history to exclude other possible causes. Genetic testing may be recommended to identify gene variants linked to familial or hereditary pancreatitis.

Paediatric Pancreatitis

Paediatric pancreatitis is the inflammation of the pancreas in children. While usually acute and short-lived, it can sometimes be recurrent or chronic. It can cause severe abdominal pain, nausea, and vomiting, and in severe cases, can lead to complications. Treatment focuses on pain management, hydration, and addressing the underlying cause. 

Causes of Pancreatitis

IPMN – Intraductal Tumours

IPMN, short for Intraductal Papillary Mucinous Neoplasm, causes pancreatitis by transforming the cells lining the pancreatic duct into premalignant cells. IPMN is a type of cystic tumour that develops within the pancreatic ducts. These tumours are characterized by the overproduction of mucin (a thick, lubricating fluid) and can range from benign to malignant. IPMN  has the potential to become cancerous. 

Pancreas Divisum

Pancreas Divisum is a congenital anatomical variation of the pancreas where the dorsal and ventral ducts fail to fuse during embryonic development. This results in two separate pancreatic ducts. Most people with Pancreas Divisum remain symptom-free, and the condition is usually found by chance. However, in some cases, it can be associated with recurrent acute pancreatitis or chronic abdominal pain due to impaired drainage of pancreatic secretions. 

Maintaining a Healthy Pancreas

To maintain a healthy pancreas, focus on a balanced diet rich in fruits, vegetables, lean proteins, and whole grains, while limiting processed foods, sugary drinks, and excessive alcohol. Stay hydrated, maintain a healthy weight, and avoid smoking.

Liver and Pancreatic Surgery

Before Surgery

The probable diagnosis and the appropriate treatment plan will be discussed in detail with the patient during the outpatient clinic consultation. The patient is usually seen by the anaesthetist at least once prior to admission to assess his/her fitness to undergo the procedure. Liver and pancreatic surgeries are major operations, and it is important that any additional risk factors, such as heart disease and lung problems, are identified beforehand. The patient may need additional investigations of the heart and lungs, and treatment prescribed by the specialists. This helps in optimizing the health condition before surgery.

Day of Surgery

You will be admitted the evening prior to planned surgery, when you will be reviewed one final time by the anaesthetist and surgeon. They will go through the details of the operation with you and obtain legal consent from you and your family to proceed with surgery.

After Surgery

Once the surgery is completed, you will be in the ICU for 1-2 days, although this may be longer depending on the nature of the operation. You will be shifted back to the ward after this and will remain there till discharge.

During the recovery period, you will be on intravenous fluids for about 3 days, although you will be given fluids orally from the evening of surgery. Intravenous fluids are discontinued once you are able to drink enough without nausea or abdominal discomfort. It normally takes 3-4 days for the bowel to recover after abdominal surgery, so you may feel some distension early on that is relieved once you pass flatus or stool.

You will have a plastic tube placed in the abdomen at the end of the operation to drain excess fluid from within the abdomen. This is initially blood-stained but rapidly clears to being straw-coloured. The drain is normally removed 3-5 days after surgery, but may need to be left for longer on occasion. A urinary catheter will drain urine, but is usually removed about 3 days after surgery. You will be asked to wear white stockings to prevent blood clots from forming in your legs. Total hospital stay is usually 5-7 days after liver surgery and 10-12 days after major pancreatic surgery.

Pain Control After Surgery

Pain is well controlled in the postoperative period initially with epidural anaesthesia, which numbs the region of the wound. This is very effective and can be administered for 3-5 days after surgery to deal with the period when wound pain would be at its worst. After 3-5 days, the pain is less and is well controlled with tablets of Paracetamol and mild morphine derivatives.

How to Speed Up Your Recovery

The nurses and physiotherapists will work with you in the ICU and ward to ensure you cough up any mucus from the lungs to prevent postoperative lung infection. They will also get you out of bed and sitting in a chair or walking to prevent blood clots in your legs and to help your bowel function recover faster. It is advisable that you cooperate with them as the more actively you mobilise, the more quickly you will feel better and be ready to go home! If your mobility is affected due to pain at the surgical site, do not hesitate to inform the doctors or nurses, as you may need more painkillers to be comfortable.

What are the Risks of Surgery?

Liver and pancreatic surgery is now quite safe, particularly in specialized centres. The risk of mortality is below 2-3%. Complications do occur occasionally, but can usually be effectively dealt with without lasting effects. Complications specific to liver surgery include bleeding, bile leakage, and postoperative liver dysfunction. Late complications include diabetes and weight loss that may be corrected with medication.