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REMINDER:
As usual the comments and replies in this Newsletter are not necessarily the opinion of the Network and ALL medical queries should be referrred to your GP or Consultant before considering any action.
The pancreas
The pancreas is an elongated gland that lies across the upper part of
the posterior wall of the abdomen, its head in the loop of the duodenum,
its body and tail extending to the left behind the stomach. It consists
of two types of cells:
1. The acinar or gland cells, similar to cells in the salivary
glands, which secrete the pancreatic juice containing enzymes which act
on protein, fat and carbohydrate. These enzymes are activated on
meeting the duodenal juices. The main duct of the pancreas usually
unites with the bile duct to form what is called the ampulla just before
entering the second part of the duodenum. The sphincter of Oddi surrounds
the ampulla and prevents reflux of duodenal contents into the pancreatic
duct.
2. The islet cells, or islets of Langerhans, which secrete
the hormone insulin into the bloodstream. Insulin is especially concerned
with glucose metabolism, and deficiency of its action results in diabetes
melitus.
Acute pancreatitis
Cause - Acute pancreatitis is usually associated with disease of the
biliary tract or gallstones, or with alcoholism. Reflux of duodenal
contents into the pancreatic duct activates the enzymes resulting in self-digestion
of the pancreas and necrosis of surrounding fat - a very acute inflammatory
process.
Symptoms - The condition is commonest in middle-aged men and may be
precipitated by a heavy meal or high alcohol intake.
There is sudden agonising upper abdominal pain, nausea and vomiting.
The abdomen is tender and rigid. There is pallor, rapid pulse and
often hypotension and collapse, a picture commonly referred to as shock,
here due to lowered blood volume from outpouring of fluid into the intestine.
Differential diagnosis includes perforated peptic ulcer, biliary colic
and surgical conditions described above, and sometimes the picture simulates
myocardial infarction. The diagnosis of acute pancreatitis
is confirmed by a very high serum amylase, one of the enzymes that leaks
into the bloodstream; the serum amylase may, however, be slightly raised
in other acute abdominal conditions.
Treatment - This should be conservative if the diagnosis
is clear. Bed rest is indicated.
Relief of pain - pethidine 100 mg intramuscularly;
morphine causes spasm of the sphincter of Oddi and is best avoided.
Nasogastric suction - to remove stagnant gastric and intestinal
contents; removal of these secretions also helps by preventing further
pancreatic stimulation.
Antisecretory drugs - atropine 0.6 mg or propantheline 15-30
mg intramuscularly are anti-cholingergic drugs which inhibit the effect
of vagal stimuli of the pancreas.
Aprotinin (Trasylol) given intravenously antagonises pancreatic
enzymes but opinions are divided on its value.
Intravenous fluids - saline, dextrose, plasma or blood are needed
for hypovolaemia. Calcium may be required to combat hypocalcaemia
from the combination of calcium with breakdown products of fat.
Follow-up - Disease of the biliary tract such as gallstones,
and alcoholism should receive attention, to prevent recurrent attacks -
relapsing acute pancreatitis; this is associated with deposits of calcium,
seen on X-ray, in the pancreas.
Chronic pancreatitis
In chronic pancreatitis there is a destruction of the pancreatic cells with replacement fibrosis and permanent impairment of function.
The cause is often unknown, but alcoholism and dietary deficiencies
in underdeveloped countries may be responsible. Many authorities
now state that chronic pancreatitis is a rare sequel to acute pancreatitis
or biliary tract disease but a gallstone pressing on the pancreatic duct
could cause obstruction, and gradual pancreatic fibrosis. Carcinoma
of the pancreas may also be associated with chronic pancreatitis and it
may be difficult to distinguish the two conditions.
Symptoms and signs - Middle-aged men are mainly affected.
There are bouts of upper abdominal pain, persistent and demoralising often
precipitated by a heavy meal or alcohol. Pain may be worse lying
flat and antacids do not help. There may be slight jaundice, and
fever.
Sometimes there is no pain, the condition presenting as pancreatic insufficiency.
This has two effects:
1. Malabsorption syndrome from lack of digestive enzymes.
There is weight loss and steatorrhea - loose, pale, offensive, fatty stools.
Unlike the malabsorption of intestinal cause, anaemia is rare.
2. Diabetes in the late stages, from destruction of the
insulin-secreting islet cells. There is polyuria and thirst.
Further investigations - Straight X-ray may show
pancreatic calcification.
The serum amylase may be slightly raised.
Stools show a high fat content (normally less than 6 g per 24 hours.)
Glucose tolerance test may show a high diabetic curve instead of
the flat curve of intestinal
causes of malabsorption, and xylose absorption is normal.
Ultrasonic and radioisotope scans are proving most helpful and cause
no discomfort for the patient.
Pancreatic secretion tests - a tube is passed into the duodenum, and
the pancreas stimulated with
injection of secretin-pancreozymin, or by placing bile salts in the duodenum.
The pancreatic juice
obtained by aspiration is tested for volume, and bicarbonate and enzyme
content. Such tests are
difficult in practice.
Treatment - Analgesics may be necessary for pain.
The diet should be low in fat and rich in protein.
Pancreatin and proprietary enzyme preparations may be sprinkled
on food or mixed with meals but are
not always helpful.
Insulin injections are required for diabetes; its control is not
usually difficult.
Prognosis - This is variable - the condition may remain static
for years, or the course may be a downhill one and here
carcinoma should be suspected.
Fibrocystic disease of the pancreas (mucoviscidosis)
This is a disease of recessive inheritance. The pancreas is one of the secreting glands involved, its ducts being blocked with viscid mucus (mucoviscidosis) followed by fibrosis and cyst formation. An affected baby may have intestinal obstruction from thick meconium filling the intestine. In infancy and childhood, there is steatorrhea. The sweat glands are also affected, excessive salt in the sweat confirming the diagnosis and distinguishing mucoviscidosis from coeliac disease. Bronchial gland involvement causes bronchiectasis and cyst formation, with recurrent lung infections.
The pancreatic steatorrhea is treated with a low-fat high protein diet and enzyme supplements. Lung infections require antibacterial drugs but tend to be recurrent and are a frequent cause of death.
Carcinoma of the pancreas
This occurs in the middle-aged and elderly.
Symptoms and signs - The onset is insidious, and the condition often difficult to diagnose. There may be upper abdominal pain similar to that in chronic pancreatitis, anorexia and weight loss - this is usually the cachexia of malignant disease, but may be partly due to steatorrhea from associated pancreatic insufficiency. Similarly the condition may present as diabetes in middle-age, and despite the control of the diabetes, the patient deteriorates.
Obstructive jaundice may be the first sign in carcinoma of the head of the pancreas. The jaundice is deep with itchy skin, pale stools and dark urine containing bilirubin but no urobilinogen.
Metastases are frequently the first clinical indication - thus, there is ascites from peritoneal deposits, or liver swelling and jaundice. Involvement of the inferior vena cava causes venous obstruction and oedema.
Sometimes recurrent phlebitis is associated with carcinoma of the pancreas.
Further investigation - Barium meal
may show distortion of the loop of the duodenum. The ESR may be raised,
as in any
malignant disease.
Ultrasonic and radioisotope scanning of the pancreas may be helpful.
Treatment - Palliative surgery may relieve the biliary obstruction
in carcinoma of the head of the pancreas. It is, however, rarely
possible to remove a pancreatic growth, and the risks of autodigestion
and fistula formation render operations hazardous.
Treatment is therefore generally conservative, with the proper use of analgesics and opiates to prevent pain and alleviate suffering, and the course is a downhill one, with death in months or weeks.
Another medical extract passed on by a member. Sorry, no information
available on source of article.
As I am passed on articles and extracts that I think may be of interest
to us all I will publish the same in the Newsletter. (Editor)
REMEMBER:
The purpose of these article are to
help us become better informed and are not designed to depress anyone.
Anyone who has any concerns over their medical treatment should consult
their Consultant or GP.
Responses to Joan Hemingway's Letter
Re Joan Hemingway and her Putting-on-Weight Problem
A couple of years ago I had an operation to remove my pancreatic head, gall bladder and duodenum and while in hospital picked up a bug which affected my liver, and consequently stayed there for some seven months while the problem was dealt with.
I lost weight - boy did I ever lose weight: I went from 70 kilos down to 44, and the doctors were quite concerned. What they (or rather, a redoubtable senior registrar at King's College called Howard Bradpiece) did was to get me to eat everything slimmers are supposed to avoid: full cream milk, cheese, potatoes, streaky bacon, white bread and so on. However, being rather unwell I had a very poor appetite, so eventually they decided to insert a tube into my stomach, through my nose (actually not as unpleasant as it sounds), and overnight, every night while I slept, I was drip-fed a litre of a confection called Fresubin 750 which is a highly concentrated 'complete' liquid food.
The tube was plugged up during the day, normal meals were taken at normal meal times, and supplemented overnight by the Fresubin. Fresubin (which comes in various strengths) can also be drunk; it is available in various flavours, however the advantages of having it dripped into you while you are asleep should be self-evident. The only disadvantage I experienced with the nose tube was that it sent the neighbour's dog into hysterics.
Nestles produce something called build-up which the doctors tried on me, but that gave me the runs.
Joan could start each day with a pint of Channel Islands milk and a banana which one chap I know swears by as a cocktail for increasing weight.
Whatever she goes for, her GP should be able to refer her in the first instance to a dietician, and I hope Joan will, through the newsletter, let us know how she gets on.
With regard to the fatigue, Pancreatitis really exhausts the whole system, doesn't it?
The news that Joan's pancreas has healed is very good indeed however she is now in convalescence and if my experience is anything to go by, it will be many months before she gets all her strength back. However she will get it back eventually.
Best wishes
John Duerden
"I too have bouts of extreme tiredness which suddenly occur. I am now thinking it is part of the stress symptoms - does she lead a busy, action packed life like I did? I am know seeking psychiactric help to help me to slow down. It is very difficlut to get a diagnosis as to the cause of bouts of tiredness. I have been mentioning it to my doctor for a number of years, but even when I started collapsing, the connection wasn't made. Tell her to persevere. Sooner or later, the jigsaw bits fit together!
All for now,
Karen Abbott.
(I think it is very brave of Karen to mention seeking for psychiactric help as there is such stigma even today to this type of medical help. I can personally vouch for the psycho-therapy that I went though and I am sure other members have as well. Editor.)
Other questions from Members:
"I have just been given some new pain killers but haven't tried them yet as was told they are very new! Wonder about the side effects! Has anyone else had them? The name is Zydol Caps 50mg.
Mrs Valerie Wright
"I have chronic pancreatitis - I cannot eat any Dairy food without causing pain. I wonder if this applies to other sufferers?"
Mrs A P Paddock
All I can say is Joan really started something with her letter questioning members on diet and due to the number of responses I have had I am devoting this next page or so to responses from members over the whole area of diet and foods.
In order to save having to get each article verified by the author
before printing I have left peoples' names off.
Here we go extracts from members letters:
...Except being told to eat no fat where possible or keep it down to
2.0g in any product (or below) and no alcohol of any sort and dairy stuff
to be skimmed or non-fat or none at all, I was not given any more advice.
I have found out for myself, just recently, and often after such a
lot of acute pain, that the following foods were obviously not helping
me one bit and causing years of pain.
This may be helpful news to other members if included in the Newsletter to come - I leave you to decide how to present it.
1) I cannot digest any salad food and have not eaten any this Summer
(a few tomatoes if boiled and de-skinned)
2) I cannot digest any citrus fruits or had any fruits - apples etc
and just occasionally raspberries, strawberries etc.
3) All vegs are OK so long as they are cooked (never raw) and I eat
a lot of every kind.
4) I buy tinned soft fruit (mangos are super) and find this I can cope
with - supermarkets selections are not too expensive and it is all fruit
and no peel, skin and pips - which are no good to me!
...I am OK with all meats, fowl and fish cooked any way and even bacon grilled and the odd oven chip!
I am taking in a bit more fat like biscuits, cake, chocs, semi-skimmed milk and yogurt etc (but only once a week).
I think Sanatogen powder, Glucose powder and Luctulose are doing me a lot of good!
________________________________________________________________________________________________
Yes, I cannot eat any Dairy food only perhaps once a month, very little,
check when weekly shopping you do not buy any food containing cheese sauce,
or sauces of any kind (very fat). I always read labels on the back of packets
etc, if it contains more than 4g fat put it back. Make your own soups,
hot or cold with lots of Pasta, Veg, sometimes fruit. No cakes or
goodies from sweet shelf, but in-between have a go at different cakes as
a filler.
________________________________________________________________________________________________
Mrs A P Paddock - Yes! This is me also! Have for 7 years been on non-fat or low-fat food:
Skimmed milk
Low-fat yogurt
No cheese, biscuits, cakes, chocolate, fat meat, suet etc.
Had to be brain washed to read every label on everything and if it was
above 2.0g fat content, don't buy it or eat it!
________________________________________________________________________________________________
I thought the enclosed might be of interest to your members who, like me, have to limit their fat intake from all sources. to no more than 50g per week (see next section - Editor, Also restriction to 50gms fat contradictory information to 100gms as recommended by the Pancreatic Society of Great Britain and Ireland). I tried them and found they enlivened a salad and they contain 1g per 100g instead of the normal 24-30g. I wrote to the manufacturers to get to know more about other items in their low fat range, also supplies.
(Response to above letter below - Editor)
THE LOW FAT SNACK CO
1A Standard Road
London
NW10 6EX
Tel 0181 965 8687
Thank you for your recent letter regarding our low fat snacks.
.......The 99% Low Fat Potato Waffles were launched by SAFEWAY. .....The BOOTS stores will be launching two new products in the middle of October which are called 'Shapers Very Low Fat Pizza Pieces' and 'Shapers Very Low Fat American Waffles'.
......Another product is called 'Pasta Snacks' (which is 50% lower in fat than normal crisps) and we currently supply to some of the SAINSBURY'S stores. .....WAITROSE have a similar product called 'Spicy Tomato Pasta Crisps' and 'Garlic and Herb Pasta Crisps' and ASDA also have a similar product called:
'Italian Style Snacks' - which are under their own respective labels.
...Unfortunately we cannot supply direct to the public.
________________________________________________________________________________________________
Causes of Pancreatitis?
I have had a couple of interesting calls about what people have
been told caused their pancreatitis from:
Mumps, Severe blow to the pancreas, Scorpion sting, heredity etc.
What about you? Write in and tell us.
________________________________________________________________________________________________
Drug information
Zydol Capsules. I was asked about the following
and had to wait until our latest copy of MIMS to get this information:
Opiate analogue. Tramadol hydrochlor. 50mg green/yellow capsule.
Used for moderate to severe pain.
Not recommended for CHILDREN.
End
