Re: acute vs. chronic

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This is a medical emergency marked by acute abdominal stress. Symptoms are

caused by spillage of pancreatic fluids into the abdominal cavity. These

fluids contain enzymes which begin to digest and destroy the lining of the

intestine and the intestinal wall itself as well as any internal organs it

encounters.

Pain typically radiates from the pit of the abdomen through to the back with

nausea, vomiting, low-grade fever, and shock. Some patients exhibit none of

these save shock. There may be evidence of intra-abdominal bleeding.

Causes include direct trauma, overindulgence in alcoholic beverages, viral

and bacterial infections, duodenal ulcer perforation into the pancreas,

certain metabolic insults, and toxicity from some pharmacological drugs.

The diagnosis is made by ultrasound with supporting evidence from elevated

pancreatic enzyme levels (amylase and lipase). These people usually have

elevated white cell counts.

Acute pancreatitis is a medical emergency and must be treated in a hospital

setting. In addition to the usual management doctors in nutritional medicine

have noted that intramuscular selenium followed by repeat doses 24 hours

later, then daily doses are useful in the management of this disorder. Only

doctors who practice nutritional medicine have a clue about the use of

selenium for this indication.

In the acute stage of acute pancreatitis the patient should have nothing by

mouth, intravenous feeding should be instituted, calcium and magnesium

levels maintained, pain managed, and the cause of the disorder treated. This

may involve surgery.

Chronic pancreatitis may result from one or more bouts of acute pancreatitis

and this condition is marked by radiologic evidence of calcification of the

pancreas, passage of undigested fat in the stool, diabetes, vitamin B12

deficiency, and poor digestion due to loss of pancreatic enzymes. Also a

cyst-like condition may develop requiring surgery.

The most important aspect in the treatment of acute pancreatitis is

supportive care. This includes replacement of fluid and electrolytes,

correction of metabolic abnormalities such as symptomatic hypercalcemiaand

nutritional support. Other measures such as the use of nasogastric suction

and antibiotics should be decided on a case-by-case basis.

Agents that have been used to inhibit pancreatic secretion have not been

found to be useful in altering the course in acute pancreatitis. These

include somatostatin and glucagon. Protease inhibitors, which are effective

in laboratory studies, have not been shown to be useful in clinical

pancreatitis.

Emergency surgery is not indicated in mild acute pancreatitis. Some surgical

procedures such as resection of necrotictissue and peritoneal lavagemay have

a role in select patients with severe, progressive necrotizing pancreatitis

or pancreatic abscess. Cholecystectomy has been demonstrated to be effective

in patients with recurrent acute pancreatitis and microlithiasis (Figure

17).

Surgical sphincteroplasty of the pancreatic sphincter is an alternative

approach to endoscopic pancreatic sphincterotomy in patients with pancreatic

sphincter dysfunction. Although the patient outcome is the same as for the

endoscopic approach, it is more invasive, requiring laparotomy and .

duodenotomy

Sphincteroplasty of the minor papilla is indicated for unsuccessful or

failed endoscopic minor papilla sphincterotomy in patients with . pancreas

divisum

Endoscopic therapy has a therapeutic role in three specific areas in the

management of acute pancreatitis: 1) acute gallstone pancreatitis, 2)

recurrent pancreatitis due to pancreatic sphincter dysfunction, and 3)

recurrent pancreatitis due to . pancreas divisum The rationale for

endoscopic therapy in each area is the relief of obstruction to flow of

pancreatic juice.

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Although it would seem logical that removal of the gallstones from the

common bile duct early in acute gallstone pancreatitis would improve the

clinical course, there is a lack of a " predictable " good outcome as

suggested by propective clinical trials. It appears, however, that the

patients with suspected stones who benefit from early ERCP are those with

evidence of biliary obstruction such as jaundice or dilation of the bile

duct and severe pancreatitis. Further clinical trials are needed before more

definitive recommendations can be made. In a subgroup of patients with acute

recurrent pancreatitis and ,microlithiasis endoscopic sphincterotomy has

been shown to significantly reduce the frequency of attacks (Figure 18).

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With the advent of manometric studies of the pancreatic sphincter, many

cases of so-called idiopathic recurrent pancreatitis are now known to be a

result of pancreatic sphincter dysfunction. Endoscopic pancreatic

sphincterotomy may be expected to have a good outcome in up to 90% of these

patients. There are two techniques for endoscopic pancreatic sphincterotomy;

one is with a pull-type sphincterotome followed by stenting of the

pancreatic duct and the second is with a needle-knife sphincterotome

performed over a pancreatic stent. Following pancreatic sphincterotomy there

may be tissue swelling that could result in obstruction to pancreatic

outflow. Therefore, short-term pancreatic stenting is indicated when

pancreatic sphincterotomy is performed to maintain patency of pancreatic

outflow (Figure 19).

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Endoscopic minor papilla sphincterotomy is effective treatment for patients

with recurrent pancreatitis and pancreas divisum (Figure 20). Good long-term

results are found in about 70% of patients but may be significantly less if

there are changes of chronic pancreatitis.

There are two techniques for endoscopic minor papilla sphincterotomy; one is

with a pull-type sphincterotome followed by stenting of the pancreatic duct

and the second is with a needle-knife sphincterotome performed over a

pancreatic stent (Figure 21). Following pancreatic sphincterotomy there may

be tissue swelling that could result in obstruction to pancreatic outflow.

Therefore short-term pancreatic stenting is indicated when pancreatic

sphincterotomy is performed to maintain patency of pancreatic outflow.

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acute vs. chronic

> Are most of the members of this site chronic sufferers? I was just

> diagnosed with pancreatitis, but they are not sure if it is acute or

> chronic. I cant get to a specialist until early Jan.

>

> It is my understanding that acute is bad, but that many acute cases

> get better and do not come back. I am more concerned about chronic.

> Even then, there are treatments, right? Enzymes, possible

> surgeries? I am very depressed right now because I want to live for

> a good thirty more years and am concerned. I do not drink, and an

> ultrasound did not reveal any stones, just a slightly " inhomogeneous "

> pancreas and my lipase and amylase were elevated (lipase 4x normal).

>

> I am 31.

>

> Thanks

>

>

>

>

> PANCREATITIS Association, Intl.

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to: Pancreatitis (AT) Yahoo

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