Pancreatitis: The Next Step after the Diagnosis
Guest: Dr. David Adams – Department of Surgery
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am talking with Dr. David Adams who is Professor of Surgery at MUSC and an expert in the treatment of pancreatitis. Dr. Adams, earlier, in another podcast, we talked about the presenting symptoms of acute pancreatitis. Let’s imagine, now, that you have made the diagnosis of the patient based on the blood work and, perhaps, an imaging study. What is your next step to treat the patient?
Dr. David Adams: After the acute episode of pancreatitis is over, the goal is to identify a cause that can be fixed. So, the most likely cause that could be fixed in a simple manner would be to identify gallstones that had caused the pancreatitis. When the patient recovers from the acute pancreatitis, the gallbladder could be removed laparoscopically and the patient could go home from the hospital the next day. If the patient had suffered no permanent injury to the pancreas, he/she would be well indefinitely.
Dr. Linda Austin: Explain a little bit more about, I mean, you said that in a very simple way, you just remove the gallbladder, I am sure there is a lot more to it than that. What goes into that procedure?
Dr. David Adams: That involves going to an operating room and being put to sleep with a breathing tube in and using four small puncture sites in the abdomen where the gallbladder rests, putting a telescope with a TV camera inside the abdomen, and then operating on the abdomen and removing the gallbladder, taking it out through a small half inch incision and letting the patient recover from the anesthesia and go home the same day, or the next day.
Dr. Linda Austin: Now, let’s imagine that the pancreatitis is not caused by gallstones, what is your next step?
Dr. David Adams: Then you would attempt to identify a plumbing problem with the pancreas. Is there something wrong with the pancreatic duct so that it does not empty? This could involve having studies done where the ducts of the pancreas are outlined with an MRI scan or with a special study which is done by experts in endoscopy where a scope is put down through the mouth and a small tube is put into the pancreas and can inject a dye into the pancreas and also measure pressures in the pancreatic ducts. If an abnormality is identified there, frequently these can be fixed without an operation, but simply with an endoscopic procedure, a procedure done through a scope to open up these ducts.
Dr. Linda Austin: Now, is that a procedure you do as well?
Dr. David Adams: That is a procedure that the gastroenterologists do. I get involved in the patients when normal medical treatments, such as endoscopic treatment or other medical treatments which involve cessation of alcohol, avoiding fatty foods, and frequently patients are put on pancreatic enzymes to decrease pancreatic secretions as medical treatments of pancreatitis. When those medical treatments fail, then I get involved in the treatment of the patients.
Dr. Linda Austin: So, how long, typically, would a physician attempt to treat a patient with those more conservative methods before you get called in?
Dr. David Adams: It depends on the intensity, severity and frequency of the pain because, chiefly, what we are treating when we treat chronic pancreatitis, or when we treat pancreatitis after the acute episode, is pain. So, if the pain can be managed without undertaking a procedure then that is the first choice. When all medical treatments of the pain fail, then endoscopic, or surgical treatment, is undertaken.
Dr. Linda Austin: And what does that consist of?
Dr. David Adams: So, the endoscopic treatment consists of opening up the pancreatic ducts by placing the scope through the mouth, right next to the pancreatic duct. These are very elegant procedures. We have some of the best experts in the world here at MUSC. Now, those procedures are not successful 100 percent of the time. So, when patients are unable to get relief of their pain with these procedures or, more commonly, the pain recurs, then they require an open operation where you have to do old fashioned surgery and open up the abdomen and go in and fix the plumbing of the pancreas.
Dr. Linda Austin: And that is the type of work you do?
Dr. David Adams: Yes.
Dr. Linda Austin: How often does that do the trick?
Dr. David Adams: What I tell patients is that the causes of pain in pancreatitis are poorly understood so our treatment is not successful all the time. But, about 70 percent of the time, patients improve with surgery for chronic pancreatitis. Sometimes the improvement is not restoring the patient to the way they were when they were 16, pain free and normal, but it may be that they are not going to the emergency room several times a week. They are not spending several weeks or months in the hospital per year but it is something that can improve their quality of life.
Dr. Linda Austin: Do some of these patients, where treatment is not 100 percent effective, end up chronically on pain medications?
Dr. David Adams: Yes, they do. What we have seen is that patients who are on chronic pain medications can achieve a high quality of life, so they are able to function. I have some patients who are on chronic pain medicines and taking college courses, going to college. It is amazing what level of function and quality of life patients can achieve even though they have chronic pain that they live with daily.
Dr. Linda Austin: So, in other words, to you, as their physician, the chronic pain, obviously, is a symptom to be taken seriously because it is so uncomfortable but it is not necessarily medically alarming to you, if you can manage the pain. Do I have that right?
Dr. David Adams: That is right. In other words, after you have addressed the acute episode of pancreatitis and you have repaired everything that is broken, that can be fixed, and patients still have persistent pain from inflammation and irritation of nerves around the pancreas, then they can achieve a stable situation where you can treat the pain safely for long periods of time.
Dr. Linda Austin: Can chronic inflammation of the pancreas, as in pancreatitis, be a set-up or risk factor for carcinoma of the pancreas?
Dr. David Adams: The risk factors for pancreatic cancer, most commonly, are smoking and alcohol use. Pancreatitis is a risk factor in terms of chronic inflammation of the pancreas. So, yes, chronic pancreatitis can be a risk factor. And there are patients who have an inherited form of pancreatitis, familial pancreatitis, who are at increased risk for pancreatic cancer.
Dr. Linda Austin: Dr. Adams, thanks so much.
Dr. David Adams: You are welcome.
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