Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
2 May 2007

 A REALLY BAD BELLYACHE 

            This is a column about three patients that presented the past several months with a common problem but with three different causes.  All three patients presented with disabling terrible abdominal pain and all three patients had a long and ugly course. 

            The first patient was a 48 year old lady executive who knew she had gallstones.  She had had intermittent episodes of slight abdominal pain an hour or two after a large meal.  Initially, she thought this was just indigestion and maybe eating more than she should.  But when she came to medical attention, an ultrasound examination of her gallbladder showed that she had gallstones.  She was told that these needed to be removed in order to avoid further problems of the type she was having.  She was told not to wait.  Unfortunately, she said she was much too busy to get involved in a surgical consideration at this time.  She said that she would just watch her diet and get the gallstones removed sometime later.  Bad choice!!

            Two weeks later at about three o’clock in the morning, she came to the hospital with a new kind of abdominal pain.  She indicated that this was located in the mid portion of the abdomen radiating through to her back and much worse than any pain she had ever experienced with her gallbladder problem.  She didn’t feel that the two were related at all.  In fact, they were.  The gallstones had stopped up her common bile duct and bile had backed up into her pancreas and caused the condition called pancreatitis.  To make a long story short, she has been through a six week ordeal off from work.  Whatever it was that was keeping her so busy she couldn’t do surgery, simply didn’t get done the last six weeks.

            The second patient was an unfortunate alcoholic.  This gentleman had been drinking for many years and despite going through alcohol treatment more than once, he had never managed to discontinue his alcoholic habit.  On this occasion, he came to the hospital with the same type of severe mid abdominal pain radiating through to his back, now with nausea and vomiting blood.  To make a long story short, he spent about six weeks treating a case of alcohol induced pancreatitis.  Now in addition to being alcoholic, he had become diabetic because the pancreatitis destroyed his ability to make insulin. 

            The third individual was another unfortunate diabetic who was quite substantially overweight.  At thirty-eight years of age, he liked his beer and chips on the weekend, eating much more than was needed.  He was a robust farmer and as far as he was concerned there was nothing wrong with him.  He took no medications.  He presented to the hospital in the early hours of the morning with severe abdominal pain in the mid portion of the abdomen.  The pain radiated through to his back and he was vomiting uncontrollably.  It was found that his triglyceride level (a form of fat in the blood) was about 2,000 milligrams % (normal 150 milligrams %).  His blood looked like milk because there was so much fat in it.  He, too, had a case of pancreatitis.  His ordeal was also about six weeks and he, too, became diabetic and required insulin injections.  He did have a good sense of humor and acknowledged that his disease seemed to have an excellent weight loss program associated with it as he lost 40 pounds during those six weeks. 

            The pancreas is an organ immediately behind the stomach lying against the back of the abdomen.  It makes all of the juices that dissolve meat and potatoes and carrots or gravy or corn or anything else that you eat.  It dissolves and metabolizes our food so that it can be absorbed into our blood as proteins and sugars and fats we need.  Pancreatic juice that we secrete into our intestine has been described as the juice that “can dissolve anything”. 

            The pancreas also has many tiny structures called Islets of Langerhans that secrete a number of hormones best known of which is insulin.  When the pancreas is destroyed, the body’s ability to make insulin is lost and the person becomes diabetic.

            Imagine what happens when this wonderful pancreatic juice that can dissolve anything somehow or other gets loosed upon the person who makes it.   Normally, pancreatic juice is contained within the special ducts within the pancreas and within the intestine that has special protective layers so that the intestine doesn’t get dissolved too.  But when the pancreatic ducts or the intestine get disrupted and pancreatic juice gets released into the tissue of the pancreas itself, or into the tissue of the abdominal wall, that pancreatic juice begins to dissolve the person who made it.

            That is indescribably painful.  The injury that occurs takes weeks to heal and during that time, the person cannot eat at all.  Any nutrition that they are to receive must be given intravenously.

            Pancreatitis is an ugly, ugly disease, very difficult to treat and with a long period of painful disability.  The very best and most important thing a person can do is never get pancreatitis. 

            In order to avoid this problem, there are three basic rules:

            1.  When a person develops gallbladder symptoms, get the gallbladder taken care of as quickly as possible.  Waiting can lead to disastrous results. 

            2.  I have no good answer for alcoholism.  It has been an issue over many years time and continues to be such.  Once pancreatitis happens in an alcoholic, continued drinking will lead to recurrent episodes and that somehow or other seems to solve the problem as alcoholics don’t like to hurt that bad.

            3.  Everyone should have their lipid panel checked at a young age and determine if triglycerides are an issue.  A high carbohydrate diet along with alcohol intake from a six pack of beer in a day can lead to very high triglyceride levels and a sudden unexpected case of pancreatitis.  Avoiding hypertriglyceridemia is well worth the effort.

            The healthcare providers at your local clinics are well aware of these problems. Pancreatitis patients require not only extensive hospital care but extensive post hospital followup and support.  Of all of the many conditions in medicine, this is one to avoid all together.