Gastroenterology: PANCREAS
CASE
49yo male
sudden onset epigastric pain
radiating to back on right side
pain relieved by leaning forward
nausea and vomiting, fever
known gallstones, heavy drinker (min 2-3/day)
FHx: hypertryglyceridemia
DX: acute pancreatitis
Vitals: BP 90/50, HR 120, RR 35, Temp 98.9
(why is temp not higher? taking analgesics? high for normal? no infx?)
(dr t says average american temp at this age is 97.6)
PE: cold clammy, profuse sweat
epigestric tenderness and guarding
BS sluggish but present 4 quadrants
WANT LABS: serum amylase and lipase, CBC, Chem panel, ALP, ALT/AST, UA (amylase, bili)
FOUND: WBC 15.3 hi, gluc 243 hi, Ca 7.3 low,
BUN 47 Vhi, LDH 657 hi, AST 287 hi, ALB 2.9 hi,
TGs 600 hi, amylase 630 hi, lipase 350 hi
IMAGING to order: abd xray, US, or CT depending
DDX: acute pancreatitis, cholelithiasis, appendicitis, gastroenteritis, AAA, bowel obstrx/ischemia, duod ulcer perf, ascending cholangistis, perforated viscus, ruptured eptopic (female), MI, pneumonia
TX: going to hospital (waiting for hospital: vinegar pack for pain, homeop, acupx, etc)
ACUTE TX: pancreatic rest in hospital, IV fluids, pain management
x3-5 days until acute is resolved
NG tube to empty gut
watch hourly
daily CBC, UA, ESR, CA, gluc, amylase
ABX may reduce septic complications
Day 3 developed severe vomiting
seen 6 weeks later, he had stopped drinking
ended up getting a cholecystectomy, statins, still having attacks
many pts deny alcoholism
pts tend to start drinking again
alcoholism is hardest part of underlying cause to resolve
diet issues usu based on alcoholism
GI HORMONES
CCK = cholecystokinin is most imp hormone influencing panc secretion
secretion stimulated by smelling, cooking, thinking about food
bicarb also released by panc duct cells to neutralize chyme entering duodenum
panc makes enzymes that finish digesting prots, fats and carbs
LABS
to assess pancreatic fx: measure fecal chymotrypsin and elastase
fecal fat is done but he doesn't think it's "that great" a marker
if only mild panc exocrine deficiency-->may look fine
test is confirmatory but not 100%
secretin based test still used by gastroenterologists
CYSTIC FIBROSIS PTS
present as children
salty skin
excess mucus, coughing, choking, from every orifice
URIs
steatorrhea
part of tx: pancreatic enzymes, otherwise can't digest much
PANC HAS RESERVE FUNCTION
over 90% of panc is destroyed before pt is type I diabetic
PANCREATIC INSUFFICIENCY
a DX not used in conventional medicine
ETIO: overeat, too much carbs/alc, low fiber, SAD diet
too much caffeine, no raw food, def of zinc, manganese, magnesium, prot, B6
prevalent
SX: gas and bloating, fatigue, fatty stool, indigestion, diarrhea, like hypoHCl
SX: assorted GI distress no matter what kind of food, food sensitivities
usu has leaky gut and dysbiosis too
*we all have leaky gut in years 1-2 of life
SX: floating stool, wt loss
SX: L shoulder/scap reflex pain, low blood sugar/DM
LABS: fecal chymotrypsin and elastase
he doesn't know anyone who does indican test anymore, because of toxic chems
CBC: incr MCV (low B12/folate or panc insuff)
Heidelberg low bicarb output
UNEXPECTED CAUSES OF VITAMIN B12 DEFICIENCY
why megaloblastic anemia?
Dr T went through this process in his practice:
MCV doesn't go down with B12 injx and panc insuff, why?
he did weekly B12 injx for a couple months and repeated CBC and MCV went 96-->100
he checked serum B12: it was very high
what happens after B12 absorbed?-->goes to every cell in body
travels bound to transcobalamin carrier protein which is made in liver and WBCs
look at WBCs, if low, may not be able to transport
how does B12 get into big toe? possible problem with receptors (peptides on them?)
TX: digestive enzymes (or DT used homeopathic pancreas: pancreatinum 4ch)
rechecked MCV: decreased
TX FOR PANC INSUFF
fasting/cleansing diet, incr fiber, low carb, adequate trace minerals and prot
food hygiene, chew 31 times
eat cooked carbs
apple cider vinegar to stim acid and enzymes
lots of pts would rather take pills than stop eating crappy diet
Dr T doesn't give enzymes because he doesn't want them to feel better without changing diet
he wants to treat the cause
enyzmes: plant enzymes (aspergillus) brand Similase (Tyler), Phytozyme (N), V-enyzmes (seroyal)
papain/papaya, bromelain/pineapple, pork enz/pancreatin Panplex 8 (tyler) etc
all proteolytic enzymes mb used for anti inflam and anti-ca effect
ACUTE PANCREATITIS
sudden onset
pain like being stabbed through epigastric to back
ETIO: acronyme IGETSMASHED idiopathic, missed the rest of it
SX he hasn't seen grey-turner sign = red brown flanks, cullen's sign = grey brown
urine amylase stays up longer than blood
incr amylase is nonspecific
if 3x normal --->very suggestive
lipase is most sensitive and specific to panc
gluc up, ca down
xray
dilated loop of bowel
US for abscess
CT best for DX of acute
contrast enhanced good dx for panc necrosis
CTs
cancer pts get way too many of them
and it causes cancer
more docs are actually thinking of minimizing radiation exposure
"we're not checking until you have sx because the treatment doesn't work anyway"
ERCP
can cause gall stone pancreatitis
PROGNOSIS
significant mortality
85% mild, self limiting
10-15% need ICU, many die
rating systems used in hospitals
Ranson: over 55, wbc over 16,000, ODH over 350, gluc over 200, AST over 250, CHT decr
APACHE: variation on a theme
GOALS FOR TX
panc rest until no pain and amylase is normal
support, pain control, antiemetic
may need NG tube
enteral nutrition
mild acute-->oral may help
SCIENCE SAYS IT DOESN'T WORK
Dr Thom doesn't agree but warns us that the science disputes efficacy of pancreatic rest:
EBM: chinese herbs and IV antiox don't seem to help
probiotics increases mortality and bowel schemia in pts with predicted severe acute pancreatitis
insuff evidence re which kind of nutrition (cochrane)
COMPLIC
necrotizing
pseudocysts w/ chronic and repeated acutes, bad signs
CHRONIC PANCREATITIS
pain not as severe, comes and goes
etio: alc 70%, idiopathic 20%, other 10%
SX: pain, malabsorption, diabetes
mb better leaning forward, knees to chest
LABS: don't tell much
Bentiromide test: para-aminobenzoic acid in urine with chronic panc, none if healthy
Image: plain abdominal film shows calcifications, pseudocysts
TX: incr vit CADKB12, folic, calcium
avoid animal fats except fish
avoid alc, sugar, hot/spicy, fried/fatty, rich, salty, coffee/caffeine, sug, cowmilk/dairy
avoid: white bread, refined/processed
SUPP: lots of vits and selenium, magnesium, list looks like a good multi
Dr T likes to give single nutrients, B complex, panc enzymes initially
hydrotherapy, castor oil packs
herbal meds: for pain, tonify GI tract
homeop: bell, carb, etc
EBM: discont alc, supp antiox, fat restrx not necc in most pts
COMPLIC: exocrine insuff, lousy digestion
YOU WILL SEE THIS
very common, so is cancer
CANC OF THE PANC
grim, poor survival rate, very common cancer, very painful
early dx hardly ever happens
CC: pain is dominant feature
SX: pain, nausea, wt loss, diarrhea, dehydration
ETIO: smoking is #1
arises from ductal cells
CR19-9 is tumor marker that works to monitor for recurrent
DX: imaging, BX
TX: pain management (morphine pump)
radical surgical procedures (dangerous): Whipple procedure: take it all out
chemo/radiation
no transplants offered
Prog: most pts don't make it 2 years
don't do all those tx, don't make it 6 months
only cancer dx where pain is the big deal
Dr T's tx: go to Hawaii and enjoy the time you have left
but last 2 pts got very angry with him for saying that
oncologists may not tend to tell them their true prognosis
only pt Dr T saw to live 28 mo was living for someone else, died when she was allowed by life