Pancreatitis Symptoms, Causes, Treatment and More

Podcast Transcript

Scott Steele:  Butts and Guts, a Cleveland Clinic Podcast, exploring your digestive and surgical health from end to end.

Welcome back to another episode of Butts and Guts. I'm your host, Scott Steele, the Chairman of Colorectal Surgery here at Cleveland Clinic in beautiful Cleveland, Ohio. It's always great to have repeat guests on Butts and Guts. Very excited to have Dr. Prabhleen Chahal, who is the program director of the Advanced Endoscopy Fellowship here at Cleveland Clinic. Prabhleen, welcome back to Butts and Guts.

Prabhleen Chahal:  Thank you so much Scott. Thanks for having me.

Scott Steele:  Unlike last time, we're going to talk a little bit about pancreatitis. Now, a lot of people out there may have heard this term, but we're going to start really big this time. What's the pancreas?

Prabhleen Chahal:  Pancreas is what I would call as a digestive organ. It helps with digestion of mainly fat that you take in your diet, and carbohydrate to some extent. The second important function it serves is, it helps with maintaining your sugar level, so it secretes certain hormones. It's a very important organ and it lies right behind your stomach and in front of your spine.

Scott Steele:  Yeah, it's one of those organs that's just kind of tucked in there way in the back. It seems to do wonderful things and we don't really give it enough credit. We're going to focus today a little bit about pancreatitis. What is pancreatitis?

Prabhleen Chahal:  I think generally rule of thumb, I tell all my patients, whenever you hear a term that ends with -itis, that always means inflammation. So, pancreatitis terms mean inflammation of pancreas gland. The two most common causes of pancreatitis are alcoholic, excessive alcohol consumption, and the second most common is gallstones. When the pancreas get inflames, the most common presentation is sudden onset off a pain in your abdomen. Most of the times it starts right under your breastbone, and then becomes generalized all over your belly. Oftentimes patient tell us it goes through towards their back, radiating towards the spine, often associated with nausea and vomiting. And with a mild attack of pancreatitis is a relentless pain that can last for weeks to a couple of weeks.

Scott Steele:  I have patients out there that may say, "Listen, I don't have a gallbladder anymore and I don't drink." Can you still get pancreatitis, if those two things aren't the cause?

Prabhleen Chahal:  Absolutely. So, gallstone and alcohol, they account for about 70% of our pancreas patients, but the rest of the patients, they can have pancreatitis from very high triglyceride levels. By very high, I mean more than thousand, in a thousand range. And then sometimes patient can get pancreatitis from a procedure called ERCP, what we call as post-ERCP pancreatitis.

Certain kind of a pancreatitis, which is we increasingly recognize in the United States is called auto immune pancreatitis. Oftentimes we see that in patients with inflammatory bowel disease, Crohn's disease, what we call is type two autoimmune pancreatitis, kids with bicycle trauma or trauma to the belly, certain metabolic causes like high calcium levels, problems with the thyroid, et cetera, can lead to pancreatitis and then in sudden and tropical countries scorpion stings, et cetera. Those are one of the rare ones, which I haven't seen in life yet.

Scott Steele:  Yeah. Something we don't really have to worry about here in beautiful Cleveland, Ohio. Yet another reason why Cleveland is such a fantastic place to live. Let's focus on those first two causes that you mentioned there. So what is it about the alcohol or the gallstones that can cause pancreatitis? On the converse side, we may have patients that say, "You know, I drink a little, or I've been told I have gallstones. Am I going to get pancreatitis?"

Prabhleen Chahal:  I think the answer to that would involve a lot of physiology, but I will try to be a little bit brief and broad. I think little bit of alcohol consumption. Is there a safe amount of alcohol to consume as far as your pancreas is concerned? Answer to that is perhaps yes. Usually anywhere from four to seven drinks per day is associated with alcohol related pancreas damage or what we can translate into 50 to 80 grams of alcohol per day. If somebody were to continue drinking on a daily basis, maybe even one to two drink per day and cumulative effect over five to 10 years can lead to what we call is a chronic pancreatitis, which is chronic scarring of the pancreas and that's irreversible damage.

Similarly for gallstones. Gallstones, when they trickle down through the bile duct, the opening of the liver, what we call as the bile duct, is in the small intestine in an area called ampulla. Right next to it is the opening off the pancreas gland. The proposed mechanism is when the gallstones trickled down they block the opening of the bile duct leading to obstruction in the pancreas. And as a result it sets off an inflammatory cascade, which leads to certain release of enzymes which damaged the pancreas and lead to pancreatitis.

Scott Steele:  You mentioned briefly some of the symptoms of pancreatitis. You know, you talked about abdominal pain underneath the breastbone thing. Are there any other symptoms that a patient may, maybe even more subtle symptoms that can be pancreatitis or is all belly pain that's underneath the breastbone? Is that pancreatitis?

Prabhleen Chahal:  Excellent question. Most of the pancreatitis that we see on context with alcohol and gallstones, what we call as acute pancreatitis, that's the classic presentation. Pain, nausea, vomiting, relentless pain that doesn't let up. It's not something that lasts for hours and then it goes away. That's not pancreatitis.

However, if we talk about certain other conditions that can lead to pancreatitis, for example, autoimmune pancreatitis. The most common presentation for autoimmune pancreatitis would be somebody who presents with just failure to thrive, fatigue, weight loss, they may become jaundice, it's painless jaundice, to some young individual with underlying inflammatory bowel disease. They may have just localized pain which is on and off. The presentation can be varied.

Scott Steele:  Is pancreatitis pancreatic cancer?

Prabhleen Chahal:  Know the answer to that is no, it's inflammation of the pancreas gland, but one point I would like to make is if somebody has chronic pancreatitis, which I said is a chronic permanent inflammation of the pancreas, there is a sudden increase in the risk of pancreatic cancer development down the road. It depends upon the severity chronic pancreatitis, whether a person is smoker or if they are still drinking and other underlying risk factors. The risk can be as high as 24 compared to a regular population.

Scott Steele:  How is pancreatitis diagnosed?

Prabhleen Chahal:  Acute pancreatitis. The definition involves having to have the following three criteria. Out of these three, If a person has a classic abdominal pain as we discussed recently. Second, if the blood test, all amylase and lipase, they are high, at least three times upper limit of normal. And third if any sort of imaging, either CT scan, MRI or ultrasound, they show inflamed, swollen pancreas, you need to have two of these three to make a diagnosis of pancreatitis.

Scott Steele:  When you talk about pancreatitis, what you mentioned a little bit about the diagnostic tests, what are they exactly that diagnosis pancreatitis?

Prabhleen Chahal:  Apart from the clinical diagnosis, symptom presentation, the most important diagnostic tasks that we do is the blood test and then imaging. Out of the options for imaging available we CT scan or MRI are preferred because they give a better visualization of pancreas, which is nicely tucked behind stomach, bowel, et cetera. Out of CT and MRI, MRI probably gives us a little bit more detailed information. Not to mention there is no contrast injury or radiation exposure. MRI gives us a lot more information about the pancreatic duct, which is the plumbing tube that drains the pancreatic juices and secretions into the small intestine. So given an option, if no contraindication, we prefer MRI for a variety of reasons.

Scott Steele:  Let's first talk a little bit about how pancreatitis is kind of managed or treated. Most pancreatitis, does it need an operation? Does it need an intervention? Give me kind of just the broad overview of the treatment.

Prabhleen Chahal:  Fortunately, even though pancreatitis as the number one diagnosis for all the gastrointestinal related problems that people get admitted to, but majority of the pancreatitis are mild. By mild way mean yes, patient get inflamed pancreas, but there is no permanent damage to pancreas. So we divide pancreatitis into two categories. The medical terminology for that is interstitial pancreatitis, where the pancreas tissue or the meat off the pancreas, if you will, it's all intact and viable and is alive, it just a little bit swollen and inflamed.

The second category is necrotizing pancreatitis, where the damage was so severe, that part of the pancreas gets destroyed and the destruction is permanent. Now it depends upon the severity of pancreatitis a person had that determines what are the possible complications, the hospitalization, a need for intervention. It depends upon the severity of the underlying attack. Majority are mild attack patients. They are in the hospital from three to five days. They start eating and get discharged. But if you have necrotizing pancreatitis, where's there's destruction of pancreas, it can lead to complications, which usually include fluid buildup, what we call as acute necrotizing fluid or a Walled-off pancreatic necrosis. If that gets infected or if it becomes so big, which starts compressing the stomach or small bowel or people get jaundice because of the compression from this fluid collection, that's when we intervene on these complications.

Scott Steele:  Before we get into the interventional components of it, let's just stick with the medical components. So somebody gets pancreatitis. You said earlier that anything with -itis means kind of inflammation. Do you need antibiotics for pancreatitis?

Prabhleen Chahal:  No. The mainstay of treatment for acute pancreatitis is fluids, fluids, fluids. We hydrate the patients really well. Number two, we make sure that they start getting nutrition as early as possible, preferably within first 24 hours. And third is their pain management. So these are the usually three pillars of management of acute pancreatitis. When do we use antibiotics? As I mentioned, if they had very complicated pancreatitis, they have now fluid leaks and fluid buildup, what we call as a pseudocyst or walled off necrosis. If they get infected, that's when antibiotics kick in.

Scott Steele:  I'm a patient that's coming in to your office. What can they expect if they carry a diagnosis of pancreatitis as an outpatient visit? I recognize that some patients are pretty darn sick and they get admitted to the hospital and that's a whole different pathway and we're not going to cover that today, but exactly what can you expect in a visit to your office?

Prabhleen Chahal:  Most of the times when we see patients with a diagnosis of pancreatitis in our clinic, they have chronic pancreatitis, which is a chronic ongoing problem. The most common presentation for patients with chronic pancreatitis is pain. That's at least the first 10 years of the diagnosis and later on is just we deal more with what we call as the atrophy of the gland, which then other complications like diabetes, et cetera kicks in.

So when we see patients in the clinic with pancreatitis diagnosis is as often time chronic and our goal is to again help first of all determine what led to the chronic pancreatitis. Again, smoking and alcohol are number one, but sometimes in about quarter of the patients we never find rhyme or reason. Another goal for me as a pancreatitis and endoscopy is to make sure there's no problem with the plumbing system. Sometime two people can have stones blocking the pancreatic duct and in that case we try to come up with the some options, either endoscopic or surgical options for removal of stones.

And third would be making sure that they are absorbing the nutrients well. We check them for a fat soluble vitamin levels because if pancreas is not functioning properly, they may not absorb fat soluble vitamins. So we check for all the fat soluble vitamins, make sure they are getting appropriate nutrition and then refer them for pain management if that's the main concern.

Scott Steele:  Okay. Let's dive a little bit into some of the interventions now. You mentioned a couple of different things out there, the infected necrotic pancreas, the kind of the chronic pancreatitis with a problem with the plumbing, the ducts, and we'll exclude those patients that get better from gallstone pancreatitis who ultimately need to get their gallbladder out and just will, we won't worry about them right now, but what are some of the interventions that you need to go, including those patients that develop that pseudocyst that you spoke of earlier?

Prabhleen Chahal:  I can safely say that nowadays in centers where expertise available, if we need to intervene upon fluid collections called pseudocyst or walled off necrosis, endoscopy is superior. Multiple randomized studies have demonstrated that. So what is a pseudocyst? Pseudocyst is just a sterile collection off inflammatory fluid with what we call an inflammatory wall around it. If it becomes really big and starts compressing the stomach or small bowel, if people have nausea, vomiting because of that or if it really gets infected, that's when we drain.

And the drainage often involves a task called endoscopic ultrasound. It's usually done as an outpatient if patient is at home, we bring them in the endoscopy unit. They are under anesthesia and we go down with a flexible camera tube, which has a tiny ultrasound probe attached. The ultrasound allows us to look outside the stomach beyond the stomach and under ultrasound we access the pseudocyst and deploy certain type of stents which are dumbbell shaped. One end of the stent is in the cyst another end of the stent pumps into the stomach or into the small intestine, thereby creating a fistula communication where they drain out.

Similarly, this approach is utilized for an infected necrosis as well. The management for infected necrosis is much more involved and carries higher risk because if it's a significant necrosis, by that I mean if more than one third of the pancreas is destroyed, that leads to a heavy solid dead debris that we have to go in, through these stents, into what we call is the retroperitoneum and debris out with the endoscope. Those patients often time need two or three endoscopy sessions with each can be an hour long and usually the recuperation process for those patients can be a few months.

Scott Steele:  Does everybody that has fluid collections around the pancreas or is recovering from a bout of pancreatitis, do they need to have these interventions?

Prabhleen Chahal:  Excellent question. Answer to that is no. Majority of the pseudocysts, fortunately resolve on their own. By that I mean 60 to 70% of them there resolve on their own. They may form a fluid collection in an acute phase, but when we follow these patients over time, maybe two to three months down the road, the fluid collection gets reabsorbed or resolved. It's very small portion of these patients that we have to intervene on.

Scott Steele:  And then maybe a more controversial point out there. When you have patients that do have these fluid collections, do they need a biopsy? Do we have to be able to sample that fluid to see they're infected or do we avoid biopsying them for fear of seeding that fluid collection and making it infected?

Prabhleen Chahal:  I think this is something that we used to do in past, you know what we call as a CT guided aspiration of the fluid to see patient has infection or not. But then the research has shown one third of them can be false negative. By that I mean if even if they're infected, the fluid collection may not grow or show anything. So we usually rely on multiple symptoms and signs and if the patient has fever, they have elevated, what we call as a white cell count, which tells us there's something like infection going on in the body, we have ruled out other causes like their urine is clean, they don't have pneumonia, their I.V. line site is all clear. We check for everything else and if they have had these fluid collections for awhile and now their course has deteriorated with all these new developments, then this points towards being infection in those collections.

Scott Steele:  It sounds like the interventional way is the way to go. It's a little bit easier on the patients and if they fail then they can go onto more traditional surgical procedures. But how successful are the interventional procedures for these different types of presentations?

Prabhleen Chahal:  I'm glad you asked that question. So we just published. Our study got accepted. We looked at our own data at Cleveland clinic. I and my colleagues, we specialize in these procedures. Our hands, and this is what happens in other high volume centers as well, we are successful about 87 to 88% of the time in successfully managing these fluid collection, including necrotizing pancreatitis.

There are some patients where made need a surgical intervention or what we call as a percutaneous drain, especially the ones where the fluid is now going down or seeping down towards the pelvis. That's an area that is not easily reachable through the stomach or from the small bowel. And those patients, they get drains placed from the outside by interventional radiology. And those drains allow aggressive lavage of that fluid and aspiration and helps with the resolution of fluid.

Then there are some patients who do undergo surgery, but the shift has been more towards what we call is a minimally invasive route. Hardly ever do we see patients getting a big open surgical scar, what we call as a laparotomy. Most of the times they go what we call as a V.A.R.D. Video Assisted Retroperitoneal Debride, where they go through a tiny incision made on the back and they go about and debride the dead tissue out. But more and more it's a less invasive or minimally invasive route.

Scott Steele:  Well that sounds like fantastic stuff and I appreciate you leading the charge here. Like most disease processes, it'd be better if they didn't get it in the first place. Can pancreatitis be prevented?

Prabhleen Chahal:  Yes, to some extent. As we mentioned, the alcohol is the one of the top leading causes. We talked about how four to seven drinks per day can lead to an attack. I would suggest minimizing or eliminating that. If somebody has gallstones and if they are having symptoms from gallstone, pain or abnormal blood tests, what we call as a liver LFTs, I would suggest getting the gallbladder out. Anybody with gallstone, if they're not causing any problem, I'm not recommending gallbladder surgery for them, but if they are causing any trouble. But then again there are certain situations where we don't have control of what we call as a non-modifiable risk factors. For example, somebody with genetic mutation.

If you have a genetic mutations, there are certain mutations that we check for that puts you at a risk for pancreatitis and unfortunately nothing much can be done. There are very few things that are in our control that we can use and modify. Lead healthy diet, watch alcohol, red meat, smoking, those other things that we ask patients to avoid.

Scott Steele:  Anything on the future horizon for either the diagnosis or the management of pancreatitis that we haven't covered already?

Prabhleen Chahal:  No, I think we have... The management, it has evolved. I think within past two to five years we have gone from a surgical route to more endoscopic route and we'll continue to see progression along that realm. As far as the complications from chronic pancreatitis go, I think we are making some strides. For example, endoscopic management of stones. Surgery has been proven to be superior in somebody with stones in the pancreas. But again, with the newer tools and techniques being made available to us, I'm hoping we'll see advances being made in that direction as well.

Scott Steele:  Well, that's fantastic stuff. And as you know from being a prior guest, we like to end up with all of our guests with some quick hitters. So number one, give me one of your least favorite foods, something that you're just saying. I'm not going to eat that.

Prabhleen Chahal:  Scott, I'm not a picky eater. I'm vegetarian, so anything that's not vegetarian is off my plate.

Scott Steele:  What was the first car that you ever had?

Prabhleen Chahal:  It was, I grew up in India. It was a Fiat.

Scott Steele:  In what was the best place that you said you've gone, there may maybe a lot of them, but what does one that jumps to mind that you've traveled to?

Prabhleen Chahal:  Banff.

Scott Steele:  It's a nice area. What's your favorite place to go in Cleveland, if you just want to go out for a night, what would you suggest?

Prabhleen Chahal:  I love going on hikes. My husband and my kids, we go for all the Metroparks around the Cleveland area. We've been to each and every one of them.

Scott Steele:  One of the joys of living in Cleveland. So for more information about pancreatitis, please visit clevelandclinic.org/pancreas. That's P-A-N-C-R-E-A-S. Again, clevelandclinic.org/pancreas. And to schedule an appointment with a Cleveland Clinic specialist call (216) 444-7000. That's (216) 444-7000.
Dr Chahal, thanks so much for joining us on again on Butts and Guts.

Prabhleen Chahal:  Thank you so much, Dr. Steele. My pleasure.

Scott Steele:  That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.