24th June 2001
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Pancreatic reverse action

Ask a question from Dr. Maiya Gunasekera, MBBS (Cey), M.S., FRCS (Eng), FRCS (Ed), Consultant Surgeon. If you wish to consult him on your personal health through this page, write in, c/o The Sunday Times, P O Box 1136, Colombo
By Chris Fernando
Q: My father was recently admitted to hospital with abdominal pain. The doctors informed us that they suspected acute pancreatitis. We were on pins since the doctors told us that acute pancreatitis could be very life threatening. But apparently, he had had a mild attack of pancreatitis from which he recovered completely. 

Could you tell me why these doctors were so overwhelmingly concerned about this disease?

Dr. Maiya, the Consultant Resident Sugeon at the Nawaloka Hospital practising general surgery and gastro-enterology says: 

Acute pancreatitis is a discreet episode of inflammation resulting from intra-pancreatic activation of digestive enzymes and is a disease with a wide spectrum of severity, complications and outcomes. 

The pancreas is responsible for producing enzymes, which digest the food we eat such as proteins, fat and carbohydrates, together with the help of bile salts and bile that are produced in the liver.

This digestion takes place in the small intestine. The enzymes that the pancreas pours into the small bowel, breaks down the bigger components of fat, protein and carbohydrates into absorbable small units.

But however, what you must understand is that these digestive enzymes which are produced in the pancreas, are stored in the pancreas in an inactive form until the need arises, i.e. when food reaches the small bowel. 

Then these enzymes get activated and are poured into the small bowel through its duct as shown in the diagram.

This function of producing digestive enzymes is known medically as the exocrine function of the pancreas. It is noteworthy at this stage to be also mindful of the fact that the pancreas also produces the all-important insulin, which is sent directly to the bloodstream to regulate the blood level of glucose.

In a patient suffering from pancreatitis, these enzymes get activated inside the pancreas and start eating away into and around the pancreatic tissue. 

These activated enzymes are capable of digesting and destroying the surrounding tissue which consists of blood vessels, elastic connective tissues, fatty tissue and this causes a lot of swelling and bleeding in and around the pancreas. These enzymes will do the same digestive process to the surrounding tissues and break them down completely.

It is of utmost importance for you to have an idea of the location of the pancreas inside the abdomen.

The pancreas is positioned behind the stomach in the rectro peritoneal space adjacent to the aorta, the main blood vessel of the abdomen and its head is surrounded by the first part of the small bowel. (See diagram),

The rectro peritoneal location of the pancreas and the absence of a well-developed pancreatic capsule allow the inflammatory process to spread freely.

Activated pancreatic enzymes disperse through the tissue plane and can affect any organ. The surrounding organs that are commonly affected will be the common bile duct, which passes through the pancreas (see diagram), on its way out into the duodenum and the beginning of the small bowel. The large veins, the diaphragm, the large bowel and the fatty tissue, which surround these organs, too get involved in this digestion.

So in a severe attack, the vessels can bleed and the patient can go into shock with severe abdominal pain and a distended bloated abdomen. Therefore, a patient can very often present a surgical emergency when in shock.

In a milder attack where the inflammation is mild and confined to the pancreas, the patient may have mild to moderate abdominal pain and the disease may abate by itself. 

Probably, this is what your father had. However, the doctors were quite right in advising you as they did because acute pancreatitis can lead to a wide spectrum of severity and complications, the worst of which is haemmorrhagic and nectrotizing (destructive) pancreatitis, which would give rise to extensive necrosis of the pancreas and surrounding tissues. Also, in addition to the local destructive effect, the active substances from the destructive process gets absorbed into the blood stream and has destructive effects on distal organs such as the liver, the lungs and the heart, causing near total organ failure.

So when a patient is diagnosed as having acute pancreatitis by routine laboratory tests, it is not something that one must sit on. 

Treatment must be instituted immediately and lab tests, haemotological and biochemical, done repeatedly to monitor the course of the disease.

I will not detail methods of treatment, but it is worth noting that investigations such as X-rays, ultra sound, CT Scans and MRI are invaluable for diagnosis and also to monitor the progress of the disease and detect complications such as abscess formations, which need surgical attention

The two most common aetiological factors associated with pancreatitis are alcoholism and biliary tract disease (gallstones). These two factors account for 75 -80% of all cases. There are many other causes such as viral infections, etc. But the significance in gallstone pancreatitis is that if the pancreatitis occurs as a result of a gall stone blocking the common channel from which bile and pancreatic juice pours into the small intestines, relief can be brought on by endoscopic removal of gallstones which are stuck in the common bile duct and its outlet. 

Prostate gland: a large issue

Almost every other male over the age of sixty years suffers from enlargement of the Prostate gland, a small structure in the urinary system that is more of a nuisance than of value. When the enlargement is more pronounced, it gives rise to troublesome symptoms associated with difficulty in passing urine, which sometimes needs surgery to correct. Here then are the facts regarding this troublesome gland: 
What is the prostate gland? 
The prostate gland is about the size of a walnut and sits at the base of the bladder around the tube (urethra) that urine passes through. It makes liquid to keep the urethra moist and healthy and adds to the fluid that carries sperm on ejaculation. How are men affected? The prostate starts to enlarge in all men once they reach their 40s. As it gets bigger it prevents the normal flow of urine, like a kink in a hose pipe. Some men suffer severe symptoms whilst others suffer only minor symptoms or nothing at all. It's estimated that one in four men in their 50s and one in two men over 60 years of age will be troubled to some degree by this enlargement of the prostate gland which is called Benign Prostatic Hyperplasia (BPH). 
What are the symptoms? 
Difficulty in passing urine; a weak stream; repeatedly having to get up at night to pass urine; feeling the bladder isn't empty and needing to go again almost immediately; having to pass urine more and more frequently; and dribbling after passing urine are the commonest symptoms that patients present with. Often they also find they have to run to the toilet urgently, sometimes not making it in time. It may be just an inconvenience for some but for others it can cause extreme discomfort and the anxiety can dominate their daily activities. 
What treatments are there?
Before treatment is undertaken, several tests may need to be performed to assess the nature and degree of enlargement of the gland. The tests a patient will undergo will depend on what his doctor thinks is appropriate. These tests include a rectal examination, a urine test for possible infection, blood tests for the Prostate Specific Antigen (PSA), kidney function tests and an ultra-sound of the prostate gland. In some cases, a biopsy of the prostate gland may be necessary. Troublesome symptoms can be treated with medicines or surgery, which reduces the size of the prostate gland and improves the flow of urine. Earlier it was common to perform open surgery but now surgery done through the urethra- the tube through which urine emerges- is becoming popular. This method, called the Trans-Urethral Resection of Prostate (TURP) is practised widely now and is performed in Sri Lanka too.

Medical diary:

*Sir Nicholas Attygalle oration- 'Definition of the stomach and the oesophagus' by Professor Parakrama Chandrasoma, MD, MRCP, FACP and Professor of Pathology, Keck School of Medicine, University of Southern California, USA on Sunday June 24 (today) at the Lionel Memorial Auditorium, Sri Lanka Medical Association, Wijerama Mawatha, Colombo 7 at 7.00 p.m.

*Law-Medical Sports day- on Sunday, July 22 at the Health Department Sports Club, Castle Street, Colombo 8. Sports include cricket, tennis, table tennis, netball and billiards.

*Jaffna Medical Association Annual Scientific Sessions- from August 9 to 12, at the NTS lecture Hall, Jaffna. Travel, accommodation and meals arranged by the Association. Participants should contact the Sri Lanka Medical Association for details.

Secrets of a good night's sleep 

Insomnia-or the lack of proper sleep- is one of the commonest complaints encountered by doctors. It can be a complaint in its own right or a symptom of another illness. If it is caused by any other condition, that needs to be addressed but either way, simple measures can go a long way in restoring a healthy sleeping pattern:

1. Stick to a regular routine. Go to bed at the same time (or as close as possible) and get out of bed at the same time. Make the sleep period as long as you think you need. Don't try to skimp on sleep at night. 

Conversely, if you sleep for too long you can experience very disturbed sleep and dreams. The amount of sleep we need depends on age and other individual factors, but it is usually between six and nine hours. Prepare yourself for sleep each night with a regular relaxing routine. 

2. Make sure you relax and wind down in the evening. If your day is stressful, try techniques such as yoga, meditation or massage to deal with the stress. 

3. Avoid late night stimulants. Coffee, tea, hot chocolate and alcohol can all disrupt normal sleep as they contain chemicals which stimulate the brain or upset its normal activities. Try milk instead. 

4. Avoid large amounts of food late at night. However, a light snack about an hour before bed may help to induce sleep. 

Wholemeal bread could be ideal - whole wheat is said to encourage the production of an important sleep chemical in the brain called serotonin. 

5. Make sure you have done some exercise during the day - ideally during the afternoon. 

Avoid exercise late at night as it can stimulate both body and mind. However, a short walk in the cool evening air can help. 

6. Make sure your bedroom is the perfect environment for sleep, comfortable and not too hot or cold, noisy, smoky, or poorly ventilated. An uncomfortable bed is also a common reason of continuing insomnia.

7. Keep the TV out of the bedroom- watching television keeps your mind alert and retards the onset of sleep. Bedrooms should be reserved for sleep and sex - another good sleep-inducing activity. 

8. Try to avoid sedatives. They might help in the short term during very stressful times but induce an abnormal type and pattern of sleep, and can cause daytime drowsiness and naps. And, worse still, They cause addiction if used for long periods. 

9. Daytime naps are the subject of great debate. Some believe that a short snooze can help some people feel better during the day, but a big nap can disrupt your daily sleep pattern. 

10. Finally, if it's some other condition that is keeping you awake- a painful joint, difficulty in breathing or backache, for example- that needs to be attended to by your doctor. 

Physician heal thyself

Doctors must realize that they no longer command respect from the public automatically, nor are they immune from criticism and that respect must be earned through their work 

The medical profession has been pressured recently with increasing public complaints about alleged callousness or negligence and calls for remedial measures to be introduced at undergraduate level and even some suggestions for changes in selection criteria for medical students. Prof. M. T. M. Jiffry, Dean of the Sri Jayewardenepura medical faculty, offers his perspective:

Today, the 'Letters to the Editor' columns of newspapers are flooded with complaints against doctors almost every day. 

This cannot be without reason and those in the profession need to turn the searchlight inwards.

On a closer perusal, it appears that most complaints are against rudeness, not attending to patients promptly, spending too little time with them (especially in the private sector) and the prescription of high-priced drugs. A common thread that runs through these complaints is that the doctor-patient relationship has been more like a commercial transaction rather than a caring partnership.

There are always two sides to this story. For every complaint that we see in the newspapers there are hundreds of doctors doing their duty diligently, day and night, every day and we rarely find 'thank you' notes for them in the newspapers. Nevertheless, the frequency of complaints against doctors - mostly in the private sector - suggests that doctors must learn to deal with their patients in a more humane manner.

Those of us involved in training future doctors do realize that some doctors at least need to be trained in the gentle art of communication. 

This is an aspect that is being incorporated into medical curricula now for it is a precious tool: an underpaid, overworked doctor working with minimal facilities has to develop public relations skills or else all his good work will be undone by the one harsh word he utters!

The state too can do much to help: it can offer a better wage for doctors to deflect the lure of private practice, it can institute a proper referral system so that specialists are not flooded with trivial complaints and may be even introduce an insurance scheme to make distribution of healthcare more equitable. 

But until such measures evolve, doctors need to tread warily, being mindful of their duties and responsibilities- as much as their rights and privileges. 

Of course, being still considered an elite section of society doctors, will always have their detractors. We at the Sri Jayewardenepura Medical Faculty had our share of allegations to endure when we earned a grant for Rs. 500 million worth of equipment from the Japan International Co-operation Agency (JICA) but the university and its officials were vindicated when a Sri Lanka Police Special Branch investigation concluded after an exhaustive investigation that there was no fraud. 

Likewise, doctors must realize that they no longer command respect from the public automatically, nor are they immune from slander and that respect must be earned through their work and proved under intense scrutiny, may be even by legal means. 

That is the challenge facing doctors today and the first step in overcoming this challenge is acknowledging its existence- not demanding special concessions on account of their professional expertise. 

Doctors - the endangered species! 

By Dr. Riley Fernando 
Doctors in our land have now become a kind 
Of endangered species- so hard to find;
In the state hospitals they are never seen at all-
Often they are channelling or on some private call.

But they are only doing what most public servants do-
Never in their seats but appearing busy too.
If for lack of treatment, the patient were to die,
'People die- it can't be helped' is the blunt reply!

Doctors have their training free of any cost
But after they have passed, to their land are lost,
Greener verdant pastures lure them soon away,
Wealth their sole attraction- money rules the sway.

So the Health Department their cadres cannot fill,
Although many doctors are churned out like a mill,
Now in desperation, they are scanning foreign lands,
For kind-hearted doctors with gentle healing hands! 

(excerpted from 'Rhymes of our times').

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