tag:blogger.com,1999:blog-30499448.post3760723047857363306..comments2024-02-18T13:53:30.168-08:00Comments on Surgeonsblog: Pancreas stuff, #3Sid Schwabhttp://www.blogger.com/profile/14182853083503404098noreply@blogger.comBlogger73125tag:blogger.com,1999:blog-30499448.post-79896435022064066982016-08-15T08:07:40.171-07:002016-08-15T08:07:40.171-07:00Wow, what a saga, and what fabulous care he must h...Wow, what a saga, and what fabulous care he must have received! And how great you and he have been since then. <br /><br />I'm sure his surgeon would have much more relevant and particular thoughts than I ever could from this far away. As you suggested, it's possible that additions or changes to his enzyme regime might help; I assume you've been trying to determine if any type of foods are associated with his symptoms, too. Intermittent partial bowel obstruction from adhesions related to his operations is a possibility as well, although I'd expect the pain to be crampy, and usually there'd be abdominal distention during the episodes. Again, I'm sure his surgeon would have better insight into the possibility than I could.<br /><br />My intention for this blog has always been to tell a few good stories, provide general information; to entertain, and to give a look into the life of a surgeon. I can't be very helpful for specific issues people have. I wish I could, but it's really not possible (or, probably, ethical) to try to do so. I wish you well, and, again, share my admiration for the care your husband received and for the way you have adjusted to the new reality.<br /><br />Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-27333239674537604622016-08-14T20:43:54.536-07:002016-08-14T20:43:54.536-07:00Hello Doctor,
I'm so glad I found your blog. ...Hello Doctor,<br /><br />I'm so glad I found your blog. Here is a synopsis of our story: in June of 2015 my husband was admitted to the ICU due to pancreatitis. His kidneys shut down, he was on life support and a coma was induced. Long story short, the condition worsened and his pancreas became necrotic. There were several other complications but he eventually pulled through. He was admitted to the regular hospital ward where, for some unknown reason, they promptly began feeding him regular food - after being in the ICU on life support, ie feeding tube, dialysis, breathing machine - for three months. He then developed an infection and was sent to our university hospital where he was rushed into surgery to remove most, if not all, of his pancreas. Nobody knows how much is gone because the surgeon says it was such a mess in there he couldn't tell. Fast forward to today, less than a year after his release from hospital (September of 2015), he is doing amazingly well. Considering he had to relearn how to walk after being on life support for months, then immediately having to undergo major abdominal surgery. For the most part, he's been taking care of himself. We've always had a very healthy diet, he takes his medications as required, doesn't drink alcohol (which was the likely cause of his pancreatitis), keeps his appointments and requests help when needed. He has, however, resumed smoking. He's mostly adjusting to his new normal quite well but we have a couple of concerns. Of course, he's diabetic, injecting insulin four times a day as well as taking Cotazym ECS 20 with meals. We think he's found the right amount of enzymes to take. This was an issue initially but seems to be sorted. However, it seems that he is on a bit of a cycle whereby he'll be doing really well and then every 6-8 weeks he'll hit a rough spot. He feels pancreatic type pain and encounters bowel issues - diarrhea, urgency, foul and frequent gas. We do not know what to attribute this to. Is it part of the healing process? Is there something he needs to tweak as far as the enzymes go? Could this be due to a complication of the surgery? We're not exactly sure what long-term complications there are, and therefore do not know what symptoms to watch for. For the time being, we are being extra cautious and he goes to the emergency room within a day or two of experiencing these symptoms. They just put him on IV, take blood tests, sometimes an ultrasound and x-ray then send him home. It eventually goes away after a few days. We have an appointment with his surgeon coming up. Are there any questions you can think to ask him based on these symptoms? Any tests we should request or possible complications we should get clarification on and look out for? The care from the surgeon and his team was top notch. They saved his life and were amazing with his care while in hospital recovering, but he was released with very little info about what to expect. We've mostly been winging it and there is not much information out there regarding his specific situation. Any suggestions of insight would be very much appreciated.<br /><br />Thank you.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-19926365328070566922016-05-10T11:57:47.973-07:002016-05-10T11:57:47.973-07:00I'd say the most important thing is to rule ga...I'd say the most important thing is to rule gallstones in or out, since pregnancy can cause them, and they're a frequent cause of pancreatitis. I assume that's been done. If not, it should be. Beyond that, not knowing the severity or details of your episode, I hesitate to make any recommendations. It's one of those things best discussed with your own doctors.Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-90487803916613686472016-05-10T10:50:19.810-07:002016-05-10T10:50:19.810-07:00Hi,
I was diagnosed with acute pancreatitis grade ...Hi,<br />I was diagnosed with acute pancreatitis grade D two months after delivering a baby boy. Doctor said it's post-partum pancreatitis. Main cause is progesterone hormones playing their part during pregnancy. I would like to know if i can plan for second baby? Is pregnancy is advisable?? What precautions should be taken? thanks doc Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-65536606981775058682015-10-13T02:30:12.049-07:002015-10-13T02:30:12.049-07:00Thanks for replying so promptly. I understand you ...Thanks for replying so promptly. I understand you can't give specific advice but what you've said is helpful. Thanks again.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-4534972478396380382015-10-12T15:54:01.688-07:002015-10-12T15:54:01.688-07:00Much as I'd like to help, I really don't f...Much as I'd like to help, I really don't feel right in making specific recommendations for people whose situation I can never know as well as those in direct contact. I'll acknowledge it's a difficult situation, and that there are several surgical options, including one or two you haven't mentioned. When that's the case, it's best, if possible, to connect with a surgeon who has lots of experience in the area. Often that means going to a "tertiary care" institution, meaning one that receives lots of referrals from other places. University hospitals, for example. <br /><br />In my experience, duodenal switch and gastric bypass are primarily used as weight-loss procedures. To treat esophageal reflux might require an anti-reflux procedure in addition to whatever diversion is chosen to address bile gastritis. Deciding which operation or combination of operations, as I said, requires knowing your situation in detail, and the input of a surgeon experienced in such situations. Nowadays there are some surgeons who've done extra training in "biliary-pancreatic surgery." You might want to seek out such a person.Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-76654985448201102162015-10-12T14:33:40.941-07:002015-10-12T14:33:40.941-07:00Hi,
I recently had a laposcopic cholecystectomy s...Hi,<br /><br />I recently had a laposcopic cholecystectomy some months ago. Pre-existing chronic pancreatitis with exocrine failure/steatorrhea and chronic pain, plus lots of small gallstones which formed after development of CP.<br /><br />Immediately after the lap whole operation, I developed severe constant reflux and stomach/throat pain, and have been diagnosed with bile reflux and bile gastritis and also bile acid diarrhea. Currently taking PPI, gaviscon, bile acid sequestrant to seemingly minimal effect for this.<br /><br />The only operations I have found that appear to offer hope is the duodenal switch (suprapapillary duodenojejunostomy), which as far as I can tell is performed rarely in a few places globally and the roux-en-y gastric bypass, which appears more radical in some ways but performed more generally although possibly not as effective. Given I already have maldigestion/malabsorption due to CP steatorrhea, further exacerbated by bile acid diarrhea, are these operations viable for me as presumably that will worsen ? Any thoughts or suggestions would be gratefully received.<br /><br />ThanksAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-5380807125707333272015-08-11T10:34:55.256-07:002015-08-11T10:34:55.256-07:00Thanks for your response, Dr. Schwab.
Yup, had sp...Thanks for your response, Dr. Schwab.<br /><br />Yup, had sphincterotomy with all 3 ERCPs and temporary stent placement. Symptoms improved for a while after each then came back and when they went back in, the duct had narrowed again. I do have a skilled GI at a major tertiary center but it never hurts to get more info :)<br /><br />By the way, in response to a post about pancreatic enzymes. They have been so helpful, at least for me. I did learn that sometimes scans (HIDA, MRCP) do not catch the problem. Prior to my 1st ERCP, all my imaging studies were normal but GI went in and found the divisum and the almost closed pancreatic duct. <br /><br />Thanks again! Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-16525969504310986192015-08-10T17:28:25.689-07:002015-08-10T17:28:25.689-07:00So much of treatment planning depends on the speci...So much of treatment planning depends on the specific anatomy of your ducts that I can't say anything very specific. Surgical sphincterotomy is one option, depending on the anatomy, and is likely to be more durable than endoscopic papillotomy. In addition to resection of pancreas (of varying amount), there are also drainage procedures, as I described in the posts, such as the Peustow operation, if there's suitable ductal dilatation. <br /><br />Not many surgeons in community settings have a boatload of experience in such things; if you want a more comprehensive and expert opinion I'd suggest that, assuming you haven't already, you arrange consultation at a tertiary care center. Depending on where you are, that could be a university hospital or a specialty referral clinic, of which Mayo is a well-known example, but far from the only one.Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-31624238611281792092015-08-10T16:39:51.537-07:002015-08-10T16:39:51.537-07:00Hi! Always glad to find docs who appreciate the se...Hi! Always glad to find docs who appreciate the seriousness of pancreatitis. I am in the ER often for pain and nausea control and once in a while, I come across that one doctor who insists "it's not that painful" or "if you are THAT miserable, you should be crying/taking pain meds regularly". <br /><br />I have recurrent pancreatitis secondary to type 1 sphincter of oddi and symptomatic pancreas divisum. Had a chole (made things worse) and 3 ERCPS (manometry pressure is 6times higher than normal) so far but after a few months, there is stenosis of the duct. <br /><br />Partial removal of the pancreas has been suggested for sometime in the future. A 4th ERCP is on hold because the subsequent acute pancreatitis attacks get worse with each procedure. <br /><br />Have you dealt with a similar case? I am always looking for ideas to share with my docs as we wait to move forward. Thanks again for your article.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-12888419922153599772015-07-27T07:48:27.958-07:002015-07-27T07:48:27.958-07:00I still try to answer questions and respond to com...I still try to answer questions and respond to comments.Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-55550577537552669472015-07-27T01:12:04.684-07:002015-07-27T01:12:04.684-07:00Hi DR Schwab
Are you still available for question...Hi DR Schwab <br />Are you still available for questions/answers regarding chronic pancreatitusAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-41540288876060913802014-08-04T18:00:23.965-07:002014-08-04T18:00:23.965-07:00I think the surgeon's opinion about your optio...I think the surgeon's opinion about your options will be more useful than that of the non-surgeons. Having had previous surgery can make it more difficult but won't likely exclude the possibility. Similarly, whether you're a candidate for Peustow or not depends on the anatomy of the pancreatic duct. <br /><br />You're as aware as I am that chronic pancreatitis is a pretty bad hand to have been dealt. I had good results with Peustow, but I never had a patient who'd begun with annular pancreas. Nor have a done a total pancreatectomy for the disease; but I know it's a reasonable option in the right circumstances. I'm old enough that islet cell infusion was in its infancy when I was in active practice. I think it represents a significant advancement.<br /><br />I'm late in answering your questions, and for that I apologize. I assume they've been dealt with much better than I did; I'd love to know what you learned and what you've decided.<br />Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-87151700468076101192014-08-03T15:50:32.382-07:002014-08-03T15:50:32.382-07:00gI was born with an annular pancreas that caused a...gI was born with an annular pancreas that caused a complete obstruction of my duodenum. I had surgery at 5 days old to remove the obstruction. In my early 20's, I begin to have bouts of pancreatitis. I am now 44 and have been diagnosed with chronic pancreatitis. This year alone I have had 5 er visits and 1 hospitalization. I was seen at the Mayo clinic in Rochester, Mn in 2012. They did not have a lot to offer me. Said I was not a good candidate for surgery because of previous surgery. I was just seen last week at the Mayo in Jacksonville and they are saying I need surgery. Either puestow procedure or total pancreatectomy with islet cell transplantation. I meet with the surgeon tomorrow to hear his recommendations. My GI doctor doesn't think the puestow will be an option as he feels there is only a small amount of pancreas left and not enough to be able to attach to anything. I do not feel as though I will be on board with the pancreatectomy and islet cell transplant. Everything I've read says that this is not for me. Removing the pancreas seems like a drastic measure. Even though I have suffered with pain quite a bit, and my life has been altered in many ways, I just think this surgery would be even worse. Any advice or experience with people who have had this done and if they have any regrets?Anonymoushttps://www.blogger.com/profile/08154066866979295128noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-84614036576755868262013-12-12T12:59:38.171-08:002013-12-12T12:59:38.171-08:00No hunches. I don't like to get into the diagn...No hunches. I don't like to get into the diagnosis business online. But I'll say that in my experience, and knowledge such as it is, the sort of stones that cause pancreatitis and pass are those formed in the gallbladder, passing into the bile duct. Calcifications can occur in the pancreas, but as far as I know they stay there.<br />Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-24367444526931381142013-12-12T12:43:49.954-08:002013-12-12T12:43:49.954-08:00One October, out of the blue, i developed severe c...One October, out of the blue, i developed severe chest pains. as an active mid 30's guy in good health i was freaked out by what seemed like a heart attack so I went to the ER. After a lot of head scratching, the diagnosis was pericarditis. i was prescribed steroids and took them for a couple of weeks and everything turned out fine. weird. so then two years later to the day i go back in to the ER with pancreatitis. several dr's, lots of blood work, a bunch of images later and i get the idiopathic diagnosis. I was told to go home, eat light and don't drink. so that's what i did with only tiny excursions (one beer here or there). all was good for two years and then wham. October comes around and i'm back in the er with pancreatitis again. <br /><br />my dr thinks my pancreas just makes stones, they clog the duct, the enzymes back up, i go into acute pancreatitis, the stone passes and i'm back to normal.<br /><br />my wife thinks i have lymes disease since i spend loads of time in the woods building mt bike trails. i dunno what's going on but this thing about every two years having a nasty "itis" is a drag. do you have any hunches? autoimmune maybe?Stephennoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-22911812070656625482013-12-12T12:30:44.302-08:002013-12-12T12:30:44.302-08:00from what i've gathered, the notion is that wh...from what i've gathered, the notion is that when your food has been digested, the signal goes back to your pancreas to say "turn off". Fats digest more slowly so they prolong the duration of pancreatic activity. if enzymes are supplemented then the digestion process should go a little faster and the pancreas get's "all clear" a little sooner than w/o the enzymes.Stephennoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-8011303648664982422013-11-13T08:33:24.777-08:002013-11-13T08:33:24.777-08:00Excellent question, Stephen, forcing me back to my...Excellent question, Stephen, forcing me back to my med school days to dredge it up. Fact is there are all sorts of feedback mechanisms in all sorts of places in the body; the gut and the pancreas participate actively. <br /><br />When food hits the gut, and, for that matter, the stomach, there are several hormones, notably CCK, which is the one used to test gallbladder function in a HIDA scan, a long with a few others. They stimulate pancreatic secretion, and gallbladder contraction.<br /><br />I don't know that it's "harder" on the pancreas to secrete fat-digesting enzymes than the ones for proteins; again, if your doc knows something I don't I'd not find it astounding. <br /><br />Here are a couple of links, which I'm too lazy to HTML-ify for you: <br /><br />http://www.ncbi.nlm.nih.gov/pubmed/2644146<br /><br />http://www.ncbi.nlm.nih.gov/pubmed/3953805<br /><br />http://en.wikipedia.org/wiki/Cholecystokinin Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-51447935375099483402013-11-13T08:04:13.718-08:002013-11-13T08:04:13.718-08:00So how does a pancreas "know" what's...So how does a pancreas "know" what's entering the gut? I've been told to avoid fat since that's hard on the pancreas (i.e., requires more enzymes to digest). Is there some mechanism through which the constituents of the chyme prompt a specific response from the pancreas or does the pancreas simply get turned off and on whenever the stomach empties regardless of what I've swallowed?Stephen Chttps://www.blogger.com/profile/09695115151434611819noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-35939558885776024842013-11-11T13:30:31.109-08:002013-11-11T13:30:31.109-08:00Doubt it. There are such feedback mechanisms, for ...Doubt it. There are such feedback mechanisms, for hormones, such as thyroid hormone, sex hormones, etc; but I'm unaware of such a feedback loop for pancreatic enzymes. There is, of course, for insulin from the pancreas. But entirely another kettle of fish. <br /><br />If your doctor knows something I don't, it wouldn't be the first time it's happened.Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-5227183147002935822013-11-11T13:23:00.823-08:002013-11-11T13:23:00.823-08:00thanks for the quick reply. my gall bladder has b...thanks for the quick reply. my gall bladder has been looked at a few times with ultrasound and nothing remarkable has ever been observed. It seems that the more time passes, the more my doctor feels like an idiopathic diagnosis is appropriate. <br /><br />I've done loads of web searches for information about use of Creon to "rest" the pancreas but I've come up empty handed. I just wonder if the pancreas receives feedback from the digestive system as would be provided by the presence of Creon. If not then it would respond the same to food regardless of the presence/absence of the creon (which happens to be very costly). Do you know if such feedback would be reasonably expected?Stephennoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-28365139924767947232013-11-11T12:13:39.782-08:002013-11-11T12:13:39.782-08:00I've not heard of using pancreatic enzymes to ...I've not heard of using pancreatic enzymes to "rest" the pancreas, which is not to say it isn't done or isn't rational. Just that I'm only aware if them being used for people who don't produce enough of them on their own.<br /><br />It's not rare that people with CP have flareups with no evident cause. I assume your gallbladder, if still present, has been evaluated for stones...Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-10053885433272680272013-11-11T11:57:30.890-08:002013-11-11T11:57:30.890-08:00Two years ago I developed sudden intense abdominal...Two years ago I developed sudden intense abdominal paind, went to the ER and was diagnosed with acute-on-chronic pacreatitis. So I quit drinking, reduced fat consumption, felt fine after a couple months. Dr said I could ease back into a normal diet so I did and felt totally fine for 2 years. This September I went to an amusement park with the kids, ate a fatty sandwich a buttery soft pretzel and went on some rides. That night I fell into sudden pain, vomited and ended up in the ER with another attack. My doctor says he doesn't know what triggered either attack. I think fatty sandwiches have something to do with it. Now he has me on Creon "to rest my pancreas". Does that sound like a reasonable prescription? Also, is it "normal" for a person with CP to have an occasional attack despite attempts to control fat intake (currently aiming for about 50g of fat per day).Stephennoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-56013545799907364012013-10-08T19:40:38.174-07:002013-10-08T19:40:38.174-07:00I'm sorry, I'm well aware of but have no p...I'm sorry, I'm well aware of but have no personal experience with total pancreatectomy for CP. I've done subtotal pancreatectomy, and drainage procedures (pancreaticojejunostomy) but not total. I'd have to look up the answers to your questions the same way you would, as to life expectancy, and how it's altered by islet cell transplant. <br /><br />I hope you can find satisfactory answers. It's a very difficult situation, as you well know.Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-18206504502468797472013-10-08T13:55:29.466-07:002013-10-08T13:55:29.466-07:00Hi, What is the life expectancy for someone who ha...Hi, What is the life expectancy for someone who has a total pancreatectomy for CP ? The figures I've read all seem to relate to TP for PC rather than CP which I guess would reduce it ? What are you thoughts on TP with auto islet transplantation ?<br />ThanksAnonymousnoreply@blogger.com