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Pancreatitis Supporters Newsletter 8

We now have our own Franking Machine!!

Thank you Duphar and especially Mr Bruce Faulkner-Dunkley for your most generous donation of 500 towards the fund for the Franking Machine.

REMINDER:

As usual the comments and replies in this Newsletter are not necessarily the opinion of the Network and ALL medical queries should be referrred to your GP or Consultant before considering any action.

The pancreas

The pancreas is an elongated gland that lies across the upper part of the posterior wall of the abdomen, its head in the loop of the duodenum, its body and tail extending to the left behind the stomach. It consists of two types of cells:

1. The acinar or gland cells, similar to cells in the salivary glands, which secrete the pancreatic juice containing enzymes which act on protein, fat and carbohydrate. These enzymes are activated on meeting the duodenal juices. The main duct of the pancreas usually unites with the bile duct to form what is called the ampulla just before entering the second part of the duodenum. The sphincter of Oddi surrounds the ampulla and prevents reflux of duodenal contents into the pancreatic duct.

2. The islet cells, or islets of Langerhans, which secrete the hormone insulin into the bloodstream. Insulin is especially concerned with glucose metabolism, and deficiency of its action results in diabetes melitus.

Acute pancreatitis

Cause - Acute pancreatitis is usually associated with disease of the biliary tract or gallstones, or with alcoholism. Reflux of duodenal contents into the pancreatic duct activates the enzymes resulting in self-digestion of the pancreas and necrosis of surrounding fat - a very acute inflammatory process.

Symptoms - The condition is commonest in middle-aged men and may be precipitated by a heavy meal or high alcohol intake. There is sudden agonising upper abdominal pain, nausea and vomiting. The abdomen is tender and rigid. There is pallor, rapid pulse and often hypotension and collapse, a picture commonly referred to as shock, here due to lowered blood volume from outpouring of fluid into the intestine.

Differential diagnosis includes perforated peptic ulcer, biliary colic and surgical conditions described above, and sometimes the picture simulates myocardial infarction. The diagnosis of acute pancreatitis is confirmed by a very high serum amylase, one of the enzymes that leaks into the bloodstream; the serum amylase may, however, be slightly raised in other acute abdominal conditions.

Treatment - This should be conservative if the diagnosis is clear. Bed rest is indicated.

Relief of pain - pethidine 100 mg intramuscularly; morphine causes spasm of the sphincter of Oddi and is best avoided.

Nasogastric suction - to remove stagnant gastric and intestinal contents; removal of these secretions also helps by preventing further pancreatic stimulation.

Antisecretory drugs - atropine 0.6 mg or propantheline 15-30 mg intramuscularly are anti-cholingergic drugs which inhibit the effect of vagal stimuli of the pancreas.

Aprotinin (Trasylol) given intravenously antagonises pancreatic enzymes but opinions are divided on its value.

Intravenous fluids - saline, dextrose, plasma or blood are needed for hypovolaemia. Calcium may be required to combat hypocalcaemia from the combination of calcium with breakdown products of fat.

Follow-up - Disease of the biliary tract such as gallstones, and alcoholism should receive attention, to prevent recurrent attacks - relapsing acute pancreatitis; this is associated with deposits of calcium, seen on X-ray, in the pancreas.

Chronic pancreatitis

In chronic pancreatitis there is a destruction of the pancreatic cells with replacement fibrosis and permanent impairment of function.

The cause is often unknown, but alcoholism and dietary deficiencies in underdeveloped countries may be responsible. Many authorities now state that chronic pancreatitis is a rare sequel to acute pancreatitis or biliary tract disease but a gallstone pressing on the pancreatic duct could cause obstruction, and gradual pancreatic fibrosis. Carcinoma of the pancreas may also be associated with chronic pancreatitis and it may be difficult to distinguish the two conditions.

Symptoms and signs - Middle-aged men are mainly affected. There are bouts of upper abdominal pain, persistent and demoralising often precipitated by a heavy meal or alcohol. Pain may be worse lying flat and antacids do not help. There may be slight jaundice, and fever.

Sometimes there is no pain, the condition presenting as pancreatic insufficiency. This has two effects:

1. Malabsorption syndrome from lack of digestive enzymes. There is weight loss and steatorrhea - loose, pale, offensive, fatty stools. Unlike the malabsorption of intestinal cause, anaemia is rare.

2. Diabetes in the late stages, from destruction of the insulin-secreting islet cells. There is polyuria and thirst.

Further investigations - Straight X-ray may show pancreatic calcification.

The serum amylase may be slightly raised.

Stools show a high fat content (normally less than 6 g per 24 hours.)

Glucose tolerance test may show a high diabetic curve instead of the flat curve of intestinal causes of malabsorption, and xylose absorption is normal.

Ultrasonic and radioisotope scans are proving most helpful and cause no discomfort for the patient.

Pancreatic secretion tests - a tube is passed into the duodenum, and the pancreas stimulated with injection of secretin-pancreozymin, or by placing bile salts in the duodenum. The pancreatic juice obtained by aspiration is tested for volume, and bicarbonate and enzyme content. Such tests are difficult in practice.

Treatment - Analgesics may be necessary for pain.

The diet should be low in fat and rich in protein.

Pancreatin and proprietary enzyme preparations may be sprinkled on food or mixed with meals but are not always helpful.

Insulin injections are required for diabetes; its control is not usually difficult.

Prognosis - This is variable - the condition may remain static for years, or the course may be a downhill one and here carcinoma should be suspected.

Fibrocystic disease of the pancreas (mucoviscidosis)

This is a disease of recessive inheritance. The pancreas is one of the secreting glands involved, its ducts being blocked with viscid mucus (mucoviscidosis) followed by fibrosis and cyst formation. An affected baby may have intestinal obstruction from thick meconium filling the intestine. In infancy and childhood, there is steatorrhea. The sweat glands are also affected, excessive salt in the sweat confirming the diagnosis and distinguishing mucoviscidosis from coeliac disease. Bronchial gland involvement causes bronchiectasis and cyst formation, with recurrent lung infections.

The pancreatic steatorrhea is treated with a low-fat high protein diet and enzyme supplements. Lung infections require antibacterial drugs but tend to be recurrent and are a frequent cause of death.

Carcinoma of the pancreas

This occurs in the middle-aged and elderly.

Symptoms and signs - The onset is insidious, and the condition often difficult to diagnose. There may be upper abdominal pain similar to that in chronic pancreatitis, anorexia and weight loss - this is usually the cachexia of malignant disease, but may be partly due to steatorrhea from associated pancreatic insufficiency. Similarly the condition may present as diabetes in middle-age, and despite the control of the diabetes, the patient deteriorates.

Obstructive jaundice may be the first sign in carcinoma of the head of the pancreas. The jaundice is deep with itchy skin, pale stools and dark urine containing bilirubin but no urobilinogen.

Metastases are frequently the first clinical indication - thus, there is ascites from peritoneal deposits, or liver swelling and jaundice. Involvement of the inferior vena cava causes venous obstruction and oedema.

Sometimes recurrent phlebitis is associated with carcinoma of the pancreas.

Further investigation - Barium meal may show distortion of the loop of the duodenum. The ESR may be raised, as in any malignant disease.

Ultrasonic and radioisotope scanning of the pancreas may be helpful.

Treatment - Palliative surgery may relieve the biliary obstruction in carcinoma of the head of the pancreas. It is, however, rarely possible to remove a pancreatic growth, and the risks of autodigestion and fistula formation render operations hazardous.

Treatment is therefore generally conservative, with the proper use of analgesics and opiates to prevent pain and alleviate suffering, and the course is a downhill one, with death in months or weeks.

(Typed by Sub-Editor)

Another medical extract passed on by a member. Sorry, no information available on source of article.

As I am passed on articles and extracts that I think may be of interest to us all I will publish the same in the Newsletter. (Editor)

I would like to take this opportunity of welcoming John as Sub-Editor to the Network Newsletter. He is kindly retyping articles for me of interest to the Newsletter. This will teach him to offer! Seriously John, thank you and your help is most welcome.

(Editor)

REMEMBER:

The purpose of these article are to help us become better informed and are not designed to depress anyone. Anyone who has any concerns over their medical treatment should consult their Consultant or GP.

REPORT ON THE AGM OF THE PANCREATITIS SUPPORTERS NETWORK

Meeting Held 21 April 1995

Time Opened: 7:30pm

Apologies: J E Rodin, C Dewsbery, R M Peters, T Brooks, P & M Bird, M & G Brown

Present: Mr J Armour (Chairman), Mrs E Armour (Secretary), Mr Steve Carse (Treasurer), Ms Diane Nevin

Welcome: Mr J Armour - Chairman welcomed two new members who also agreed to be co-opted for the meeting in order to fulfil the quorum requirements namely, Ms Diane Nevin and Mr Steve Carse. Mr Carse has offered to take over the role of Treasurer and Mrs Elizabeth Armour will now become the Secretary of the Network.

Number of members rejoined: We had 67 members last year and lost some sadly through death. To date 33 of the old membership have rejoined and we have had three new members join bringing up the numbers to 36 at present with April being the membership month.

It was agreed at the meeting that all the membership, including those who had not rejoined to date be given another chance to join the Network. After which they would be removed from the mailing list.

Donation by Duphar: I am pleased to report a donation of 500 by Duphar and their continuing support in the production of the booklets in which the Network will appear. These booklets are hopefully due to be produced in the next two months.

Purchase of Franking Machine: We have managed to gain an excellent deal with Pitney Bowes for the same as has already been outlined in the Newsletter in which this report appears.

Sub Editor: The Chairman welcomed Mr John Duerden as sub editor for the newsletter who has been of great help in producing passages of text which are too long for my scanner to cope with.

Fund-raising: We have had members volunteering to undertake sponsored walks and car boots I will let you know the results of these in the Newsletters as and when these happen.

Mailshots: I have been undertaking mailshots to raise money for the Network and to date have sent out 36 letters from which we have received a good response from two giving a total of 600, this is giving a return of approx. 16.66 per 19p stamp so I think this is a worthwhile process for the Network to persue.

In this area I have formed links with another Charity who are willing to give me access to their database for mail-lists in return for my entering other addresses from their reference books.

Membership: Since the start of the Network in November 1993 to April 1995 we have taken in total 1,772 and have an outstanding balance of 166.29 to carry us forward into the next year for the production of Newsletters. I was asked to point out that as yet the Network makes no contribution to the cost of telephone calls made by myself to the membership.

The Meeting closed at 9:00pm with the Chairman thanking all those who attended.

The X-Pain Machine

At the beginning of this newsletter I mentioned about the TENS machine and would like to take this opportunity of alerting members about the X-Pain device.

We DO NOT have any of these units for loan at present BUT the manufacturers APR Medical will loan this to you to try for the first 10 days, after which you can return the device for a full refund less 10, the cost of repackaging and the pads you have used. in trying the unit.

I have personally purchased one of these units as has another member Geof Brown who appears to gain benefit from the same. Personally I find it works but again this is an individual thing, you need to try before you buy.

In order to bring you news of latest devices I have asked APR Medical to write a piece about their machine and this is heavily edited and attatched at the end of this Newsletter. I will report back in the next Newsletter on how I get on with the X-Pain.

Remember:

Just because we inform you of the TENS and X-Pain machines it does not mean we endorse their use.

An Answer to Pancreatitis Pain?

Written by Wiliam D Broadfoot FISTC, MCIM [Heavily edited by the Editor!]

The author is a Fellow of the Institute of Scientific and Technical Communicators and is also a Chartered Consultant who is working alongside two Bristol based doctors (AJR MacDonald and TW Coates) to help them introduce a new method of pain relief known as Transcutaneous Spinal Electroanalgesia ("TSE" for short). The doctors have been responsible for developing a product which they have called "X-Pain" and which is now available at a Recommended Retail Price of 169 from the manufacturers:

APR Medical of Exmoor House, Exmoor Street, Bedminster, Bristol BS3 1HD (Telephone/fax 0117 953 1441)

[Editor: If you are going to purchase one of these please use the coded order forms or mention the Pancreatic Supporters Network when you order]

The X-Pain machine is fundamentally different to the well established "TENS" machine and indeed has more in common with the surgical technique known as Spinal cord (Dorsal Colum) Stimulation which has been practiced since 1967 to provide sufferers of acute pain with a measure of relief. Over a 28 year period there has been no indications of any possible side effects related to the transmission of electricity to this area.

In a major scientific breakthrough it was discovered that when injury was caused to any part of the body, spinal cord interneurones (nerve cells) exhibit a dramatic behavioural change which is manifest by the production of c-FOS protein.

Once spinal cord interneurones have been triggered by "news" of an injury it would appear that these nerve cells can subsequently remain active for decades - and certainly long after the injured part has healed completely. As a result - and for reasons which remain obscure - spinal cord interneurones continue to send warning messages to the brain which results in millions of people suffering completely unneccessary pain for much of their lives.

Having identified the possible cause of suffering from uneccesary pain, the next challenge obviously was to find a cure. Since electricity was first generated and harnessed for use; its pain releiving properties have been noted and applied. Transcutaneous Electrical Nerve Stimulation (TENS) devices use electrical stimulation to excite AB [Editors note: the B here is the Greek symbol] fibres in the area where pain is experienced. They are arguably the modern equivalent of applying a hot water bottle or ice pack (or healers hands) to the apparent seat of the pain. All these methods have an indirect effect on the mechanism of the spinal cord interneurones. However they have to be applied to the correct place [My italics, Editor], and therefore considerable skill is required by the practitioner. When pain is flet in the elbow, for example, the tender region which requires treatment may well be in the neck. If the patient has two elbows in trouble and a knee as well, several regions require simultaneous treatment [rather like acupuncture: Editor]. the only way to do this was to aim for the spinal cord itself.

The key to success, the two Bristol doctors discovered, was to determine the precise intensity, frequency and pulse width of electrical input to the spinal area which would cause the spinal cord interneurones to become dormant. To achieve this they placed two electrodes at the top and base of the spine. Obviously, electrical energy takes the most direct route and will therefore flow parallel to the spine. To reach the spinal cord with the correct pulses of electrical energy it was neccessary to increase the voltage so that the radial width of each electrical impulse would extend through the five centemetres or so of tissue that lie between the skin and the spinal cord. Most of this voltage is dissipatedby the natural conduction of the body's subcutaneous tissue. The electrical energy which reaches the spinal cord is minute in terms of duration so there is no stimulation of the periferal nerves in the area - in other words, no localised pain.

The doctors then developed a simple portable pulse generator which the patient adjusts until a slight warming sensation is felt. There is no discomfort.

One patient who was treated by doctors using this device suffered recurring spasms of pain for over 40 years since being struck in the stomach by a rifle butt during the Korean War [Geof Brown: Editor] . Now for the first time he can walk, drive and even weed his garden again! [Mayby a bit over the top but certainly Geof walked upright rather than like a bent old man after using this as witnessed by myself: Editor]. Other patients using the X-Pain device have experienced almost immediate relief where the original cause of the injury has long healed or is "on the mend". This iparticularly true of neck and back sufferers who have sufferes an injury to their spine sometime previously. The same is true to people who suffer from painful limbs, stress aches, migraines, headaches, post-operative pains, arthritis, menstrual pains, and "modern living" complaints such as repetitive stress injury and M.E.

The X-Pain method of pain relief is not an anaesthetic. It will not provide relief for patients suffering from any pain generating condition. Equally, it will not hide the symptoms of heart attacks, or angina, or where there is inflammation to any organ brought about by disease. Such pains are on-going and the signals will continue to be sent to the brain regardless of any TSE treatment. People who have a medical condition which requires the use of a Pacemaker or other implanted electrical stimulator whould not use the TSE method - nor should pregnant women, without first seeking medical advice.

The closest sompetitor to the TSE method is the widely practiced method of the TENS machine. TSE offers five distinct advantages when compared to this form of treatment:-

a) TSE provides longer lasting relief from pain (possibly even permenant relief in some cases)

b) The pain relieving benefits do not diminish the more you use the TSE machine.

c) TSE takes less time to use (4 hours per week as opposed to 40 hours) and provides relief from pain much sooner (8-20 minutes as opposed to 40-60 minutes)

d) TSE provides simultaneous relief of pain across the entire body rather than one place.

e) TSE does not require anatomical knowledge to site the electrodes correctly.

In summary, TSE would appear to represent a major advance in pain therapy.

Responses to Joan Hemingway's Letter

Re Joan Hemingway and her Putting-on-Weight Problem

A couple of years ago I had an operation to remove my pancreatic head, gall bladder and duodenum and while in hospital picked up a bug which affected my liver, and consequently stayed there for some seven months while the problem was dealt with.

I lost weight - boy did I ever lose weight: I went from 70 kilos down to 44, and the doctors were quite concerned. What they (or rather, a redoubtable senior registrar at King's College called Howard Bradpiece) did was to get me to eat everything slimmers are supposed to avoid: full cream milk, cheese, potatoes, streaky bacon, white bread and so on. However, being rather unwell I had a very poor appetite, so eventually they decided to insert a tube into my stomach, through my nose (actually not as unpleasant as it sounds), and overnight, every night while I slept, I was drip-fed a litre of a confection called Fresubin 750 which is a highly concentrated 'complete' liquid food.

The tube was plugged up during the day, normal meals were taken at normal meal times, and supplemented overnight by the Fresubin. Fresubin (which comes in various strengths) can also be drunk; it is available in various flavours, however the advantages of having it dripped into you while you are asleep should be self-evident. The only disadvantage I experienced with the nose tube was that it sent the neighbour's dog into hysterics.

Nestles produce something called build-up which the doctors tried on me, but that gave me the runs.

Joan could start each day with a pint of Channel Islands milk and a banana which one chap I know swears by as a cocktail for increasing weight.

Whatever she goes for, her GP should be able to refer her in the first instance to a dietician, and I hope Joan will, through the newsletter, let us know how she gets on.

With regard to the fatigue, Pancreatitis really exhausts the whole system, doesn't it?

The news that Joan's pancreas has healed is very good indeed however she is now in convalescence and if my experience is anything to go by, it will be many months before she gets all her strength back. However she will get it back eventually.

Best wishes

John Duerden

"I too have bouts of extreme tiredness which suddenly occur. I am now thinking it is part of the stress symptoms - does she lead a busy, action packed life like I did? I am know seeking psychiactric help to help me to slow down. It is very difficlut to get a diagnosis as to the cause of bouts of tiredness. I have been mentioning it to my doctor for a number of years, but even when I started collapsing, the connection wasn't made. Tell her to persevere. Sooner or later, the jigsaw bits fit together!

All for now,

Karen Abbott.

(I think it is very brave of Karen to mention seeking for psychiactric help as there is such stigma even today to this type of medical help. I can personally vouch for the psycho-therapy that I went though and I am sure other members have as well. Editor.)