What is Chronic Pancreatitis?

Chronic pancreatitis is an inflammation of the pancreas that may not heal completely or improve. Over time, it is likely to become more severe and can lead to permanent organ damage. Chronic pancreatitis occurs when there is inflammation of the pancreas leading to scarring and stone formation. It may be triggered by a single episode of acute pancreatitis that damages the pancreatic duct, causing the damaged duct to become inflamed, develop scar tissue and slowly lose functionality. The process is insidious in onset and the disease may be recognized only late in its course.

Causes - The most common causes of chronic pancreatitis are:

• sustained alcohol abuse – this is the commonest cause of chronic pancreatitis in the Western countries  
• Tropical pancreatitis is a type of chronic pancreatitis most commonly found in India. Although many patients are non-alcoholic, the disease affects the young generation – 15 – 25 years of age. The disease is characterized by formation of multiple stones in the pancreatic duct causing obstruction to the outflow of the enzymes. This causes pain due to increased pressure, and over a period of time can lead to malabsorption and diabetes. Some Indians are genetically predisposed to developing this disease.
•  repeat episodes of acute pancreatitis may eventually lead to chronic pancreatitis
• congenital disorders of the pancreas – pancreas divisum
• hereditary disorders of the pancreas – cystic fibrosis

Symptoms - Chronic pancreatitis may often remain undetected during its early course, and abdominal pain may be mistaken for that due to peptic ulcer, gall stones or else.  Pain may become more frequent and increase in intensity as the condition worsens. Chronic pancreatitis symptoms include:

• Abdominal pain – continuous or recurrent
• Fatty, oily stools, or diarrhea
• Malnutrition causing weight loss – even though a normal diet is maintained.
• Back pain not getting addressed by regular medicines
• Recent or early onset of diabetes mellitus

Diagnosis – A very high index of suspicion is required to diagnose chronic pancreatitis. Clinical examination is often of limited value and early disease can be missed on most investigations.

• Blood, urine, and stool tests may show malabsorption or diabetes
• Abdominal Ultrasound – can show stones
• CT Scan – can show stones and damage to the gland
• Endoscopic Ultrasound (EUS) – is the most sensitive test for diagnosis, and is of value to diagnose the condition early in its course
• Magnetic resonance cholangio-pancreatography (MRCP) – helps to show the duct morphology and to plan treatment

Treatment - Treatment of chronic pancreatitis revolves around the 3 cardinal symptoms – pain, malnutrition and diabetes. Pain may require hospitalization with IV hydration, painkillers and nutritional support. Malnutrition can be treated by enzyme supplements and diet modification. Diabetes needs to be treated according to standard protocols.

Definitive management of chronic pancreatitis includes treatment (removal) of stones, dilatation of strictures (narrow segments in the duct) and drainage of the pancreatic duct. Therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary method employed to achieve these measures. Pancreatic stones often require prior fragmentation using extra-corporeal shock wave lithotripsy (ESWL) after which they can be removed by ERCP. Special stents can be placed across strictures to dilate them and to achieve pancreatic duct drainage.

Surgery may be required in some advanced stages of this disease, or when superadded cancer is suspected in EUS.

Do’s and Don’t’s for patients with chronic pancreatitis

• If you consume alcohol, stop immediately and permanently
• Avoid fatty foods
• You may remain lean all your life and may not experience significant weight gain; as long as you are healthy and not losing weight, don’t worry
• Your disease is chronic – you require life long treatment and follow up with your doctor. Repeat episodes of pain are not uncommon. Maintaining a dialogue with your physician is the best way to minimize long term problems.

What are pancreatic duct stones?

Pancreatic duct stones usually develop from the salts present in the pancreatic secretions. They may obstruct the outflow of digestive enzymes from the pancreas to the small intestine. They occur in individuals who suffer from chronic pancreatitis. When the stones block the pancreatic duct, which connects the pancreas with the small intestine, the pancreas loses its ability to release digestive enzymes. It leads to inflammation and fibrosis of the gland due to the increased backpressure within the duct. Also, the secretion of hormones that regulate blood sugar levels may be affected. 

 Causes - Pancreatic duct stones often result from chronic pancreatitis associated with tropical pancreatitis, alcohol abuse or hyperparathyroidism.

Symptoms – Stones cause symptoms when they obstruct the outflow of pancreatic juice. The common symptoms are those seen in patients with chronic pancreatitis -

• Abdominal pain that is felt in the upper left side or the middle of the abdomen. The pain may be worse after drinking or eating (especially foods that have a high fat content) or when lying on your back, and may radiate to the back or below the left shoulder blade.
• Nausea / Vomiting
• Malnutrition presenting as weight loss, fatty stools or diarrhea
•  Diabetes mellitus

Diagnosis – In addition to a physical examination your physician may also order one or more of the following tests:

• Blood, urine and / or stool tests
• Abdominal X-ray
• Abdominal Ultrasound
• Endoscopic Ultrasound (EUS)
• CT scan
• MRCP

Treatment - Effective treatment requires that the stones be removed.  Most pancreatic stones can be removed using a combination of ESWL and ERCP. A small percentage of large stones may require surgery. Often, patients with chronic pancreatitis may have a combination of strictures and stones. In such situations, multiple sessions of ERCP may be required to achieve complete clearance of stones and opening up of the strictures.

What is a colonic polyp?

A polyp is a general name for a benign warty growth of the lining of any organ. If the growth arises from the large bowel or colon it is a colonic polyp.

Colonic polyps can be described and divided in various ways:

• Number – single, two or multiple in the colon.
• Size – small (approximately 2mm or so) up to large (5cm or more).
• Site – exactly where in the colon they are, for example in the rectum only or throughout the bowel.
• Shape – most polyps are on a stalk or pedunculated but others are flat called sessile.
• Type – the most important division of colonic polyps is by cell type. This can most accurately be determined by examining the whole polyp or at least part of it under a microscope in the laboratory. This is called histological examination.

What causes polyps? Is this condition dangerous?

There is no single definitive cause for colonic polyps. Research shows the older you get the more likely you are to have colonic polyps.
By the age of 60 about a third of the population, men and women, will have at least one adenomatous polyp. 
Environmental factors in Western civilization, particularly a diet high in red meat, fat and low in fibre, has been suggested as important factors in developing colonic polyps.

During the last few years (a decade or so), the incidence of colonic polyps in the Indian population is on the rise. This can possibly be attributed to the fast-changing lifestyle and diet patterns of urban India.
Obesity and cigarette smoking may also be involved. 
A few rare patients have genetic or inherited tendencies to develop colonic polyps, often at a young age. The most important of this disease is familial adenomatous polyposis (FAP), when hundreds of colonic polyps occur by the age of 20 years.

Over a long time period, probably three years or more, some adenomatous polyps may grow and start to invade the bowel wall and become colonic cancer.
For this reason it is important to identify and remove these polyps to prevent colon cancer developing.
Colonic polyps may produce symptoms without becoming cancer and therefore require removal.

What symptoms do polyps cause?

Most colonic polyps cause no symptoms.
The larger the polyp and nearer to the anus or end of the bowel, the more likely the patient will notice symptoms. By far the most frequent is rectal bleeding or iron deficiency anemia.
Some large flat villous polyps especially in the rectum can cause mucus and diarrhea. Only rarely do colonic polyps cause pain.
Unfortunately this means significant polyps can still be present, especially on the right side of the colon away from the anus, without any symptoms.
Identifying these polyps is important. The only definitive test to detect polyps is a colonoscopy (a telescopic examination of the whole large bowel starting at the rectum). Stool testing for occult (or concealed) bleeding  an indirect pointer towards possibility of colonic polyps. .

What is the treatment for polyps?

Polyps can be removed during colonoscopy whilst the patient is sedated. This is done by passing a wire snare down the colonoscopy, looping and tightening the snare around the stalk of the polyp then passing an electric current through the wire.
This coagulates the blood vessels and then cuts through the stalk. The polyp is then usually sent to the pathology laboratory for microscopic examination.

Flat, sessile or villous polyps can be removed by a newer technique called endoscopic mucosal resection (EMR) or endoscopic sub-mucosal dissection (ESD).
With this technique the flat polyp is lifted off the colonic wall by injection beneath of a special solution. This produces a temporary artificial cushion to enable safe use an electrical snaring, reducing the risk of perforation. The polyp is then peeled off from the colonic wall using electrical current. The injected solution is quickly reabsorbed.

Polypectomy is painless because the colonic nerves are only sensitive to stretching.

Polypectomy is safe but carries a risk of perforation (going through the bowel wall) in about one case in 300.Bleeding occurs in 1 per cent of cases after polypectomy. Bleeding usually stops by itself.  Clearly larger the polyp, greater the risk.

Surgical excision of polyps is rarely required but may be the only safe option in selected cases.

Large rectal polyps can sometimes be removed through the anus under general anaesthetic without the need to cut open the abdomen.

Can polyps recur once removed?

People with adenomatous polyps are likely to grow further polyps. Follow-up however is determined by a number of factors: the size, type and number of polyps; whether polypectomy has been complete; the general health and age of the patient and of course, the patient’s individual wishes.
Routinely repeat colonoscopy will be around three years after the colon has been cleared of significant polyps but may be between one and five years dependent on the factors above.

What are the gallbladder and gallstones?

The gallbladder is a small sac found just under the liver. It stores bile made by the liver. Bile helps you digest fats. Bile moves from the gallbladder to the small intestine through tubes called the cystic duct and common bile duct.
Gallstones are made from cholesterol and other things found in the bile. They can be smaller than a grain of sand or as large as a golf ball.
Most gallstones do not cause problems. But if they block a duct, they need treatment.

What causes gallstones?

Gallstones form when cholesterol and other things found in bile make stones. They can also form if the gallbladder does not empty as it should. People who are overweight or who are trying to lose weight quickly are more likely to get gallstones.

What are the symptoms of gall stones?

Most people who have gallstones need not have symptoms.
But if you have symptoms, there may be:

• Sudden development of mild to severe pain in the center of your stomach or in the upper right part of your belly. Usually occurs after a meal
• Pain may spread to your right upper back or shoulder blade area. Sometimes the pain is more severe. It may be steady, or it may come and go. Or it may get worse when you eat
• Pain with fever and chills

•   Skin or the whites of your eyes may turn yellow. This indicates that a gallstone has slipped into the bile ducts and is causing obstruction to the outflow of bile from the liver

How are gallstones diagnosed?

An ultrasound of the belly is the best test to find gallstones. This test does not hurt.
However at times ultrasound may not show gallstones. So if your doctor still thinks you have a problem with your gallbladder, he or she may order further tests like endoscopic ultrasonography (EUS). EUS is a test wherein a flexible tube is inserted through your mouth into the stomach and intestine. The tube is fitted with a special ultrasonic probe that enables ultrasonography. Since the examination is done from inside, the resolution and diagnostic capability of this test is superior to that of conventional ultrasonography.

How are they treated?

If you do not have symptoms, you probably do not need treatment.
If your first gallstone attack causes mild pain, your doctor may tell you to take pain medicine and wait to see if the pain goes away. You may never have another attack. Waiting to see what happens usually will not cause problems.
If you have a bad attack, or if you have a second attack, you may want to have your gallbladder removed. A second attack means you are more likely to have future attacks.
Many people have their gallbladders removed, and the surgery usually goes well. Doctors most often use laparoscopic surgery. You will probably be able to go back to work or your normal routine in a week or two, but it may take longer for some people.

Do I need my gallbladder?

Your body will work fine without a gallbladder. Bile will flow straight from the liver to the intestine.

What is irritable bowel syndrome (IBS)?

Irritable bowel syndrome (IBS) is a disorder of the intestines. It causes stomach pain, cramping or bloating, and diarrhea or constipation. Irritable bowel syndrome is a long-term problem, but there are precautions you can take reduce symptoms.
Symptoms may be worse or better from day to day, but your IBS will not get worse over time. IBS does not cause more serious diseases, such as inflammatory bowel disease or cancer.

What causes IBS?

It is not clear what causes irritable bowel syndrome, and the cause may be different for different people. 
These may include problems digesting certain foods, and stress or anxiety. People with IBS may have unusually sensitive intestines or problems with the way the muscles of the intestines move.
For some people with IBS, certain foods, stress, hormonal changes, and some antibiotics may trigger pain and other symptoms.

What are the symptoms?

The main symptoms of irritable bowel syndrome are:

• Stomach pain with constipation or diarrhea.
• Bloating, mucus in the stools, or a feeling that you have not completely emptied your bowels
• Going back and forth between having constipation and having diarrhea. For most people, one of these happens more often than the other.

How is IBS treated?

Irritable bowel syndrome is a long-term condition, but there are things that can be done to manage symptoms. Treatment usually includes making changes in diet and lifestyle, such as avoiding foods that trigger symptoms, getting regular exercise, and managing stress.
There are also medicines that may help.  If diet and lifestyle changes do not help enough on their own, your doctor may prescribe medicines for pain, diarrhea, or constipation.

Is Acid reflux disease same as heartburn or GERD?

At the entrance to your stomach is a valve, which is a ring of muscle called the lower esophageal sphincter (LES). Normally, the LES closes as soon as food passes through it. If the LES doesn't close all the way or if it opens too often, acid produced by your stomach can move up into your esophagus. This can cause symptoms such as a burning chest pain called heartburn. If acid reflux symptoms happen more than twice a week, you have acid reflux disease, also known as gastro esophageal reflux disease (GERD).

What Causes Acid Reflux Disease?

Acid reflux or heartburn is a common condition. The common risk factors for acid reflux disease are:

•  Eating large meals or lying down right after a meal
•  Being overweight or obese
• Snacking close to bedtime
• Consuming  certain foods, such as citrus, tomato, chocolate, mint, garlic, onions, or spicy or fatty foods
• Drinking certain beverages, such as alcohol, carbonated drinks, coffee, or tea
• Smoking
• Pregnancy
• Medicines such as aspirin, ibuprofen, certain muscle relaxants, or blood pressure medications
• One another common cause of acid reflux disease is a stomach abnormality called a hiatus hernia. 
  
• This occurs when the upper part of the stomach and LES move above the diaphragm, a muscle that separates your stomach from your chest. Normally, the diaphragm helps keep acid in our stomach. But if you have a hiatal hernia, acid can move up into your esophagus and cause symptoms of acid reflux disease. Hiatus hernia needs a surgery.

What Are the Symptoms of Acid Reflux Disease?

Common symptoms of acid reflux are:

• Heartburn: a burning pain or discomfort that may move from your stomach to your abdomen or chest, or even up into your throat
• Regurgitation: a sour or bitter-tasting acid backing up into your throat or mouth

Other symptoms of acid reflux disease include:

• Bloating
• Bloody or black stools or bloody vomiting
•  Burping
•  Dysphagia -- a narrowing of your esophagus, which creates the sensation of food being stuck in your throat
• Hiccups that don't let up
• Nausea
• Unexplained weight loss
• Wheezing, dry cough, hoarseness, or chronic sore throat

How Is Acid Reflux Disease Diagnosed?

Symptoms such as heartburn are the key to the diagnosis of acid reflux disease, especially if lifestyle changes, antacids, or acid-blocking medications help reduce these symptoms.
If these steps don't help or if you have frequent or severe symptoms, your doctor may order tests to confirm a diagnosis and check for other problems. You may need one or more tests such as barium X ray, endoscopy or a biopsy.

Can Acid Reflux Disease Be Treated With Diet and Lifestyle Changes?

One of the most effective ways to treat acid reflux disease is to avoid the foods and beverages that trigger symptoms. Here are other steps you can take:

• Eat smaller meals more frequently throughout the day.
• Quit smoking.
• Put blocks under the head of your bed to raise it at least 4 inches to 6 inches.
• Don't eat at least 2 to 3 hours before lying down.
• Try sleeping in a chair for daytime naps.
• Don't wear tight clothes or tight belts.
• Take steps to lose weight with exercise and diet changes, if overweight or obese
• Also, ask your doctor whether any medication could be triggering your heartburn or other symptoms of acid reflux disease

Can Acid Reflux Disease Be Treated With Medications?

In many cases, lifestyle changes combined with over-the-counter medications are all you need to control the symptoms of acid reflux disease.
Antacids neutralize the acid from your stomach. But they may cause diarrhea or constipation, especially if you overuse them. 
If antacids don't help, your doctor may suggest more than one type or suggest a combination of medications.

Is Acid Reflux Disease Ever Treated With Surgery?

If medications don't completely resolve your symptoms of acid reflux disease and the symptoms are severely interfering with your life, your doctor could recommend surgery. A surgical procedure called fundoplication can help prevent further acid reflux. It creates an artificial valve using the top of your stomach. The procedure involves wrapping the upper part of the stomach around the LES to strengthen it, prevent acid reflux, and repair a hiatal hernia. Surgeons perform this procedure through either an open incision in the abdomen or chest or with a lighted tube inserted through a tiny incision in the abdomen. This procedure is done only as a last resort for treatment of acid reflux disease.

What is cholecystectomy? Is it a common condition?

Surgical removal of the gallbladder is referred to as a cholecystectomy. This is the most common treatment methodology for gallstones. The procedure can be performed using a laparoscopic (minimally invasive) procedure, robotic, or traditional, open procedure.

Is laparoscopic surgery different from minimally invasive surgery?
Laparoscopic surgery is also known as a minimally-invasive surgery. It is a surgical technique through which several small incisions in the abdomen allow the insertion of surgical instruments and a video camera.

The camera illuminates the surgical field and sends an image to a video monitor, providing the surgeon an enhanced view of the surgical site. The surgeon uses the monitor image to perform surgery by manipulating the surgical instruments through the operating ports.

Laparoscopic surgery may result in fewer complications, reduced blood loss and pain and improved recovery time as compared to the traditional (open) surgical approach.

When is ERCP (Endoscopic Retrograde Cholangio-pancreatography) performed? 

ERCP is an advanced endoscopic technique that combines endoscopy and fluoroscopy to diagnose and treat problems like narrowing or blockages associated with the pancreatic duct system and biliary system.

This procedure is performed by a gastroenterologist with specialized training in ERCP. Using an endoscope (a flexible, fiber-optic scope), the gastroenterologist injects contrast dye into the pancreatic duct or bile ducts in order to highlight the ducts and assist in taking x-rays. 

Endoscopic Sphincterotomy (ERS) can be performed as part of a ERCP procedure, during which instruments are inserted through the endoscope in order to enable the removal of stones, place stents, or expand narrowed biliary or pancreatic ducts.

•  Gallstone Removal - used to remove pancreatic or bile duct stones. A sphincterotomy is sometimes performed at the same time.
• Stent placement – allows for the placement of a device to keep the pancreatic duct or bile duct open.
• Balloon dilatation – allows a narrowed pancreatic duct or bile duct to be opened.

What is a stent?

 A stent is a thin, tube-like structure that is used to open and support a narrowed portion of the pancreatic duct or bile duct, and prevent the reformation of the stricture. Stents may be made of plastic or metal. 
Biliary system stent placement can be performed during endoscopic retrograde cholangio-pancreatography (ERCP).