For July 20, 2002 Philip S. Chua Acute Pancreatitis: Bangungot ? What is pancreatitis ?

Pancreatitis is inflammation of the pancreas, which is a gland located behind the stomach. The pancreas mainly produces digestive juices (enzymes and a substance called sodium bicarbonate, and insulin), which, together with bile from the liver and gallbladder, is secreted into the small intestine to aid in the digestion of food. In the Philippines, the acute form of this malady is labeled by many laymen as Bangungot. With the demise of the young, famous and beloved Filipino actor, supposedly from this illness, I would not be surprised if some people now call it Rico Yan Syndrome. How prevalent is acute pancreatitis? In the United States, about 80,000 persons are afflicted each year with acute pancreatitis. I do not know the prevalence in the Philippines. What is bangungot ? The term bangungot is loosely used to describe a severe, agonizing nightmare that many times ends in death. The term bangungot is somehow implicated by the local folks to a condition, where the victim, who had ingested a lot of food (presumably fatty foods, sea foods) and alcoholic beverages immediately before going to bed, never woke up from sleep, which could also be the clinical picture of acute pancreatitis. What are the types of pancreatitis? The types or stages are: acute and chronic. Acute pancreatitis happens suddenly, immediately following self destruction (where the pancreatic enzymes eat

up and destroys the pancreas with its own digestive enzymes). It is postulated that alcohol, a lot of fatty foods, a lot of sea foods, or gallstones may play a role in its etiology. Gallstone may get stuck in the bile duct, resulting in a blockage that causes pancreatic enzyme build up, which destroys (auto-digests) the pancreas. Some persons may be sensitive to alcohol, enough to irritate the pancreas. But why ithappens only to an individual, whose companions ate the same food and drank the same alcoholic the night before, is not known. Medical data show that 80% of acute pancreatitis is associated with excessive alcohol intake and presence of gallstones. The rest are due to viral or bacterial infection, drugs, trauma, surgery in the abdomen, elevated calcium levels or excessively high triglyceride (circulating fats in the blood). The association with cigarette smoking is unclear. The cause and mechanism are still poorly understood. What actually happens to the pancreas? During acute pancreatitis, the pancreas is damaged (digested) by its own enzymes, leading to swelling and hemorrhage of the pancreas, internal bleeding and shock, not infrequently fatal. The others who survive but continue to abuse themselves with alcohol and fatty foods progress to the chronic form of pancreatitis. What are the symptoms? Acute pancreatitis presents with a slow or rapid onset of pains in the central part of the abdomen which radiate to the back. This is usually accompanied by nausea, vomiting, fever, fever, abdominal distention, clammy perspiration, rapid pulse, and shock that may be fatal. If slower in onset, there may be weight loss, jaundice (yellowish discoloration of the skin), rapid heart beat and breathing, and symptoms of diabetes mellitus. Why diabetes? The pancreas has cells in it called islets of Langerhans, which produce

insulin, the hormone that allows and ensures normal carbohydrate metabolism. With acute, or even chronic, pancreatitis, these islets are destroyed and rendered functionless to varying degrees. The inability to produce enough insulin expectedly causes diabetes mellitus, which is a disease caused by lack of insulin (the reason why many diabetics get insulin shots for treatment). Does drinking one or two drinks increase the risk? No, there is no medical evidence among healthy people to show that drinking alcoholic beverage in prudent moderation increases the risk for acute pancreatitis. It is excessive alcohol intake that burns not only the liver and the stomach lining but the pancreas as well. The latter could lead to acute and/or chronic pancreatitis and its potential complications. Can drug cause acute pancreatitis?Yes, drugs can, especially so among drug addicts. Prescribed medications taken as directed and under the physicians supervision are safe. How is the diagnosis made? A thorough history and physical examination are essential. Blood test for pancreatic enzymes, white blood count, blood sugar and diabetic screening, calcium and liver function are done. Stool exam for excess fat, and a stimulation test to check pancreas function. Abdominal X-ray for pancreatic calcification (in chronic stage), CT scans for bile duct problems, stones, inflammation and cysts are also a part of the diagnostic regimen. What is the treatment for pancreatitis? The main regimen includes low fat diet, medications and possibly surgery. For those with acute pancreatitis who are seen by physicians, intravenous fluids are started to prevent malnutrition, dehydration and electrolyte imbalance. A temporary soft plastic tube through the nose may be passed down to drain the stomach and minimize nausea and vomiting. Pain medications are usually used for

the abdominal pains. If the suspected culprit is a gallstone that is obstructing the duct, surgery may have to be done. Today, ERCP (endoscopic retrograde cholangiopancreatography) allows physicians (using a tiny flexible fiberoptic telescope, with light and a magnifier built-in, passed down from the mouth to the small intestine) to inject dye into the ducts and examine the pancreatic duct, common bile duct, and/or the sphincter of Oddi (where the stone could be stuck), and remove the stone to allow normal resumption the flow of bile and pancreatic juices. In severe cases, open abdominal surgery may be needed to drain the pancreatic duct or remove a part of the pancreas. After ERCP or surgery, low fat diet, abstinence from alcohol and cigarette, and possibly oral pancreatic enzyme supplements may be instituted. Regular medical follow-up is strongly recommended. How is pancreatitis prevented? Although the cause is not clearly identified, there are some preventive measures people can take. Low fat diet is a must, especially for those with gallstones and gallbladder. Red meat, eggs, butter, etc. are real killers. Limiting alcoholic beverages to one or two drinks a day reduces the risk tremendously. A healthy lifestyle goes a long way, in more ways than one. How about the prognosis? Those patients who survive the acute phase, and so with those with chronic pancreatitis have a good chance of healing and warding off potential sequelae and complications of pancreatitis by strictly adhering to the regimen outlined above: lowfat diet, no over-eating, no alcohol, no cigarette, taking the prescribed medications religiously, and living an overall healthy lifestyle.