Are we headed for a silent Pancreatitis epidemic?

Figure: MRI images of dilated pancreatic duct that is a sign of pancreatitis (R) and Contrast CT Scan images of acute necrotizing pancreatitis (L)

In Bangladesh, where general people are still not oriented towards healthy living and a pro-active lifestyle, environmental and dietary pollution play an immersive role in causing some chronic diseases. And pancreatitis is gradually becoming a notorious name in this list of doom.

We are concerned about the major two groups of patients we find in our day-to-day practice - those suffering from acute pancreatitis and chronic pancreatitis. There are several sub-types in relation to severity and urgency of this disease such as recurrent acute pancreatitis, acute necrotising pancreatitis etc. 

To be brief, when the pancreas, an immensely important and sensitive organ of our body, gets an inflammation in its parenchyma (functional tissues), we term it as pancreatitis. But the scenario is much graver than depicted in the definition. 

The fatality is gravest in comparison to any other chronic illness of the human body. And if we run down the history, its rate and proclivity is rising in an aggressive fashion.

Acute pancreatitis may be majorly of two variants, (i) interstitial oedematous pancreatitis (mild) and (ii) necrotising pancreatitis (the severe form). However, the Atlanta classification of acute pancreatitis (1992) recommends that patients with acute pancreatitis be stratified into three groups: (a) mild acute pancreatitis (no organ failure, no local or systemic complications), (b) moderately severe acute pancreatitis (organ failure that resolves within 48 hours or transient organ failure, local or systemic complications without persistent organ failure) and (c) severe acute pancreatitis (persistent organ failure for more than 48 hours). 

We, the surgeons, traditionally and effectively, use the Ranson and Glasgow scoring system to assess the severity of acute pancreatitis.

Among the chronic spectrum, there is another name 'tropical chronic pancreatitis' that is predominantly diagnosed in poor-socioeconomic groups where the patients are usually young male ones (less than 40 years). 

Devouring a root vegetable named cassava (tapioca) in large quantities may be responsible for these familial based pancreatitis (cyanogen toxicity). Lack of amino acid (proteins) in diet is a prominent cause behind this grave illness.

According to two renowned overseas specialists, Dr Graeme J Poston from England and Dr Leslie H Blumgart from the US, approximately 20% to 25% of patients developing acute pancreatitis have a severe form of respiratory illness, renal compromise, cardiac insufficiency, coagulation disorder and neurological illness. Mortality rate is an alarming 15% to 40% in such cases.

Bangladesh has also been a fertile land for this notorious disease and the prevalence has reached incredible heights quite silently. For example, in Shaheed Suhrawardy MCH, Dhaka, almost five people are suspected and evaluated as a case of pancreatitis on the OPD and on an average, one to two cases are admitted daily. 

This situation is alarming and demoralising. The first task of management, as narrated in textbooks for this disease, is a critical care environment facility (HDU or ICU) and availability of these are relatively expensive and limited.

As a surgical expert I can say, I have seen one or two cases of pancreatitis biannually during my early training period. If I ponder over my entire intern period, it would be roughly one case in a year. 

But the prevalence I am seeing and treating during the pre and post pandemic period is enough to leave me overwhelmed and the fatality of these cases are also making us extremely worried. 

The symptoms and signs observed in patients with pancreatitis include severe pain. But it is essential for physicians and also for patients to differentiate the pain of pancreatitis from other vague abdominal pains. 

This pain in the upper abdomen is severe, constant, agonising and quick, reaching maximum intensity within minutes rather than hours. It persists for hours or even days and usually remains unresponsive even to strong painkiller drugs. 

High grade fever, nausea and repeated vomiting may also occur. Breathlessness, hiccoughs, chest pain may accompany as well. 

The confirmatory diagnosis is usually reached by measuring elevated serum levels of pancreatic enzymes, namely amylase and lipase (usually three times the normal value). An ultrasonogram or contrast enhanced CT scan of the abdomen will certainly guide in the diagnosis of the disease.

I have recorded a cluster statistic of 57 patients in my government and private facilities from the period of February 2020 to February 2022. Among them 32 patients (56.1%) suffered the acute necrotising variety of pancreatitis. 17 of them (29.8%) underwent surgery of different modalities. 

Forty patients (70.1%) were treated conservatively and 12 of them got readmitted with previous symptoms of varying degrees. Amongst patients who underwent surgeries, 11 (64.7%) were completely cured of their sufferings and returned to normal life. The outcome was not the same for others, or they did not appear for routine follow-ups.

The etiology I found in my patients were gall-stones, pancreatic stones, post-ERCP status, malnutrition, chronic alcoholism and abdominal trauma. If gall-stone (cholelithiasis) was the cause of trauma, we did laparoscopic cholecystectomy under GA to abolish the primary cause. I got seven cases of pancreatic pseudocyst during this period as a sequel of acute pancreatitis.

I am not sketching these pictures of pancreatitis to spread unnecessary fear, rather to develop cautiousness. This organ is highly underestimated, and so is the disease. But now it seems, this organ and this disease should have been given utmost priority like the brain or heart. 

There is no doubt that pancreatitis is a life-threatening disease and it has to be managed in a critical care management unit by expert personnel and due sensitive care has to be offered to patients suffering pancreatitis. 

The early phase of the disease is very predictive and can easily be handled by expert surgeons. But when the cascade of complication starts, it becomes a story of a devastating storm that won't stop until it destroys every path of recovery and hope.

So, it is the duty of each and every sincere citizen of the country to know and talk about pancreatitis and make the right choices to live a healthy life. 

Dr Rajib Dey Sarker. Illustration: TBS

Dr Rajib Dey Sarker is a general surgery specialist at Shaheed Suhrawardy Medical College Hospital and an associate fellow at American College of Surgeons

Disclaimer: The views and opinions expressed in this article are those of the author and do not necessarily reflect the opinions and views of The Business Standard.