Timothy Gardner, MD, Director, Pancreatic Disorders, Dartmouth-Hitchcock Medical Center
Q1. After many years of pancreatitis and hospitalizations, a “tumor” was discovered in the head of the pancreas and I underwent a successful Whipple. The tumor turned out to be a cyst and I have had no recurrences after the healing from the surgery 7 years ago. According to my surgeon, I continue to have a more chronic pancreatitis in the tail which has been manageable thus far with a good diet and self care. What is the long term prognosis for this condition generally? I am 57 and am not diabetic.
A. Generally, the prognosis would be excellent for avoiding diabetes and needing another surgery. Of course, this is highly individualized and you have to be sure to eat a diet low in fat to avoid putting added “stress” on the pancreas, avoid tobacco products and alcohol and get plenty of exercise. However, being seven years from surgery, I think the chance of having a recurrence of the pancreatitis is quite low, especially since I assume the cyst was the root of the problem in the first place.
Q2. My father died of pancreatic disease at the age of 56. He developed acute pancreatitis about a year before his death. Is this disease known to be hereditary and if so, what precautions can be taken to try to minimize risk factors?
A. Increasingly, we are becoming more aware of the link between having acute pancreatitis and genetic factors. While we have not figured out the entire genetic story, we can test for four different genes (CFTR, SPINK, PRSS, Chymotrypsin C) currently. If individuals carry these genes, we think it is one risk factor for having pancreatic disease. It may be worth speaking to your physician about being tested, especially if your father had no risk factors for developing acute pancreatitis.
Q3. Thanks for answering these messages. Do previous pancreatic cancer patients usually develop pancreatitis? What foods would you recommend to avoid and or eat, to help prevent pancreatitis. And would you recommend any supplements to help? Basically what would you recommend to help get rid of this condition and prevent it.
A. It is pretty rare for previous pancreatic cancer patients to develop pancreatitis. However, this does occasionally occur and can be due to complications from surgery or radiation therapy, recurrent cancer or underlying genetic factors. It is important that if you have had pancreatic cancer and are now developing pancreatitis, you get a thorough evaluation from your doctor to look for causes. Generally, we don’t recommend avoiding any foods or taking supplements when you have pancreatitis, with the exception of very high fat diets (greater than 30 grams of fat per day). However, I can’t emphasize enough the importance of trying to determine the trigger for the pancreatitis.
Q4. Have pancreatic enzymes proven helpful to ease chronic pancreatitis pain?
A. This is a very good question and one that I am asked often when seeing patients in the pancreas clinic. The answer is generally no, but in certain patients, and we are not entirely clear why, enzymes can have lead to profound improvement in pain. My practice is to have every patient try enzymes because they are safe and very well tolerated – really there is no downside to trying them. If patients have a beneficial response, they can continue on the enzymes. If not, then at least they have been tried without causing any significant side effects.
Q5. Is there a surgical procedure for pancreas divisum. Have had stent therapy but continue to have off and on pancreatitis which is diagnosed chronic now. Is there any other alternative to stent placement and can you tell me the difference between EUS and ERCP? Thank you doc, we all appreciate every bit of info we can get.
A. Pancreas divisum is a tricky topic in how it relates to pancreatic disease and doctors argue all the time about its relevance. The reason is that pancreas divisum is present in about 5% of the population in the United States – and we know that 5% of the population is not having pancreatic disease! Therefore, many believe that there is another factor that predisposes patients with pancreas divisum to having pancreatitis – i.e. pancreas divisum is just one risk factor for developing pancreatitis. More and more, we are realizing that genetic factors may also be contributing to this problem – i.e. patients with pancreas divisum AND an underlying genetic problem are those who develop pancreatitis.
In reference to your question, there are surgeries that can be performed to improve pancreas divisum. However, if endoscopic stenting has not helped, it is very unlikely that a surgery to improve divisum will help your symptoms. In fact research has shown that in patients who do not respond to stenting, more aggressive surgical drainage therapies generally are ineffective.
The difference between an ERCP (Endoscopic Retrograde Cholangiopancreatography) and EUS (endoscopic Ultrasound) is that an ERCP uses a small catheter to enter the pancreas and inject dye for the purposes of looking at the pancreas ducts. An EUS uses a small ultrasound placed at the end of the endoscope to evaluate the overall structure of the pancreas.
Q6. Hello. I have chronic pancreatitis due to Cystic Fibrosis, confirmed by 3 ERCP procedures in 2007.My pancreatitis causes me pain on a daily basis, and nausea several days per week, regardless of diet. Protein and Fat make the pain even worse. I’ve tried nearly every pain and nausea medication, and traveled up to Boston to get a second opinion, and they told me that other methods of controlling pancreas pain like pain blocks/nerve blocks are not effective in Chronic Pancreatitis. I’ve seen a handful of Gastroenterologists who don’t have any answer other than to manage symptoms. I have a poor quality of life due to this. I’ve researched islet cell transplant, but it’s a huge undertaking that ultimately would put my lungs at risk due to immunosuppressants. As I already take pancreatic enzymes and insulin, I really don’t even need my pancreas, and have considered a “simple” pancreatectomy, but it’s still a major surgery.
So I would like to know if there are proven or newer treatments that you can suggest to treat Chronic Pancreatitis.
A. I am sorry that you are struggling with this and certainly empathize with your plight. I am reluctant to provide any recommendations to you here, without having met you and reviewing your case thoroughly. However, I wanted to make one correction in regard to the word immunosupressants and autoislet cell transplant. This procedure, because your own islet cells are harvested and then placed back in to your body, does not require you to be on immunusuppressants, so you may want to discuss this again with your physician.
As far as new treatments for chronic pancreatitis, drugs specifically targeted for improving function in the CFTR gene (the one that causes pancreatitis from cystic fibrosis!) are being evaluated in clinical trials so I hope these will be available soon for use. Drugs that affect the way calcium is taken into the pancreas – called calcium channel blockers – are also being tested to help patients with pancreatitis. Also, if your physician has not tried you on antioxidants (specifically vitamin E, Selenium and S-Adenosyl Methionine), this may be helpful for your symptoms
Q7. How effective is the Puestow procedure for slowing the progression of chronic pancreatitis? Can stones recur? If so, then what happens?
A. The Peustow procedure is very effective for stones that have been discovered in the main pancreatic duct and are causing back-up in the duct leading to pain. While the Peustow procedure itself does not stop the stones from forming, it does allow them to drain. If your doctor has determined that the drainage from the pancreas can be improved with a Peustow procedure, it may be a very effective treatment for the pancreatitis. However, keep in mind that it does not prevent the development of new stones.
Q8. Hello! I have been diagnosed with CP for over a year now and take Creon 24, 2 to 3 pills with meals, 1-2 pills with snacks. My question is if you’re out at a restaurant or at a gathering, how long do you have to eat a meal with the enzymes, how long will they work? If I want to have a low fat dessert an hour later, should I take an additional enzyme? Just wondering how long a meal should last based on taking the enzymes. Thank you so much!!
A. Great questions about enzymes! Bottom line is this. At every sitting, you should take enzymes once. So, if you are at a restaurant and take your enzymes at the beginning of the meal, and then that fatty dessert comes an hour later, you generally DO NOT have to take the enzymes again. However, this may depend on how large the dessert is and you may want to err on the side of taking more enzymes than less if you are concerned, because they are very well tolerated and generally have little side effects. However, the answer to your question would be only take the enzymes once. Now, if the dessert were coming 2-3 hours later, I would definitely take more enzymes.
Q9. I have had chronic pancreatitis for 19 years. I am only 32 years old. My pancreatitis is idiopathic…….I have had my gallbladder removed and have had several ERCPs Last year I developed my first pancreas stone and had 2 ercp’s and 2 procedures to break up the stone. My question is – now that I have gotten 1 stone, will it become a common occurrence? Is there anything I can do to prevent further stones? Thank you very much!
A. Unfortunately, there is little that can be done to prevent future stones. It sounds though like you have a genetic cause of your pancreatitis and you should certainly speak to your physician about genetic testing. I would also recommend that you speak with your physician about a drainage procedure for your pancreas. In patients with stones that recur, studies have demonstrated that a one-time surgical drainage procedure (like the Peustow procedure) is generally more effective than recurrent ERCPs.
Q10. I have severe pain everyday due to autoimmune . Could be from sjrogrens, or lupus not sure. However, besides celiac block or wipple surgery is there another surgery to help pain? I heard about a surgery that moves the bile duct to keep bile from backing up into the pancreas which burns it faster. Could this help me? What is the name of it? Is pain med. the only option for someone like me?
A. The treatment for autoimmune pancreatitis is typically medications to control the immune system – so be sure that this diagnosis is the correct one as painful autoimmune pancreatitis is very, very rare. Thus, I think surgery is generally not a good option for someone with autoimmune pancreatitis. Please be sure to follow-up with your doctor to make sure your diagnosis of autoimmune pancreatitis is correct, as this is very often misdiagnosed.
Q11. What percentage of people who have CP get Pancreatic cancer?
A. That is a very important question and one that I am asked frequently. The answer is that in general, very few people with chronic pancreatitis will develop pancreatic cancer. However, it depends on why someone has chronic pancreatitis. We know that patients with chronic pancreatitis from hereditary causes (especially those with the PRSS gene) are more likely than those with non-hereditary causes to develop cancer.
The best study we have is from the early 2000s in which patients with chronic pancreatitis were about 25x more likely to develop pancreatic cancer than those without chronic pancreatitis. However, keep in mind that this is what is called a relative risk – meaning it a comparative risk. The absolute risk – i.e. what percentage of patients with chronic pancreatitis will develop cancer – is still very, very small.
This project is intended to provide information and does not constitute medical advice and it should not be relied upon as such. The National Pancreas Foundation does not recommend any particular treatment and in all cases recommends that you consult your physician. The NPF and its physician consultants disclaim all medical responsibility for any content supplied thereof to patients. While the NPF and its physician consultants will not use your name when posting the questions and answers we cannot absolutely guarantee your privacy.