Acute pancreatitis — a clinical dilemma
Dr J.D. Wig

The pancreas in an elegant organ as long as it is not disturbed, quietly going about the job of producing insulin as well as enzyme that pass into the upper gastrointestinal tract and help breakdown fats and proteins.

Pancreatitis is an inflammation of the pancreas. The most common causes are excessive alcohol use and gallstones. These two are responsible for nearly 80 per cent of all hospitalisation for acute pancreatitis. Passage of gallstone or excessive alcohol use cause injury to the pancreas and the gland leaks these enzymes into the surrounding tissue. In a mild case (80 per cent), this causes inflammation and pain. When severe (20 per cent to 30 per cent), this causes tissue destruction on a big scale, resulting in the destruction of the glands (necrosis). The pancreas begins digesting itself and the cycle of inflammation begins, including swelling and loss of function. Digestion of blood vessels results in bleeding.

The disease comes suddenly. Pain is a major symptom. This is usually quite intense and steady, located in the upper abdomen and often felt all the way through to the patients back. The patient’s breathing becomes quite shallow because deep breathing causes more pain. Relief of pain by sitting and bending forward is characteristic. Shock may appear in severely ill patients.

Patients become extremely cold, and blood pressure drops dangerously low. Major organs of the body are deprived of blood and oxygen resulting in dysfunction or failure of the lungs, heart, kidney, liver and gastrointestinal tract. Patients may have changes in their mental status — may even become comatose (pancreatic encephalopathy). If a patient develops the failure of three or more organs, there is hardly any survivor. Sometimes these patients develop abdominal distension and an increase in intra-abdominal pressure which is a frequent cause of multiple organ failure.

In severe cases, pancreas gets swollen and suffers bacterial and fungal infections. The CT scan is the best diagnostic modality which shows necrosis of the gland and local complications. CT acts as a road-map and guides the surgeon for subsequent surgical intervention.

The initial management in severe cases is supportive in an intensive care unit. Patients need careful monitoring for organ failure and support. Pain is controlled with a variety of medications and the patient is not allowed to eat for a few days; oxgan in administered by a mask. Large volumes of intravenous fluids are needed. Calcium need to be given as these patients may have a low calcium level. The lung is the commonest system to fail, requiring mechanical ventilation (support of breathing with ventilator).

Surgeons are frequently involved with the care of these critically ill patients with tissue destruction — the dead tissue needs to be removed as this not only makes the patient’s sick but it may also get infected. The surgeon needs to remove this dead infected tissue. One need to search and remove the dead and necrotic tissue with care.

Attempts are made to leave viable pancreas and to avoid injury to blood vessels and adjacent structures (stomach, spleen, intestine). This operation of removing dead and necrotic tissue (pancreatic necrosectomy) is a challenging operation. Utmost care needs to be taken when removing the necrotic tissue. Repeat operations may be required to remove the dead tissue. When patients require repeat operations, the risk of complications and damage to adjacent structures increases.

These patients are in for prolonged hospitalisation, requiring every resource, and some do not survive. These critically ill patients burn up their calorie reserve and need nutrition via a feeding tube inserted into the proximal small intestine at the time of surgery.

Hospital stays are long, complications frequent. Patience on the part of patient, the family and the surgeon is required to get the majority of these patients back on their feet. Those who survive lead a normal life.

Alcohol is essentially the only preventable cause of pancreatitis. Avoiding heavy alcohol use will help prevent pancreatitis. Anyone who already has one episode of acute pancreatitis should stop drinking to prevent the conditions from coming back. Gallstones must be treated in patients with gall stone pancreatitis as gall stone pancreatitis recurs in 30 to 50 per cent after an initial attack.

Acute pancreatitis that is not related to alcohol use cannot be prevented.

The writer, a former Professor and Head, Department of Surgery, PGI, is associated with Fortis Hospital, Mohali.

Ill-fitting shoes can cause toe pain
Dr Ravinder Chadha

One of the most common problems encountered during old age is deformity of the foot. Bunion is a common deformity, also referred to as hallux valgus. The great toe tilts over towards the other toes and a bony lump/swelling appears on the toe inside of the foot. The incidence is much higher in women than men. The cause is the use of high heels with narrow toed shoes worn by the fair sex.

Radiographic findings also corroborate the fact that wearing heels of 3” or higher causes the greater toe to move towards the other toes of the foot.

Foot is made up of bones, muscles and ligaments. These three work together to perform the functions of mobility, flexibility and support. The foot has to absorb the load, provide support and assist during the movement of the body. On an average, on a day-to-day basis, a person spends several hours on his/her feet and takes several thousand steps. A seemingly simple activity like walking puts immense pressure on the feet, which is approximately two or three times the body weight. Most of the problems afflicting the foot are not because of walking but due to ill-fitting shoes. If the shoes are too tight, the foot gets squeezed, thus increasing pressure. Loose shoes make the foot slide and rub against the shoes, causing friction.

This deformity develops slowly and, if ignored, can lead to dislocation of the joint, causing instability during walking. In advanced cases, the big toe can overlap the second toe. The defect can initially be corrected with the help of orthotics / exercises. Chronic deformity is difficult to treat and halting progression becomes impossible. In cases of intolerable pain and decreased ability to perform duties, shoes are difficult to fit; then the only hope is surgery.

Causes

1. Family history of bunion — This does not mean that the siblings are bound to suffer. The connection seems to be usually flexible joints (hereditary) who are more prone to suffer.

2. Abnormal foot function, inward motion of the foot particularly in people having short first metatarsal bone (Big toe).

3. Frequent use of high heels and narrow toed shoes.

4. Rheumatoid/ osteoarthritis patients are more prone to develop bunions.

Symptoms

1. Redness, swelling or pain at the great toe.

2. Discomfort/pain on wearing shoes. The foot becomes so broad that it is difficult to get wide enough shoes.

3. Callus formation over the great toe, which may lead to ulceration.

4. Certain cases may present with a cyst or bursa containing fluid.

Treatment

The following conservative treatments can limit the formation of bunion and relieve pain.

* Apply a pad around the bunion to avoid the formation of callus, corn formation.

* Avoid high heel shoes. Wear shoes with wide and deep toe box with low heel to reduce weight on the forefoot.

* In case the bunion becomes painful and swollen, then elevate the foot and apply ice.

* In some cases, injection steroid or local anaesthesia is given to reduce the inflammation.

* Night splint/taping helps in reducing pain.

* Mobilisation is useful in early stages.

At the starting stage of the bunions, the following exercises can help to increase the range of motion:

1. While sitting, place your foot on the floor, lift the toes as high as possible while holding the ball of the foot on the flat surface for four seconds followed by bending the toes downwards. Again hold for four seconds and return to the starting position. Repeat 10-15 times twice a day.

2. While sitting, spread your toes apart as far as possible. Use your hands, if required, to hold the toes apart. Hold for four seconds. Repeat 10-15 times twice a day.

3. Towel curls: Place your foot on the wet towel on the floor. Curl the towel towards the body with the help of toes.

For good health of one’s foot and preventing oneself from suffering agonising pain, do not ignore great toe pain. Also avoid wearing high heel and narrow toed shoes in order to prevent deformity. Be more comfortable than fashionable.

The writer runs his pain management clinic in Chandigarh. E-mail —chadha_r2003@yahoo.co.in

EYESIGHT
The most valuable lens is in your eyes
Dr Mahipal Sachdev

Before you set your sight on a sophisticated camera, spare a thought for the gift of sight given to you by nature — your eyes. This marvel is made of over two million working parts and is one of those wonderful gifts most of us take for granted. Inside our eyes is a crystalline lens, which changes focus to enable us to see clearly at all distances.

What is cataract? What are its symptoms?

The normal crystalline lens, which is clear and transparent at birth, becomes cloudy and opaque as age advances, thereby causing dimness or blurring of vision. This cloudiness or opacification of the lens is called cataract. If you feel your vision is deteriorating day by day and simple tasks are becoming difficult you need to be evaluated for cataract. The most common cause of cataract is ageing. Cataract makes simple tasks difficult and in some cases impossible to perform. This happens on account of blurred vision, change in one’s perception of colours, sensitivity to bright lamps or sunlight, poor night vision, difficulty in driving, especially at night, and sometimes frequent changes in eyeglass prescription.

When to go for cataract removal?

Cataract should be removed as soon as it begins to affect daily activities. Do not wait for the cataract to get mature as unnecessary delay can lead to complications and a more difficult surgery. Cataract surgery can be undertaken successfully in any season. Summers or rainy season have absolutely no effect on the outcome of the cataract surgery.

Your treatment options

Surgery is the only treatment for cataract. You should get operated upon as soon as cataract begins to affect your daily activities. There is no need to wait for the cataract to mature.

The preferred option for the removal of cataract is phaco-emulsification with foldable intra-ocular lens implantation (also known as “no stitch, no injection, no pad” surgery.)

Your IOL (Intra-Ocular Lens) options

Once the old cataractous lens is removed, it has to be replaced with a new lens, also called IOL or Intra-Ocular Lens.

Mono-focal lenses provide clear vision after surgery but glasses are needed to do near work. Lenses with an aspheric surface provide good contrast and are ideal for people who drive at night. Toric IOLs are useful for patients with pre-existing astigmatism or cylindrical power. MIL or micro-incision lenses need a smaller incision of 1.8 mm and give faster healing rates.

For patients who do not want to wear glasses after surgery, multi-focal lenses are an option. Accommodative lenses are a recent innovation which use the natural focusing mechanism of the eye to provide a complete range of vision, including far distance, intermediate range (TV/ computer work) and near range.

Discuss these options with your doctor to choose the lens most suited for you because your eyes are precious. And every eye deserves the best.

The writer is Chairman and Medical Director, Centre for Sight, New Delhi. Email: drmahipal@gmail.com