• Pancreas and Pancreatic Diseases

The pancreas is an organ in the upper abdomen which has several functions.  The main digestive function of the pancreas is to produce pancreatic juice to break down food to be absorbed.  The tube (or duct) which drains pancreatic juice from the pancreas into the small intestine is usually smooth and regular.  Patients with chronic pancreatitis the pancreatic duct is irregular with areas of narrowing.  Chronic pancreatitis causes narrowing from scarring and ongoing inflammation in the pancreas.  Patients’  pancreatic juice does not drain well and forms stones in 22-60% of patients with chronic pancreatitis.  These stones can cause blockage of the pancreatic duct, resulting in pain.
Chronic pancreatitis is a slowly progressive disease that takes many years to develop and leads to destruction of pancreatic tissue.  In many patients chronic pancreatitis is often silent and may not cause any symptoms.  Severe pain is the most important and most difficult to treat complication.
Pancreas divisum:  The pancreas is formed in the uterus from the fusion of two separate pancreatic duct to form the adult pancreas.  One duct is the dorsal duct and the other is the ventral.  When the two ducts fail to fuse the condition is known as pancreas divisum.  In some patients this gives rise to a functional obstruction for drainage of the pancreatic juices in the duodenum.
Pancreatic duct stones.  Pancreatic duct stone is a rare disease.  The incidence of the disease has appeared to be rising in recent years, especially in the Western world.  Pancreatic duct stones are found in approximately 22-60% patients with chronic pancreatitis.  Chronic pancreatitis, pancreatic duct fibrosis, malnutrition, alcohol abuse, spontaneous pancreatic duct stone, and dysthyroid are associated with the formation. 
Pancreatic duct stones in patients with chronic pancreatitis usually result from chronic inflammation or altered metabolism.  The stones perpetuate the cycle of ductal obstruction and contribute to pain, worsening of pancreatic inflammation, ductal disruption, and deterioration of the exocrine and endocrine function of the gland.  Pancreatic duct stones have been considered a marker of chronic pancreatitis.

• What Are Pancreatic Duct Stones

Pancreatic stones develop from calcium deposits in the pancreas and can block the flow of digestive enzymes from the pancreas to the small intestine. They occur mostly in individuals who suffer from chronic pancreatitis. 

In addition to the stones that form in the pancreas, stones that form in the gallbladder (gallstones) may become lodged in the common bile duct, which merges with the pancreatic duct. If either type of stone blocks the duct, pancreatic enzymes can become active inside the pancreas, damaging its tissue.  Gallstones are pieces of hard solid matter in the pancreatic bile duct. They form when the components of bile — including cholesterol and bilirubin — precipitate out of solution and form crystals.

Pancreatic duct stones may be as small as a grain of sand, or much larger.  The stone or stones may number from one stone to many.  It is not entirely known why some people develop stones and others don’t; however, certain factors are known to increase the likelihood of developing stones:
An increased amount of cholesterol or bilirubin in bile
Obesity
Sedentary lifestyle
Female gender
Age over forty years old
Diabetes
Liver disease
Family history of gallstones
Pigment (bilirubin) gallstones are found most often in:
Patients with severe liver disease.
Patients with some blood disorders such as sickle cell anemia and leukemia.
Cholesterol gallstones are found most often in:
Women over 20 years of age, especially pregnant women, and men over 60 years of age.
Overweight men and women.
People on “crash diets” who lose a lot of weight quickly.
Patients who use certain medications including birth control pills and cholesterol lowering
agents.
Native Americans.
Hispanics of Mexican origin.

• What Are Pancreatic Duct Stone Symptoms

The most typical symptom of pancreatitis and pancreatic duct stone disease is severe steady pain in the upper abdomen or right side. The pain may last for as little as 15 minutes or as long as several hours. The pain may also be felt between the shoulder blades or in the right shoulder. Sometimes patients also have vomiting or sweating. Attacks of pain may be separated by weeks, months or even years.

Signs and symptoms of pancreatitis may vary, depending on which type you experience.

Acute pancreatitis signs and symptoms include:

• Upper abdominal pain
• Abdominal pain that radiates to your back
• Abdominal pain that feels worse after eating
• Nausea
• Vomiting
• Tenderness when touching the abdomen

Chronic pancreatitis signs and symptoms include:

• Upper abdominal pain
• Indigestion
• Losing weight without trying
• Oily, smelly stools (steatorrhea)

Complications
Pancreatic duct stones can block the duct of the pancreas and prevent this organ from releasing the enzymes needed for food digestion. The pancreas also creates the hormones needed to control the blood sugar levels in the body, and if this hormone isn’t released into the body properly, it can lead to diabetes. It is easy to see why the development of these hard deposits in the pancreas can cause severe health problems.

Pain results from blockage. When the blockage is prolonged (greater than several hours), the pancreas may become inflamed. This condition, called acute pancreatitis, may lead to fever, prolonged pain and eventually infection of the pancreas. Hospitalization is usually necessary for observation, for treatment with antibiotics and pain medications, and frequently for surgery.
Stones in the bile duct usually cause pain, fever and jaundice (yellow discoloration of
the eyes and skin) sometimes accompanied by itching.

• What Are Treatment Options for Pancreatic Duct Stones

There are several treatments for pancreatic duct stones. Stones can sometimes be dissolved by a chemical (ursodiol or chenodiol), which is available in pill form. This medicine thins the bile and allows stones to dissolve. Unfortunately, only small stones composed of cholesterol dissolve rapidly and completely and its use is therefore limited to patients with the right size and type of stones.

The most invasive treatment is surgery to remove part of the pancreas or divert the flow of pancreatic juice around the blockage.  Another way stones can be removed is through an endoscopic procedure called ERCP.  During ERCP, a small cut is made at the opening of the pancreatic duct which is located at the beginning of the small intestine.  After making this cut, the stone can be swept from the duct into the small intestine.
 Extracorporeal shock wave lithotripsy (ESWL) is a procedure which utilizes sound waves to fragment and pulverize stones.  The broken pieces then either spontaneously flow from the pancreatic duct or are removed via ERCP.
ESWL is usually performed as an outpatient procedure.  The procedure is performed under general anesthesia with the patient lying face down with the abdomen touching the shockhead or partially submerged in water.  Using X-rays, the stone is visualized and targeted with the device that produces the shockwaves.  Between 2400-3000 shockwaves are delivered to the stone.  The procedure itself takes approximately 45 minutes-1 hour.  Side effects include abdominal pain and occasional bruising. 

• What is Lithotripsy for Pancreatic Stones

Extracorporeal Shockwave Lithotripsy (ESWL) is a treatment method to treat Pancreatic and Bile Duct Stones that can not be retrieved or eliminated during ERCP. Lithotripsy is a noninvasive method of crushing or disrupting a stone located in the pancreatic duct or bile duct.
Shock waves are created outside the body and then travel through the skin and tissue until they hit the dense stone, causing it to crumble into smaller fragments or particles.  The actual lithotripsy treatment takes approximately 30-60 minutes and is done under general anesthesia.
An ERCP may be done prior to or after the lithotripsy.  The ERCP done prior to lithotripsy may involve a stent placement.  The ERCP after ESWL treatment will remove the stone fragments into the duodenum. 

Additional risks to lithotripsy include the possibility of developing pancreatitis after the procedure, plus there is the chance that skin bruising could occur where the shockwaves entered the body.

• What is an ERCP?

ERCP is short for…
Endoscopic
Retrograde
Cholangio-
Pancreatography

Endoscopic refers to the use of an instrument called an endoscope - a thin, flexible tube with a
tiny video camera and light on the end.
The endoscope is used to diagnose and treat various problems of the gastro-intestinal (GI ) tract. The GI tract includes the stomach, intestine, and other parts of the body that are connected to the intestine,such as the liver, pancreas, and gallbladder.

Retrograde refers to the direction in which the endoscope is used to inject a liquid enabling Xrays to be taken of the parts of the GI tract called the bile duct system and pancreas.

Cholangio-pancreatography is the process of taking x-rays of the bile duct and pancreas.  Cholangio refers to the bile duct system, pancrea to the pancreas.

A sedative will be given through a vein in your arm. You will feel drowsy, but will remain awake and able to cooperate during the procedure.  Although general anesthesia is usually not required, you may have the back of your throat sprayed with a local anesthetic to minimize discomfort as the endoscope is passed down your throat into your esophagus (the swallowing tube), and through the stomach into your duodenum. The doctor will use it to inspect the lining of your stomach and duodenum. You should not feel any pain, but you may have a sense of fullness, since air may be introduced to help advance the scope.

In the duodenum, the instrument is positioned near the papilla, the point at which the main ducts
empty into the intestine. A small tube known as a cannula is threaded down through the
endoscope and can be directed into either the pancreatic or common bile duct. The cannula
allows a special liquid contrast material, a dye, to be injected backwards - that is, retrograde -
through the ducts.

X-ray equipment is then used to examine and take pictures of the dye outlining the ducts. In this
way, widening, narrowing, or blockage of the ducts can be pinpointed.  Some of the problems that may be identified during ERCP can also be treated through the endoscope. For example, if a stone is blocking the pancreatic or common bile duct, it is may be possible to remove it using various methods; such as dilating a balloon to sweep the stone into the small intestine, a basket, or forceps.

First, the opening in the papilla is cut open and enlarged. Then, a special device can be inserted
to retrieve the stone. Narrowing or obstruction can also have other causes, such as scarring or
tumors. In some cases, a plastic or metal tube (called a stent), can be inserted to provide an
opening. If necessary, a tissue sample or biopsy can be obtained, or a narrow area dilated.

Other Terms:
Sphincterotomy. Using a small wire on the endoscope, the doctor finds the muscle that surrounds the pancreatic duct or bile ducts and makes a tiny cut to enlarge the duct opening. When a pseudocyst is present, the duct is drained.

Stent placement. Using the endoscope, the doctor places a tiny piece of plastic or metal that looks like a straw in a narrowed pancreatic or bile duct to keep it open.

Balloon dilatation. Some endoscopes have a small balloon that the doctor uses to dilate, or stretch, a narrowed pancreatic or bile duct. A temporary stent may be placed for a few months to keep the duct open.

You may experience soreness in your abdomen or side area.  Bruising of the skin may occur where the shockwaves entered the body.  This discomfort should disappear after several days.  Most patients report feeling “back to normal” within 24-72 hours.
An ERCP may be scheduled after your lithotripsy to collect the smaller fragments or to “sweep” them into the small intestine. Call your Physician after procedure to schedule your follow-up appointment. 

Call your Physician or go to the nearest emergency room if you have any of the following
* Fever over 101 ° F
* Pain not relieved by pain medication
* Constant Nausea and Vomiting (dehydration is a concern)
* Black tarry stools

Avoid drinking alcohol and smoking.  The combination of alcohol consumption and smoking increases the risk of pancreatitis.
Resume pre-treatment diet as recommended by your physician, trying to eat 4-5 low fat meals per day and drinking 8 glasses of water per day. Avoid beverages that can aggravate pancreatitis such as coffee and soft drinks.

Prior To Procedure

Welcome to Midwest Stone Institute
Our mission is to provide excellent care and to make sure your expectations are met by receiving compassionate quality services.
If you have specific questions about your procedure, or if you develop a cold, fever or flu like symptoms in the 24 hours before your procedure, please contact doctor directly or Midwest Stone Institute.

Before Your Procedure

• Clear, open communication is the key to a smooth procedure
• Prior to your procedure you will need to have your current insurance card
• You may be contacted by the hospital to schedule an appointment in the surgical testing area.
• At this appointment, a nurse will ask you about:
• Any medications you may be taking, including over-the counter and herbal supplements
• Please bring your medications in their original labeled containers
• Telephone numbers of your current physicians.
• At this appointment you may be required to have pre-procedure testing based on your medical history or your doctor’s orders (testing may include lab work, X-ray or EKG). If any of these tests were not performed at the hospital where your procedure will occur, please let the nurse know when and where you had your tests done. If the hospital is unable to get the results, they may have to repeat the test(s).
• You may need to speak with someone from the Anesthesia Department about your medical history.
• Please bring your current insurance card and a photo ID to the hospital
• If you have not received a call from Midwest Stone Institute 7 days prior to your scheduled procedure, please call (314) 835-1549, or (800) 770-0880. Note: you will also be contacted by the hospital; however, Midwest Stone Institute ALSO needs to speak with you regarding your procedure. The reason is that it is Midwest Stone Institute’s equipment and Midwest Stone Institute technicians who will be assisting the physician during your procedure.
• You will receive a call from Midwest Stone Institute to explain
• What to expect prior to your procedure
• Where to check into the hospital
• What time to check into the hospital
• What will happen during your procedure
• What to expect after your procedure

Midwest Stone Institute will also email you a letter with this and other helpful information on your procedure.

• STOP all aspirin products and non-steroidal anti-inflammatory medications 7 days prior to surgery, unless otherwise directed by your physician. Please refer to the link Medications that May Delay Treatment for other medications.
• STOP all vitamins and herbal supplements 7 days prior to surgery.
• STOP all diet drugs or appetite suppressant medications 14 days prior to your procedure.

On the Day of Your Procedure
DO…..

• Have someone available to drive you home after your procedure. You will not be allowed to drive after receiving anesthesia. You will not be allowed to take a taxi or public transportation home.
• Follow instructions given by the hospital concerning taking your usual medicines on the day of surgery
• Leave all jewelry and valuables at home
• Leave luggage, crutches and other personal belongings in your car
• Bring a case for dentures or partials
• Bring a case for your contact lenses or glasses
• Wear loose-fitting , comfortable clothing
• Notify your doctor of any signs of a cold, upper respiratory infection or other symptoms
• Bring your insurance card (s), including Medicare and Medicaid, and a photo ID
• A Midwest Stone Institute technician will speak to you about your procedure in the holding area.
• Do ask any questions you have about the procedure or what to expect after the procedure.

DO NOT…..

• Eat or drink anything after midnight prior to your procedure, including water, coffee, mints, juice and gum; if you eat or drink anything at or after midnight, your surgery may be cancelled or delayed.
• Take any medications the day of surgery, unless instructed to do so by your doctor or the hospital’s pre-admission nurse.
• Plan to drive yourself home. You MAY NOT drive after you receive anesthesia.
• Plan to take a taxi-cab home, unless an adult accompanies you.
• Bring anything of value with you to the hospital
• Wear make-up

What to Expect after your Procedure:

• You will be reunited with your family in the Recovery area.
• You may be discharged as soon as you meet the discharge criteria:
• Your blood pressure is stable
• You are able to walk
• You are able to drink
• Your pain is under control
• You are able to urinate (for lithotripsy [kidney stone] procedure)
• You understand your discharge instructions
• We recommend that you have a responsible adult with you for the first 24 hours after your procedure
• You will not be allowed to drive yourself home, so please have someone available to drive you home; you will want to make arrangements for going home long before you leave for the hospital. To ensure your safety, the hospital will release you only when a relative or friend arrives to pick you up and see you home safely; taxi cabs are unacceptable substitutes (unless your relative or friend are accompanying you in the taxi-cab). If your driver does not plan to wait at the hospital during your surgery, please give your nurse a number where he or she can be called.