Without pancreas, fat passes all the way through the body
DEAR DR. ROACH » I am 57 and generally in good health. My doctor diagnosed me with chronic pancreatitis, after I had weight loss with diarrhea, and was found to have fat in my stool. The CT scan showed that I have a 12-mm stone blocking my pancreatic duct. He said I have chronic pancreatitis. My doctor says I need surgery to remove the stone.
Is this a life-or-death surgery? If no one will perform the surgery, is there another way to get rid of the stone? — C.H.
DEAR READER » Chronic pancreatitis is a relatively common condition, but sometimes can go for a long time without being diagnosed. The presence of fat in the stool is a big clue to the diagnosis: Patients may notice that their stools seem oily, and it might take multiple flushes of the toilet to completely remove it. The diarrhea happens because the pancreatic enzymes are necessary for the body to absorb fat: Without the pancreas, the fat passes all the way through the body, causing fatty diarrhea, called steatorrhea. Many people have abdominal pain, sometimes episodic, but at least 20 percent of people have none.
There are many causes of chronic pancreatitis. Chronic alcohol abuse is the most common cause that I saw in my training, but obstruction of the pancreatic duct by stone or tumor is another. Unfortunately, removing the stone might not stop the pancreatitis: In many people, the changes in the pancreas from longstanding obstruction are irreversible. Nonetheless, I wholeheartedly agree with removing the cause of the obstruction.
There are several approaches to removing a pancreatic stone, including endoscopic removal, laser treatment and shockwave lithotripsy (using soundwaves to break up the stone). Only your treating physician can say what the best treatment for you is.
Although any of these may be considered “surgery,” there also are surgical treatments for chronic pancreatitis, and I’m not sure if your doctor is recommending one of those. Surgery for chronic pancreatitis (as opposed to removing the stone) usually is used for people whose pain can’t be controlled.
Another important treatment in chronic pancreatitis is the use of replacement enzymes. These help digest the fat and protein in the food, relieving the diarrhea and, in some people, relieving pain. They also can help the body absorb fat-soluble vitamins.
DEAR DR. ROACH » I recently had a PET scan. It showed that my stomach is almost completely up in my thorax with a large hiatal hernia. I have no discomfort or symptoms. Is this dangerous? Should I have surgery? — C.V.
DEAR READER » The diaphragm is a large sheet of muscle that separates the chest from the abdomen. It has a hole in it, called the diaphragmatic hiatus, that allows the esophagus to carry food into the stomach. In some people, that hole is large enough for part of the stomach to go up into the chest. This condition is called a hiatal hernia, and it may bring on variable symptoms, especially heartburn. Usually, it’s a “sliding” hiatal hernia — the stomach can go into the chest but later come back in the abdomen where it belongs.
In people with no symptoms, surgery rarely is required. However, if the entire stomach is in the chest, it’s possible for it to get stuck, which predisposes a person to bleeding and, rarely, to a condition called volvulus, when the stomach twists in the chest against the part left in the abdomen. These complications often need surgery: I have seen only two cases in my career.