Alastair Hayes

As I write this update, I am about to join the emergency general surgery team at the hospital where I work, in my scheduled duties as a surgical registrar.

The majority of the patients we see are referred because of severe abdominal pain. Typically, our surgical unit is referred around 200 patients over 7 days, so there’s never a dull moment! One of our most common diagnoses is acute pancreatitis. For many of these patients it will be the first time they have encountered an emergency general surgical team, and may know very little about pancreatitis, having been otherwise well before this attack.

Making the diagnosis is not normally a problem, as often the patient will have a high amylase level on routine blood tests, or else we can reach the diagnosis with the help of a CT scan. In acute pancreatitis a CT scan will show a swollen, inflamed pancreas deep inside the abdomen, and sometimes the blood supply to pancreas can look patchy – an alarming feature called ‘necrotizing’ pancreatitis. Regardless of how the scan looks, however, the main issue in looking after these patients is to provide general support in the form of intravenous fluids and pain-killers, whilst closely monitoring for subtle signs that they are becoming sicker.

From the 200 patients that are normally seen by the emergency surgical team over an entire week, we will diagnose around 20 patients with acute pancreatitis. Thankfully the majority will have a mild attack and can be cared for on a normal ward. If it is discovered that the underlying cause was likely gallstones, those patients will be counselled about having their gallbladder surgically removed to avoid further attacks. Unfortunately however, some patients will be readmitted in months or years to come with recurrent attacks of pancreatitis even if the original cause is eliminated; such as removing the gallbladder, avoiding alcohol or certain medications. In fact, there are multiple causes of acute pancreatitis – and though the most common are gallstones or alcohol, as many as 20% of patients never have a clear cause established despite many investigations.

When treating 20 patients with pancreatitis, you can expect to have approximately five become seriously unwell, with signs of organ failure necessitating a bed in the critical care unit. Such deterioration might become evident in the form of breathing difficulties, or low blood pressure as well as a declining urine production, as the kidneys begin to fail. The real challenge for the busy surgical team is to quickly spot, as early as possible, those who are developing severe pancreatitis, and getting them the best supportive care in the critical care unit with the hope that early support can prevent worsening organ failure. Up to date research studies of NHS hospital records have found that still one in twenty patients with acute pancreatitis will not survive. It is rare for surgeons to operate on the pancreas nowadays for acute pancreatitis (although it is occasionally required in very specific situations) as in general trying to remove the pancreas when it is inflamed can risk further deterioration.

Hopefully, this has given readers an insight into the daily reality for the surgical team trying to look after patients with acute pancreatitis. To improve outcomes we need better ways of detecting which patients are in the very earliest stages of moving from ‘mild’ into ‘severe’ pancreatitis, and an effective drug which can slow-down, limit or reverse the multiple organ damage which results in critical illness.

I have had the privilege of working with Professor Damian Mole at the University of Edinburgh and have recently passed my oral viva for a PhD. My research was funded by Guts UK through the Amelie Waring Fellowship, to whom I am extremely grateful for the fantastic opportunity. My research project focussed on the interaction between metabolism and the body’s acute inflammatory response using laboratory research models of acute pancreatitis. Our main findings were that we were able to manipulate one particular bodily chemical pathway (called the ‘kynurenine pathway’) which is altered in pancreatitis, and thereby either worsen or improve disease recovery.  Our results suggest we can limit critical illness using a potential medical therapy which blocks the function of an enzyme called KMO.

My PhD project took forward previous work by Professor Mole, and we are looking forward to publishing these results in the near future. Professor Mole has joined forces with GlaxoSmithKline to develop medicines which block KMO, and we look with great anticipation towards this being evaluated in acute pancreatitis clinical trials.

WHAT YOU CAN DO:

Dr Haye’s and Prof. Mole’s research suggests that critical illness as a result of pancreatitis can be limited. Guts UK is proud to fund the only UK research fellowship into pancreatitis, especially when research is showing such promising results – but we can’t do this without your support.

Please donate or discover how you get involved.