Pancreatitis, biliary lithiasis, and influence in driving

Pancreatitis

Acute inflammation of the pancreas is commonly associated in most cases with biliary disease, second with excessive alcohol consumption and fewer times with drugs, hypercalcemia, hypertriglyceridemia, or of idiopathic nature.

Patients start with continuous, severe, progressive acute epigastric pain, with vomiting, abdominal distention, and ileus paralyticus. Pain is relieved being seated, when bowing.

The treatment is urgent with hospital admission and multidisciplinary management.

Self-limited acute pancreatitis of benign progression and without complications, progresses with conventional treatment to cure without pain within 7–10 days.

Advice on Pancreatitis

• The patient with an acute episode of pancreatitis cannot drive.
• The physician will report to the patient on the complete recovery without sequels, that permits him to drive again.
• Acute pancreatitis for alcohol addiction forces not to drive for the adverse influence of alcohol on driving, regardless of the pancreatitis episodes.
• Advising on the danger of driving drunk can be an additional assistance against alcohol dependence.

The chronic inflammation of the pancreas

The chronic inflammation of the pancreas causes progressive functional impairment that persists even when the causal factor has been removed.

In most cases, it is caused by an excess of alcohol.

Other cases are associated with hyperparathyroidism, protein malnutrition, congenital or malignant obstructions, and inflammations associated with IBD or sclerosing cholangitis.

Chronic alcoholic pancreatitis occurs in episodes of severe epigastric abdominal pain transfixive to the back, that first are isolated but gradually appear more frequently, and the pain can eventually be continuous.

When the patient eats he worsens, so he stops doing it and loses weight. This is added to the malnutrition of pancreatic insufficiency for steatorrhea, hypovitaminosis and the eventual appearance of diabetes mellitus with frequent episodes of hypoglycemia.

It can become more complicated with portal or splenic thrombosis, and formation of pancreatic pseudocysts. At times liver cirrhosis is associated.

In addition to alcohol abstinence, malnutrition must be treated with replacing enzyme therapy, diabetes with insulin, and pain with administration of opiates such as buprenorphine.

Buprenorphine can cause respiratory depression and some somnolence that should be notified to the patients, so that they have caution when driving. It occasionally causes euphoria, nausea, vomiting, dizziness, and sweating.

Pancreatic pseudocysts subside in half of the cases, around six weeks, particularly if they are less than 4-6 cm in diameter.

After this time, if the pseudocysts persist, they can complicate further with infection, bleeding, increased size, and risk of compression and rupture. In some cases surgical drainage or puncture are required.

Advice on Chronic inflammation of the pancreas

• The patient with chronic pancreatitis is frequently alcohol addict, and while he drinks he cannot drive.
• The initial period of the disease with few symptoms allows for driving, but the progressive natural history of the disease, with permanent pain and malnutrition disables for driving.
• Medication with opiates has side effects that advise against driving, though they relieve pain, and patients should be warned.
• Pseudocystic conditions, affect, for their size, driving, since a crash or an increased pressure in an accident increment the risk of complication from bleeding or rupture.
• The physician will report to the patient with the pseudocyst if it is advisable that he stops driving, for his safety.

Biliary lithiasis

It affects 20% of the adult population in the Western world, and is symptomatic in half of them.

The most common clinical symptoms is biliary cramp, characterized by continuous, progressive abdominal pain in the right hypochondrium and epigastrium, that frequently irradiates to the back.

It is usually associated with nausea, vomiting not relieving pain, ileus paralyticus, pallor, malaise, and sweating.

• The most frequent complications are:
  • Choledocholithiasis that can lead to obstructive jaundice, cholangitis, and pancreatitis. All these situations require hospital admission and urgent treatment.
  • Acute cholecystitis with calculi that is suspected when the biliary colic is associated with fever, shivering, poor general condition, and can progress to vesicular empyema with perforation and peritonitis or cholecystoenteric fistulae. It requires emergency hospital treatment.
  • Chronic cholecystitis with fibrosis of the vesicular wall can be complicated with acute episodes or pancreatitis.
  • Other complications are Mirizzi syndrome, biliary fistulae, biliary ileus, acute pancreatitis and gallbladder adenocarcinoma.
• The treatment of biliary colic is based on a fat-free diet, and on the administration of spasmolytic drugs derived from belladonna with peripheral anticholinergic action such as hyoscine butylbromide combined with analgesics derived from aminophenazone, such as metamizole.

Metamizole metabolites have analgesic, antipyretic, antiinflammatory, and spasmolytic effect.

Anticholinergic adverse events include visual accommodation disorders, tachycardia, dizziness and, in some cases, urinary retention.

The definitive therapeutic indication is surgical, through cholecystectomy.

Advice on Biliary lithiasis

• Biliary colic prevents from driving.
• If no complications arise, they are episodes limited in time that subside with medical therapy and allow the patient to drive as soon as he has not symptoms.
• The patient should be warned of the adverse reactions to the prescribed drugs and that they frequently limit driving, so that they maximize caution when driving.
• Although the recovery from laparoscopic cholecystectomy is usually fast, the patient should be recommended not to drive until two weeks following surgery, with the appropriate wound healing of abdominal wounds that allows for adjusting the safety belt without difficulties.