Radiation Therapy of Pancreatitis

Since acute pancreatitis was first described by Fitz in 1889 (9) the diagnosis and treatment of this disease have presented an ever increasing challenge to internists and surgeons. On the whole, radiologists have not played a significant role in its management. Morton and Widger (14), in 1940, were the first to report the successful use of roentgen rays as a method of treatment. They described 3 cases of the acute edematous type in which 250 to 450 r (in air) were given with beneficial effect. Successful response to x-ray therapy has since been reported by others (4, 6, 8, 10, 11, 13, 16). This presentation of the results obtained in 53 cases affords additional evidence of the value of irradiation in the treatment of pancreatitis. For many years, the designation “hemorrhagic pancreatitis” was used for acute inflammatory disease of the pancreas. The term was criticized by many authors, in that it failed to indicate the tissue death which is the primary lesion in the severest form of the condition. Since the hemorrhage is secondary to necrosis, the terms “acute pancreatic necrosis” and “hemorrhagic necrosis” are more appropriate. A second form generally recognized is the less severe “acute edematous pancreatitis.” “Chronic recurrent interstitial pancreatitis” is the term appropriately applied to those cases characterized by exacerbations and remissions over a long period (1). The classification of pancreatitis into these three categories assists one in arriving at an understanding of the pathologic process and serves as a guide to the prognosis. Since acute edematous pancreatitis is not accompanied by necrosis, hemorrhage, and shock, its response to x-ray therapy is more favorable. Any one of the three types may exist in varying degrees, from mild to severe. Etiology The etiology of pancreatitis has not been definitely established, though undoubtedly the tendency to hemorrhage and necrosis is related to the action of activated pancreatic enzymes. For convenience, the disease may be classified into two groups, etiologically: (1) pancreatitis of infectious origin, the infection being introduced through the blood stream or the lymphatic system or by direct extension from the biliary tree and surrounding viscera; (2) pancreatitis of chemical origin. This second type may be produced (a) by reflux of bile into the pancreatic duct following obstruction of the common duct by stones, a tumor, or spasm or fibrosis of the sphincter of Oddi; (b) by reflux of duodenal contents; (c) by trauma in which pancreatic enzymes are liberated within the organ itself. The incidence of infection as a primary etiologic agent is not high, and acute pancreatitis in association with the acute infectious diseases is extremely mild, tending to disappear within a short time. Pancreatitis of chemical origin is based upon the “common channel” theory, i.e., that the pancreatic and common ducts form a communication which permits reflux of bile into the former.