Bangungot: A deadly nightmare

The Charter Bureau

Filipinos refer to it as bangungot – a word we associate with scary dreams, possibly an aftermath of watching a horror movie or telling spooky tales before bedtime. However, most of us only have vague ideas about this phenomenon. It was just recently, with the untimely demise of matinee idol Rico Yan, that we begin to realize that bangungot is not just a case of scary dreams one can wake up from. It can actually be a deadly phenomenon, wherein one sleeps straight to his death.

In medical terms, it is called "sudden nocturnal death syndrome," the most common cause of which is acute hemorrhagic pancreatitis.

Acute hemorrhagic pancreatitis or AHP is a severe swelling of the pancreas, a gland that produces digestive enzymes, particularly insulin, to metabolize the carbohydrates that we take in. In AHP, the swelling is so severe that the pancreas literally digests itself. Fatal complications may set in fast within a matter of minutes to a few hours.

The disease affects four out of 10,000 people, most of them, men. Eighty percent of pancreatitis cases are related to gall bladder stones or alcoholism. Other agents or drugs such as glucorticoids, thiazide diuretics or acetaminophen, can likewise bring on an acute attack of pancreatitis. An alcoholic binge, coupled with a high carbohydrate intake, has been postulated as a trigger. However, there are also cases of AHP wherein the specific cause or triggering factor cannot be pinpointed.

Such may be the case of the late actor. Many people have wondered how this young, healthy man, who was recognized as a model of the youth for his intelligence and clean living, would be a victim of this alcohol-related disease. Although science has explained the effects of this disease, its cause and the reason why it mostly strikes young men in their sleep is still one nebulous area.

Pain

Pain is the first and utmost symptom of AHP. The pain, which is felt in the upper mid-abdomen just below the ribs, radiating to the back and under the shoulder blades, is intense, steady and severe. The patient’s breathing then may become quite shallow because deeper breathing tends to cause more pain. Nausea, vomiting and cold clammy perspiration are all common as well. A patient may also have fever, with an increased heart rate and a low or shocky blood pressure. A fatal arrhythmia or abnormal beating of the heart can hasten the death of the afflicted individual.

Most of the victims of this disease die in their sleep. One misconception, especially among us Filipinos, is that these people die because they are not awakened from a very horrible dream. The bleeding and intense pain may cause the brain to trigger a series of wake-up calls. Some may be too deep in their sleep because of alcohol that they may not wake up. Some are awakened because of the pain, but may already be too weak to move to seek help. They may make groans or make other noises by banging their bedside table or breaking whatever that can call attention, but because others are deeply asleep, these calls for help are usually unrecognized.

Complications of AHP are caused by markedly deranged activities in the pancreas. Under normal circumstances, many of the extremely potent enzymes produced by the pancreas are not active until they are passed into the duodenum, where contact with certain other chemicals allow them to activate their digestive function. In pancreatitis, something allows these enzymes to become prematurely activated, so that they actually begin their digestive functions within the pancreas. The pancreas, in effect, begins a destructive process of auto-digestion or digesting itself.

Inflammation

A cycle of inflammation begins, including swelling and loss of function. Erosion of the blood vessels in the pancreas results in bleeding leading to AHP. Other active pancreatic chemicals cause blood vessels to become leaky, and fluid begins leaking out of the normal circulation into the abdominal cavity. The activated enzymes also gain access to the bloodstream through eroded blood vessels, and begin circulating throughout the body.

The pancreatic tissues then begin to die, and bleeding further increases. The bleeding in the abdomen causes two distinctive signs, which may be noted in patients with necrotizing pancreatitis. Turner’s sign is the term for the reddish-purple or greenish-brown color to the flank area or the area between the ribs and the hipbone. Cullen’s sign refers to the bluish color around the navel. Some may suspect foul play because of these signs, but they’re part of AHP.

Fatal complications of AHP are generally due to shock. When shock occurs, all of the body’s major organs are deprived of blood and, therefore, oxygen, resulting in damage. Kidney, respiratory and heart failure are serious risks of shock.

The pancreatic enzymes that have begun circulating throughout the body, as well as the poisons created by the abnormal digestion of the pancreas by those enzymes, have severe effects on the major body systems. Any number of complications can occur, including damage to the heart, lungs, kidneys, lining of the gastrointestinal tract and liver.

Once the pancreas is triggered to start the fatal process of auto-digesting, the damage is immediate and fast. This is why the chance of survival is relatively slim for AHP victims. When necrosis, or the presence of dying pancreatic tissues, and bleeding are already present, majority of patients may die even in the best of hands and facilities.

Treatment

However, in fortunate cases who are awakened from sleep or is conscious during the attack, treatment could still be possible if promptly administered. Treatment of acute pancreatitis involves quickly and sufficiently replacing lost fluids by giving the patient intravenous fluids. Pain is treated with a variety of medications.

In order to decrease pancreatic function and decrease the discharge of more potentially harmful enzymes, the patient is not allowed to eat for a few days. A thin, flexible tube (naso-gastric tube) is inserted through the patient’s nose into his or her stomach. Oxygen may need to be administered by nasal prongs or by a mask.

Complications, such as abscesses or other infections that often occur in cases of necrotizing pancreatitis, will require antibiotics administered intravenously. Severe necrotizing pancreatitis may require surgery to remove part of the dying pancreas and drain the abscess, if present. When diagnostic exams reveal the presence of gallstones, surgery may also be necessary for the removal of the gall bladder.

However, treatment does not mean complete cure. Those who have survived the fatal attack of pancreatitis may develop diabetes because of the decreased ability of their pancreas to produce insulin.

Prevention is important but may be just as empirical as preventing hiccups. A medical check-up may help unveil triggering factors. This will enable gallstones to be detected and surgically removed before they can block the passages (common bile duct and pancreatic duct) that can trigger damage to the pancreas.

Avoiding heavy alcohol drinking may also help prevent acute pancreatitis. Patients who survived an attack of acute pancreatitis must stop drinking alcohol completely. They should not push their luck too far. The problem can hit them at another time and may become chronic or recurrent. Drugs that may cause pancreatitis should also be avoided in high-risk individuals. Doctors also advise against eating a high carbohydrate diet before sleeping.

But after all the precautions are taken, we should also pray to God before we sleep to tell our guardian angels to wake us up and our companions should we have a bout of acute pancreatitis in our sleep. Although AHP is pretty scary, let us not lose sleep on this. It only happens in one out of 2,500 individuals. Let’s just pray that we belong to the 2,499 who will never have it.

(Charter is a non-stock, non-profit research foundation based at the Manila Sanitarium Hospital. It aims to promote a healthy lifestyle as an effective strategy in preventing most common medical problems. For feedback, e-mail [email protected].)