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The pancreas is an organ that has two important functions in digestion: the production of enzymes to digest food and the production of hormones to control blood sugar. The pancreas is positioned beneath and behind the stomach in a location referred to as the retro peritoneum.
It is surrounded by the stomach, small intestine, spleen, and liver. The pancreas has a structural shape similar to a fish with the three main parts being the head, body, and tail.
The pancreas is responsible for producing enzymes to digest food. These enzymes pass through the pancreas into the intestine through a pipe referred to as the pancreatic duct. Without these enzymes, food is not digested and absorbed, leading to malnutrition, weight loss, and diarrhea.
The pancreas makes insulin and glucagon, two important hormones that control blood sugar. Patients who do not make enough insulin develop diabetes mellitus.
Common Disorders of the Pancreas
There are a variety of disorders of the pancreas including acute pancreatitis, chronic pancreatitis, hereditary pancreatitis, and pancreatic cancer. The evaluation of pancreatic diseases can be difficult due to the inaccessibility of the pancreas.
There are multiple methods to evaluate the pancreas. Initial tests of the pancreas include a physical examination, which is difficult since the pancreas is deep in the abdomen near the spine. Blood tests are often helpful in determining whether the pancreas is involved in a specific symptom but may be misleading.
The best radiographic tests to evaluate the structure of the pancreas include CAT (computed tomography) scan, endoscopic ultrasound, and MRI (magnetic resonance imaging). Tests to evaluate the pancreatic ducts include ERCP (endoscopic retrograde cholangiopancreatography) and MRCP (magnetic resonance cholangiopancreatography).
There are also instances in which surgical exploration is the only way to confirm the diagnosis of pancreatic disease.
1. ACUTE PANCREATITIS
Acute pancreatitis is a sudden attack causing inflammation of the pancreas and is usually associated with severe upper abdominal pain. The pain may be severe and last several days. Other symptoms of acute pancreatitis include nausea, vomiting, diarrhea, bloating, and fever.
In the United States, the most common cause of acute pancreatitis is gallstones. Other causes include chronic alcohol consumption, hereditary conditions, trauma, medications, infections, electrolyte abnormalities, high lipid levels, hormonal abnormalities, or other unknown causes. The treatment is usually supportive with medications showing no benefit. Most patients with acute pancreatitis recover completely.
2. CHRONIC PANCREATITIS
Chronic pancreatitis is the progressive disorder associated with the destruction of the pancreas. The disease is more common in men and usually develops in persons between 30 and 40 years of age. Initially, chronic pancreatitis may be confused with acute pancreatitis because the symptoms are similar. The most common symptoms are upper abdominal pain and diarrhea.
As the disease becomes more chronic, patients can develop malnutrition and weight loss. If the pancreas becomes destroyed in the latter stages of the disease, patients may develop diabetes mellitus. The most common cause of chronic pancreatitis in the United States is chronic alcohol consumption. Additional causes include cystic fibrosis and other hereditary disorders of the pancreas. For a significant percentage of patients there is no known cause. More research is needed to determine other causes of the disease. The treatment for chronic pancreatitis depends on the symptoms.
Most therapies center on pain management and nutritional support. Oral pancreatic enzyme supplements are used to aid in the digestion of food. Patients who develop diabetes require insulin to control blood sugar. The avoidance of alcohol is central to therapy.
3. HEREDITARY PANCREATITIS
In some cases, pancreatitis is related to inherited abnormalities of the pancreas or intestine. Acute recurrent attacks of pancreatitis early in life (under age 30) can often progress to chronic pancreatitis. The most common inherited disorder that leads to chronic pancreatitis is cystic fibrosis. Recent research demonstrates genetic testing can be a valuable tool in identifying patients predisposed to hereditary pancreatitis.
As in chronic pancreatitis, hereditary pancreatitis is a progressive disease with a high risk of permanent problems. Patients with these disorders may have chronic pain, diarrhea, malnutrition, or diabetes. Treatment focuses on pain control and pancreatic enzyme replacement.
4. PANCREATIC CANCER
Pancreatic cancer is the fourth most common cause of cancer death in men and the fifth in women. Cancer of the pancreas is resistant to many standard treatments including chemotherapy and radiation therapy. This cancer grows insidiously and initially does not cause symptoms. The classic presentation of pancreatic cancer is referred to as painless jaundice, a yellowish skin discoloration with no other symptoms. The diagnosis is usually made using different radiographic imaging techniques.
Pancreatic Endocrine Tumour
Pancreatic endocrine tumors are those that arise from the types of pancreatic cells that produce hormones. These tumors may or may not secrete hormones themselves and may or may not be cancerous (malignant). Even if they do not secrete hormones (nonfunctioning tumors) and are not cancerous, these tumors may cause symptoms by blocking the biliary tract or small intestine or by bleeding into the gastrointestinal tract. Functioning tumors secrete large amounts of a particular hormone, causing various syndromes.
The treatment for both types of tumors is surgery. People who are not candidates for surgery receive treatments that block the production or actions of hormones.
An insulinoma is a rare type of pancreatic tumor that secretes insulin, a hormone that lowers the levels of sugar (glucose) in the blood. Only 10% of insulinomas are cancerous. The average age at diagnosis is 50.
Symptoms result from low levels of sugar (glucose) in the blood, which occur when the person does not eat for several hours (most often in the morning after an all-night fast). The symptoms include faintness, weakness, trembling, and awareness of the heartbeat (palpitations), sweating, nervousness, and profound hunger. Other symptoms include headache, confusion, vision abnormalities, unsteadiness, and marked changes in personality. The low levels of sugar in the blood may even lead to a loss of consciousness, seizures, and coma.
» Diagnosis and Treatment
Diagnosing an insulinoma can be difficult. Doctors try to perform blood tests while the person has symptoms. Blood tests include measurements of blood glucose levels and insulin levels. Very low levels of glucose and high levels of insulin in the blood indicate the presence of an insulinoma. Because many people have symptoms only occasionally, doctors may admit them to the hospital. In the hospital, the person fasts for at least 48 hours, sometimes up to 72 hours, and is closely monitored. During that time, the symptoms usually appear, and blood tests are performed to measure the levels of glucose and insulin.
If the blood tests suggest the person has an insulinoma, the location must then be pinpointed. Imaging tests, such as endoscopic ultrasonography (which shows the lining of the digestive tract more clearly because the ultrasound probe is placed on the tip of the endoscope) or positron emission tomography scans, can be used to locate the tumor, but sometimes exploratory surgery is needed.
A gastrinoma is a tumor usually in the pancreas or duodenum (the first segment of the small intestine) that produces excessive levels of the hormone gastrin, which stimulates the stomach to secrete acid and enzymes, causing peptic ulcers. Most people with gastrinomas have several tumors clustered in or near the pancreas. About half of the tumors are cancerous. Sometimes a gastrinoma occurs as part of multiple endocrine neoplasia, a hereditary disorder in which tumors arise from the cells of various endocrine glands, such as the insulin-producing cells of the pancreas.
» Symptoms and Diagnosis
The excess gastrin secreted by the gastrinoma causes Zollinger-Ellison syndrome in which a person suffers the symptoms of aggressive peptic ulcers in the stomach, duodenum, and elsewhere in the intestine. However, as many as 25% of people with Zollinger-Ellison syndrome may not have an ulcer when the diagnosis is made. Rupture, bleeding, and obstruction of the intestine can occur and are life threatening. For more than half of the people with a gastrinoma, symptoms are no worse than those experienced by people with ordinary peptic ulcer disease. In 25 to 40% of people, diarrhea is the first symptom.
A doctor suspects a gastrinoma when a person has frequent peptic ulcers or several peptic ulcers that do not respond to the usual ulcer treatments. Blood tests to detect abnormally high levels of gastrin are the most reliable diagnostic tests.
Once blood tests diagnose gastrinoma, doctors use several imaging techniques, such as computed tomography (CT) of the abdomen, scintigraphy (a type of radionuclide scanning), endoscopic ultrasonography, PET scans, and arteriography (an x-ray taken after a radiopaque dye is injected into an artery), to locate tumors. These tumors may be difficult to find, however, because usually they are small.
If the tumor is completely surgically removed, people have a greater than 95% chance of surviving 5 to 10 years. If the tumor is not completely removed, people have a 43% chance of surviving 5 years and a 25% chance of surviving 10 years.
A vipoma is a rare type of pancreatic tumor that produces vasoactive intestinal peptide (VIP), a substance that causes severe watery diarrhea. About 50 to 75% of these tumors are cancerous. In about 6% of people, vipoma occurs as part of multiple endocrine neoplasia.
The major symptom is prolonged massive watery diarrhea. People produce 1 to 3 quarts (1,000 to 3,000 milliliters) of stool per day, causing dehydration. In 50% of people, diarrhea is constant, and in the rest, the severity of the diarrhea varies over time.
Because the diarrhea removes many of the body's normal salts, people often develop low blood levels of potassium (hypokalemia) and excessively acidic blood (acidosis). These changes can cause lethargy, muscular weakness, nausea, vomiting, and crampy abdominal pain. Some people have flushing.
A glucagonoma is a tumor of the pancreas that produces the hormone glucagon, which raises the level of sugar (glucose) in the blood and causes a distinctive rash. About 80% of glucagonomas are cancerous. However, they grow slowly, and many people survive for 15 years or more after the diagnosis. The average age at which symptoms begin is 50. About 80% of people with glucagonomas are women. A few people have multiple endocrine neoplasia.
» Symptoms and Diagnosis
High levels of glucagon in the blood cause the same symptoms as diabetes, such as weight loss and frequent, excessive urination. In addition, 90% of people have the very distinctive features of a chronic brownish red skin rash (necrolytic migratory erythema) and a smooth, shiny, bright red-orange tongue. The mouth also may have cracks at the corners. The rash, which causes scaling, starts in the groin and moves to the buttocks, forearms, hands, feet, and legs.
The diagnosis is made by identifying high levels of glucagon in the blood and then locating the tumor by performing an abdominal CT scan followed by endoscopic ultrasonography. Magnetic resonance imaging (MRI) or a PET scan may be used if the CT scan does not show a tumor.