Pancreatic Cancer

THE PANCREAS

The pancreas is located in the abdomen, tucked behind the stomach. between the upper part of your small intestine (duodenum) and the spleen. It is shaped somewhat like a tadpole - fat at one end and slender at the other - and is around 25cm in length.

The pancreas serves two distinct and vital functions;

1. The exocrine pancreas

Once food has been mulched and partially digested by the stomach, it is pushed into the duodenum (first part of the small intestine). The pancreas helps to digest food, particularly protein. Most of the pancreas is compose of cells called exocrine cells that produce digestive enzymes. Pancreatic enzymes flow from these cells through small ducts into the main pancreatic duct, which leads to the duodenum. Pancreatic juices contain enzymes that only become activated once they reach the duodenum. This is to prevent the protein-digesting enzyme trypsin from 'eating' the protein-based pancreas or its duct. Other enzymes produced by the pancreas include amylase (to break down carbohydrate) and lipase (to break down fats).

The exocrine pancreas also makes sodium bicarbonate, which helps to neutralise stomach acid entering the duodenum.

2. The endocrine pancreas

The pancreas makes the hormone insulin, which helps to control blood sugar levels. Insulin is manufactured by a small clump of pancreatic cells called the 'islets of Langerhans'. High blood sugar levels prompt the release of insulin, so that the sugars can pass into cells. The endocrine pancreas also
makes glucagon, another hormone involved in the regulation of blood sugar.

DIAGNOSIS OF PANCREATIC DISEASE

Diagnostic methods depend on the disorder under investigation, but may include:

· General tests - such as blood tests, physical examination and x-rays.

· Ultrasound - sound waves form a picture of the pancreas.

· Computerised tomography (CT) scan - a specialised x-ray takes three-dimensional pictures of the pancreas.

· Magnetic resonance imaging (MRI) - similar to a CT scan, but
magnetism is used to build three-dimensional pictures.

· Endoscopy (ERCP) - a thin telescope is inserted down the throat. This device may be used to inject contrasting dye into the pancreatic duct prior to x-rays.

· Laparoscopy - the pancreas is examined through a slender instrument
inserted into the abdomen.

· Biopsy - a small tag of pancreatic tissue is taken out with a needle and examined in a laboratory.

PANCREATITIS

The pancreas plays important roles in both digestion and metabolism. These functions may be affected by pancreatitis, an inflammatory condition that occurs when pancreatic digestive enzymes become active within the gland and attack the pancreas itself.

Pancreatitis can be acute — appearing suddenly and lasting for a few days — or it can be chronic, developing gradually and persisting over many years. Both acute and chronic pancreatitis are marked by mild to severe abdominal pain, often with nausea, vomiting and fever. Both can lead to serious complications.

Heavy alcohol use and gallstones are the primary causes of pancreatitis, but other factors, including certain medical conditions, some drugs and genetic mutations also can lead to the disorder. Sometimes the cause is never found..

ACUTE PANCREATITIS

Acute pancreatitis is inflammation of the pancreas. This is a medical emergency and requires prompt treatment. It occurs when the pancreas suddenly becomes inflamed - the enzymes can't leave the pancreas and so cause irritation and burning. Enzymes may also leech into the abdominal cavity.

The two most common causes for pancreatitis are:

· Drinking too much alcohol

· Gallstones

Other causes include:

· Medications such as corticosteroids, nonsteroidal anti-inflammatory drugs, thiazides used for blood pressure lowering, antibiotics including tetracyclines and sulphonamides and immunosuppression with azathioprine and 6-mercaptopurine.

· Increased levels of triglycerides (fats) or calcium in the blood.

· Viral infections including mumps

· Damage or trauma to the pancreas

· Pancreatic cancer

Acute pancreatitis comes on suddenly, usually with mild to severe pain in the upper abdomen that may radiate through to the back and occasionally to the chest. The pain may be nearly constant for hours or even days and is likely to be worse with food. Bending forward or curling into a fetal position may provide some temporary relief.

Apart from pain the presentation may feature:

· Nausea and vomiting

· Fever

· Rapid pulse

· Swollen, tender abdomen

When severe, dehydration, internal bleeding, low blood pressure or shock

DIAGNOSIS

If acute pancreatitis is suspected, the doctor will arrange blood tests to look for:

· Elevated levels of pancreatic enzymes—amylase or lipase

· Elevated white cell count

· High blood sugar

· Elevated liver enzymes and bilirubin

· Low calcium levels

· Oxygen status

Because laboratory tests can't confirm a diagnosis of acute pancreatitis, the doctor may request an ultrasound or computerized tomography (CT) scan of your abdomen to examine your pancreas and to check for gallstones, a duct problem, or destruction of the gland. You may also have X-rays of your abdomen and chest to rule out other reasons for your symptoms.

COMPLICATIONS

Severe cases of acute pancreatitis may lead to a number of complications:

· Infection A damaged pancreas may become infected with bacteria that spread from the bowel into the inflamed pancreas. The infection may also spread to the blood-stream. Signs of infection include fever and an elevated white blood cell count. Pancreatic infections can be fatal without intensive treatment which may include drainage and surgical removal to remove infected and/or dead tissue. Sometimes multiple such operations are needed. Multi-organ failure may also occur.

· Pseudocysts These are collections of pancreatic fluid and tissue debris that form within the pancreas or in an obstructed duct. If small no specific treatment may be necessary but if large, bleeding or infected then urgent measures are needed.

· Abscess A collection of pus in or near the pancreas. Treatment involves drainage by needle, catheter or surgery.

· Respiratory failure Chemicals circulating in the blood can effect lung function, causing the level of oxygen in the blood to fall to low levels.

TREATMENT

Acute pancreatitis usually requires admission to hospital. Severe cases or those with complications often need admission to an Intensive Care Unit. Treatment goals include controlling the pain, allowing the pancreas to rest, careful fluid balance and maintaining full respiratory function.

Because the pancreas goes into action whenever you eat, you won't be able to eat or drink for a few days. Instead, you'll receive fluids and nutrition through a vein (intravenously). Your doctor may also feed you through a tube that's been passed into your stomach and intestine so that it goes past the pancreas. Placing the tube in the bowel beyond the pancreas ensures that the pancreas is not stimulated, yet you can still receive the nutrition you need.

When gallstones block the pancreatic duct, your doctor may recommend a procedure to remove the stones. You may eventually need surgery to remove your gallbladder if gallstones continue to pose problems.

Mild cases of acute pancreatitis generally improve in a week or less. Moderate to severe cases take longer.

CHRONIC PANCREATITIS

Chronic pancreatitis means recurring bouts of inflammation, even when known triggers (such as alcohol) are eliminated. Alcoholics are at increased risk of developing this condition. The relentless inflammation eventually damages or destroys parts of the pancreas, reducing its function. Symptoms include digestive upsets and passing fatty, foul-smelling stools.

In addition to pain, one may experience the following with chronic pancreatitis:

· Nausea and vomiting

· Fever

· Weight loss, even when appetite and eating habits are normal

· Oily, malodorous stools resulting from poor digestion and malabsorption of nutrients, particularly fats (steatorrhea)

· Diabetes

DIAGNOSIS

Diagnosing chronic pancreatitis can be challenging because some tests may yield normal results. It can also be difficult to distinguish acute from chronic pancreatitis. Even so, certain tests can help rule out other problems and aid in the diagnosis.

These include:

· Blood tests.

· Stool test. This measures the fat content in feces. Chronic pancreatitis often causes excess fat in the stool because the fat isn't digested and absorbed normally by the small intestine.

· Pancreatic function test. If there is weight lost or the doctor suspects a malabsorption problem, a pancreatic function test can be used. Several tests exist but are not commonly used.

· Ultrasound. In standard (external) ultrasound, a wand-like device (transducer) is placed on the body. It emits inaudible sound waves that are reflected to the transducer and then translated into a moving image by a computer.

· Endoscopic ultrasound may provide images of the pancreas and bile and pancreatic ducts that are superior to those produced by standard ultrasound.

· ERCP (X-ray of bile and pancreatic ducts). The doctor gently threads an endoscope down the throat and through the stomach to the opening of the bile and pancreatic ducts in the duodenum. A dye passed through a thin, flexible tube (catheter) inside the endoscope allows for X-ray images of the ducts.

The complications common to acute pancreatitis can also occur in the chronic form of the disease. In addition, chronic pancreatitis can lead to:

· Bleeding. Ongoing inflammation and damage to the blood vessels surrounding the pancreas can cause potentially fatal bleeding.

· Malnutrition and weight loss. Lack of digestive enzymes prevents your body from absorbing nutrients from food. The result is often unintended weight loss and malnutrition.

· Diabetes. Damage to insulin-producing cells can lead to diabetes, a disease that affects the way your body uses blood sugar.

· Drug addiction. Because medical treatments for severe pancreatic pain aren't always effective, people with pancreatitis may become addicted to pain medications.

· Pancreatic cancer. Long-term inflammation of the pancreas increases your risk of pancreatic cancer, one of the most serious of all malignancies.

TREATMENT

The main goals of treatment for chronic pancreatitis are to help stop alcohol and drug abuse, control pain and improve malabsorption problems.

. Pain relief. Unlike acute pancreatitis, in which the pain often disappears within a few days to weeks, chronic pancreatitis pain can linger. However, conventional pain relievers can be ineffective and pose a real risk of addiction. Using potent pancreatic enzymes to treat pain has proved effective for some people. Enzyme therapy works by increasing the levels of enzymes in the duodenum, which in turn decreases the secretion of enzymes by the pancreas. This is thought to reduce secretion pressure — and hence, pain — within the pancreas. For severe pain that can't be controlled, treatment options include surgery to remove damaged tissue or procedures to block pain signals or deaden the nerves transmitting the pain.

Enzyme therapy. Enzyme supplements such as pancreatic lipase (Pancrease) can help treat malabsorption problems. By replacing missing enzymes, these tablets help restore normal digestion and improve steatorrhea, leading to weight gain and enhanced well-being. These supplements are generally taken before and during meals and snacks.

Dietary changes. Your doctor may recommend eating smaller meals and limiting fats, which will help reduce your need for as many digestive enzymes.

Diabetes
Chronic pancreatitis can cause diabetes in some people. Treatment usually involves maintaining a healthy diet and getting regular exercise. Some people also need insulin injections, although insulin must be used cautiously because of the risk of low blood sugar (hypoglycemia).

Therapy for alcohol dependency. This may be the most important step in treating alcohol-related pancreatitis. In the early stages of the disease, simply stopping drinking may relieve even severe pain. People who don't stop drinking have a significantly higher chance of dying of pancreatitis