PANCREAS

 

The pancreas gland is located behind the stomach in the retroperitoneal space, it is an organ with exocrine and endocrine functions.

 

Functions of the pancreas

Exocrine function: Pancreas daily secretes 1000-2000 ml of clear, odourless, plasma containing isotonic, alkali (pH = 8.0-8.3) and approximately 20 different digestive enzymes.

It has an important role in the comminution and absorption of protein, fats and carbohydrates.

Endocrine function: the islets of Langerhans make up just 1-2% of the pancreatic mass but they receive 20% of the total pancreatic blood flow. The islets of Langerhans secretes insulin, glucagon, somatostatin, to provide electrolyte and blood sugar and metabolic balance.

 

Pancreatitis

Pancreatitis - inflammation of the pancreas gland. It can manifest itself in different way up to hemorrhagic necrosis, fibrosis, temporary or permanent exocrine and endocrine dysfunction. It is divided into two groups: acute and chronic. In acute pancreatitis after the treatment of the primary cause morphological changes are getting normal. In chronic pancreatitis recurrent attacks and inflammation cause permanent, progressive tissue damage.

 

Causes of acute pancreatitis

• Gallstones, biliary tract diseases

• Alcohol

• Medications: sulfonamides, steroids, estrogens.

• Trauma: blunt trauma, surgical interventions

• Hypercalcemia: hyperparathyroidism

• Malnutrition: protein-calorie

• Hyperlipidemia

• Ductal obstruction: pancreas divisum stricture, tumor, penetrating duodenal ulcers.

• Duodenal obstruction: afferent loop syndrome

• Infections: mumps, coxsackie, mycoplasma pneumoniae, ascaris, clonorchis.

• Ischemia

• Hereditary

• Scorpion toxin

• Idiopathic (unknown cause)

 

Biliary and alcoholic pancreatitis  are responsible for 75-80% of cases. The most common cause of acute pancreatitis are gallstones.

Acute pancreatitis is diagnosed basing on the physical examination findings . There is no biochemical test showing definitive diagnosis. The most common symptom is epigastric pain. The pain is severe and constant, often spreads on back. Often occurs together with constant nausea and vomiting, after a heavy meal or alcohol intake. In chronic form of disease acute exacerbation comes up with the same findings.

• Fever: > 38 C

• Signs of dehydration and hypotension.

• Tachycardia

• Jaundice: occurs in 20-25% of cases.

• Acute abdomen: It is especially evident in epigastrium, may be spread. Generally the mass is not palpable. If there is a palpable mass it is phlegmon pseudocyst or abscess.

• Distension: bowel sounds decreased or undetectable.

 

Treatment

Usually acute inflammation of the pancreas can be treated using conservative approach. Medical, endoscopic and surgical treatment can be applied.

Medical Treatment: IV fluid injections (intravenous)

Antibiotics

Analgesia (painkillers)

 

Interventions: Peritoneal lavage

ERCP

 

Surgery:

Due to lack of respons to the medical treatment, development of complications like

Abscess → drainage - irrigation

Hemorrhagic pancreatitis

Necrosis

Abdominal bleeding

According to the diagnosis and course of the disease cholecystectomy bile duct exploration, irrigation, drainage of abscesses, necrosectomy, resection and often relaparotomie can be performed.

 

Chronic pancreatitis

The majority of cases manifest itself by recurrent abdominal pain.

 

Etiology

The most common cause is chronic alcoholism. The mechanism is still not completely known. Hyperparathyroidism, aminoaciduria, chronic ductal obstruction caused by congenital anomalies can also lead to chronic pancreatitis.

 

Treatment

The most important approach is pain control. Alcohol intake should be stopped. Somatostatin analogues and narcotic analgesics may be necessary to use.

In chronic pancreatitis diabetic ketoacidosis occurs rare, in this cases dosing of insulin is recommended, oral anti-diabetic drugs brings no benefits.

 

Surgery:

Indications: Pain (continuous or unot responding to medications)

Bile duct obstruction

Duodenal obstruction

Colon obstruction

Pancreatic cancer suspicion

Splenic or portal vein obstruction

 

Drainage surgery: Lateral pancreaticojejunostomy (Puestow surgery), distal pancreaticojejunostomy, sphincteroplasty.

Resection: Distal subtotal (50%, 80-85, 95), total, pancreaticoduodenectomy.

Transplantation: rarely used for pancreatitis.

 

Pancreatic Cancer

Pancreatic cancer is one of the worst type of cancer. Early diagnosis is extremely important. In cases of surgical treatable and early recognized pancreatic cancer the survival rate is no more than 5-years. Life expectancy in late diagnosed cases with no chances of surgical treatment is very short.

 

Risk factors

Gender: occurs in men more often

Age: in 80% occurs in age between 60-80

Pancreatic cancer in relatives

Pancreatitis (hereditary and chronic pancreatitis)

Smoking

Diabetes (?)

 

Symptoms

Symptoms depend on the location. If cancer is located in pancreatic head symptoms are observed earlier. Patients with cancer at this location usually look for medical consultation because of jaundice. In next stage we can observe symptoms like:

weight loss (92%), pain (72%), jaundice (82%), darkening of the urine (63%), acholic stool (62%), anorexia (64%), nausea (37%), fatigue (35%), pruritus (24%), vomiting (37%).

 

Symptomes of tumors located in the pancreatic body and tail are:

weight loss (100%), pain (87%), fatigue (43%), nausea (45%), anorexia (33%), vomiting (37%), jaundice (7%), darkening of the urine (5%), acholic stool (6%), pruritus (4%)

 

Due to late and rare jaundice occurrence patients generally get medical help too late.

 

Treatment (head, neck location)

70% of head, neck and uncinate process tumor location.

Surgical treatment:

Pancreaticoduodenectomy

Extended radical pancreaticoduodenectomy

 

Treatment (body and tail located cancer)

Body and tail located tumors often are metastasis. (10% of resectable)

Surgical treatment:

Distal pancreatectomy (splenectomy, in malignant tumors)