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Pancreas

1. Definition Pancreas
The pancreas is an organ which lies in the centre of our bodies, hidden behind the stomach and next to the spine (Fig. 1). It can be divided roughly into three parts: the head, the body and the tail (Fig. 2). The head of the pancreas is closely connected to the first part of the small intestine, known as the duodenum . The tail of the pancreas has a closer connection to the spleen . The body of the pancreas lies directly in front of the point where a number of important arteries leave the aorta to supply blood to the liver, the stomach, the upper part of the intestine and the pancreas itself.

 
 
 

Basically, the pancreas has two functions:
1. The pancreas is important in the digestion process.
2. The pancreas regulates the levels of sugar in the blood.

The Pancreas and Digestion
The pancreas produces enzymes which are important in digestion. These enzymes are produced in the form of gastric juices in specialised cells throughout the pancreas These juices travel down a wide system of ducts before gathering in the main pancreatic duct and being directed towards the duodenum. Shortly before flowing into the duodenum, the pancreatic secretions , rich in digestive enzymes, merge with bile which comes from the liver. This mixture of secretions enters the duodenum , where the pancreatic enzymes are activated in order to digest the food coming from the stomach.

The pancreas produces around 30 different digestive enzymes, which after activation are capable of breaking food down into its smallest elements. Although the enzymes are produced in the pancreas, they only become active and able to do their task on reaching the duodenum. This prevents the enzymes from digesting the pancreas itself. The three most important enzymes produced in the pancreas are:
Amylase : digests the majority of carbohydrates
Trypsin : digests the majority of proteins
Lipase : digests the majority of fats


The breakdown of food into its constituent parts is necessary in order that the body can absorb these through the intestines. In the absence of the pancreatic enzymes, sugars, proteins and fats will not be broken down properly and the intestines will not be able to absorb nutrients into the bloodstream. This can lead to serious diarrhoea, flatulence and even abdominal cramps. In addition, steady weight loss will occur, as nutrients cannot be absorbed into the body.

The Pancreas and the Regulation of Blood Sugar
Apart from digestive enzymes, the pancreas also produces an important hormone , known as insulin . Insulin is manufactured in special groups of cells known as the Islets of Langerhans, which can be found throughout the pancreas, but are mainly located in the tail of the organ. The insulin is secreted directly into the bloodstream from these cells in the pancreas. The hormone is essential for the control of blood sugar levels.
Insulin opens the door, as it were, for sugar to enter all the cells of the body. Sugar is an important source of energy for our bodies. Every cell is dependent on sugar. After the sugar has been absorbed into the blood through the intestine, insulin enables the sugar to pass from the blood into the various cells of the body. If there is not enough insulin, or none at all, the sugar cannot enter the cells from the blood. As a result, the sugar level in the blood rises steadily, and this can have unpleasant or even life-threatening consequences for the patient. The disease where the pancreas fails to produce or produces insufficient insulin is known as diabetes mellitus. Diabetics suffer from varying degrees of insulin deficiency.
The production of pancreatic enzymes and the production of insulin are largely separate processes. If for any reason the pancreas is damaged, both functions, independent of each other, may be disrupted.

Methods of Examination

I have a problem with my pancreas? What tests should I expect?
First of all, on the basis of the symptoms the patient describes to him and a physical examination, the doctor will say that he suspects something is wrong with the pancreas. In order to confirm this suspicion and to establish the exact nature of the pancreatic disorder, a blood test will be carried out, together with one or more additional tests. In the following section, further details are given of the various tests which are available in order to diagnose disorders of the pancreas.

The Ultrasound Test (Sonography)
The ultrasound examination is the simplest way of obtaining an image of the inside of the body. Using a form of sensor, which the doctor lays on the skin, sound waves are transmitted into the body. These waves are reflected by the internal organs and picked up by the same sensor. The strength of the reflected signal varies from organ to organ, and this is used to produce images in which the various internal organs such as the liver, kidneys and pancreas can be recognised. By carefully examining the pictures, the doctor is able to see any changes in the organs which may indicate disease.
The test procedure is normally as follows:
In order to improve the quality of the image, the patient should not have anything to eat or drink in the 6 to 8 hours before the test (in order to have an empty digestive system), otherwise there will be too much air in the intestines, which will limit the quality of the test. The test is conducted with the patient lying down. Before the sensor is laid on the body, some jelly will be spread on the skin in order to improve contact between the skin and the sensor. The jelly may feel cold, but otherwise the test procedure does not involve any pain or discomfort. Ultrasound waves have no side effects.

Computerised Tomography (CAT Scan)
This is probably the most common procedure used in the diagnosis of pancreatic disorders. The computerised tomograph is a form of x-ray machine which produces a large number of cross section images of the body. These give a precise view of the state of the pancreas and the organs surrounding it. The test procedure is normally as follows: Half an hour or so before the test, the patient has to drink a special liquid (approx. 8 dl of contrast medium). This liquid makes the stomach and intestine appear white in the images and allows them to be easily distinguished from other organs. The test is carried out in a special room and the patient lies on an table which moves automatically. The patient receives instructions and information from the control room by intercom. The CAT machine resembles a wide tube about 1m long, and the patient is moved slowly through it as the cross-section pictures are taken. In the second half of the test another form of contrast agent is injected into a vein in the arm, and this enables blood vessels and internal organs to be seen more clearly. The entire test takes about 30 minutes.

Magnet Resonance Imaging (MRI)
The MRI test is similar to the CAT test, in that cross-section pictures are again taken. However, the test does not use x-rays, but works using changing magnetic fields. The patient has to lie in an enclosed metal tube and try to remain as still as possible throughout the procedure. Patients who suffer from claustrophobia should inform their doctors before the test is carried out, as should patients who have had a pace-maker fitted or any other prostheses containing metal parts, because, as the test involves the use of magnetism, this could possibly lead to problems. The procedure takes an hour to an hour and a half. Fig. 3 Magnetic Resonance Imaging: the patient lies on his/her back and is slid into the test chamber.

Endoscopic Retrograde Cholangio-Pancreatography (ERCP)
ERCP allows a precise examination of the bile ducts and pancreas to be carried out. This is a highly important supplementary test to the other image-producing tests. In the course of ERCP, other procedures can be carried out, such as the removal of a gall stone, which could block the bile duct or the pancreatic duct.
The test procedure is normally as follows:
The patient is sedated in order to reduce discomfort during the test. This requires that the patient has nothing to eat or drink in the 6 hours before the test. An intravenous drip is inserted into the forearm, so that the patient can be given a sedative, antibiotics and other medication before and during the test. The patient lies on his side and, as in a gastroscopy, an endoscope is fed into his mouth and through the digestive system until it reaches the duodenum. The doctor follows the progress of the endoscope on a computer screen. When the point is reached where the bile ducts converge with the duodenum, a small tube is fed out of the endoscope and into the bile duct/the pancreatic duct. A contrast medium is now sprayed from the tube into the ducts and x-rays are taken.
Sometimes it is necessary to make a small incision in the entrance to the bile duct/ pancreatic duct in order to make it larger (papillotomy). Most patients have little memory of the procedure.
In experienced hands, ERCP is safe and complication-free. In rare cases, the procedure can lead to acute pancreatitis, a bile duct infection or a haemorrhage. In exceptionally rare cases, (< 1%) an emergency operation is required.

Major Disorders of the Pancreas

Apart from certain rare hereditary disorders and abnormalities, there are three main forms of disease which are caused by changes in the digestive cells:

1. Pancreatic Tumours (Carcinoma of the Pancreas)
A tumour can form as a result of the uncontrolled growth of the pancreatic cells which normally produce gastric juices. These tumours may be benign or malignant. Malignant tumours tend to grow more quickly and invade the neighbouring parts of the organ. They can eventually produce secondary tumours (metastases) in other organs such as the liver or the lungs and in other areas of the body. The causes of pancreatic tumours remain unknown. As a result of experiments conducted by the Research Laboratory for Visceral Surgery at the Inselspital in Bern, which has carried out extensive research into pancreatic tumours, we know that alterations in the genetic material of pancreatic cells occur which cause healthy cells to become cancerous.

2. Acute Pancreatitis
A sudden and serious inflammation of the pancreas can cause major cell-damage which leads to the destruction of the organ itself. Normally this condition is caused by excessive alcohol consumption, or by gallstones, which block the pancreatic duct, although there are other less common causes.

3. Chronic Pancreatitis
The progressive destruction of the pancreas may result from recurrent inflammation and damage to the pancreas. The pancreatic tissue is broken down and replaced by scar tissue. The functioning of the pancreas in the digestive process steadily deteriorates, and less insulin is produced. Disorders of the digestive system and diabetes result. The most common causes of chronic pancreatitis are alcohol (around 80% of cases), congenital genetic defects, and other still largely unknown factors.

1. Pancreatic Cancer (Carcinoma of the Pancreas)

What is pancreatic cancer?
The causes of pancreatic cancer remain unknown at present, but a connection with smoking is suspected in some cases. Pancreatic tumours normally develop in the head of the pancreas. This results in the tumour blocking the common bile duct which means that the secretion of bile is either greatly reduced or stopped altogether and bile is backed up until it reaches the liver. This leads to jaundice, where bile-colouring in the skin causes it to turn yellow, the urine is dark and bowel movements become pale-coloured. Jaundice can also cause serious irritation of the skin, which quickly disappears as soon as the blockage of the bile duct in the head of the pancreas is cleared. A tumour in the head of the pancreas can also block the main pancreatic duct, preventing the digestive enzymes which are normally produced in the pancreas from reaching the intestines. This leads to poor digestion, weight loss and diarrhoea. These symptoms can be relieved by taking pancreatic enzyme supplements in tablet form, or by clearing the obstruction in the main pancreatic duct. Often the symptoms of diabetes mellitus appear before pancreatic cancer is diagnosed. Diabetes mellitus can however appear both after the diagnosis of cancer and after a pancreas operation. The most common form of pancreatic cancer arises in the duct cells in the head of the pancreas. Most patients are over the age of 60, but younger people may also develop the disease.

How does pancreatic cancer develop?
Pure research using methods based on molecular-biology has in recent years contributed to a significant increase in our knowledge of the causes of pancreatic cancer. Scientists have observed the increased presence of factors that stimulate the growth of cancer cells (growth factors), together with the mutation of certain genes which normally control cell growth and regulate cell death (apoptosis). Changes in the functioning of these factors allow the pancreatic cancer cells to grow more quickly than the healthy tissue and these changes are probably responsible for the resistance of the tumour to chemotherapy and radiotherapy. Further in-depth studies are necessary to investigate the precise character of these changes, as this could form a starting point for the development of new therapies. It is hoped that this research will result in the evolution of an improved form of treatment for pancreatic cancer.

What are the symptoms?
Unfortunately, in its early stages, pancreatic cancer has no characteristic symptoms. Commonly, a deterioration in general well-being takes place, with the patient suffering from loss of appetite and loss of weight. Often patients complain of a vague pain in the upper abdomen, sometimes spreading round to the back; this pain gradually increases in intensity as the disease progresses. As mentioned in the previous paragraph, tumours in the head of the pancreas can disrupt the flow of bile. This leads to jaundice, which is characterised by pale bowel movements, dark urine and irritation of the skin. Another common sign of pancreatic cancer is that the patient develops diabetes mellitus for the first time.

What are the causes?
The precise causes of pancreatic cancer remain unknown. The only known risk factor at the moment is smoking. There is no proof that certain eating habits, such as drinking a lot of coffee or eating fatty meals has any relationship with pancreatic cancer. Opinions differ at present as to whether increased alcohol consumption leads to a higher risk of developing the disease.

How can pancreatic cancer be detected at any early stage?
Even today, it often not possible to detect pancreatic cancer in its early stages. There are therefore no simple medical checks that can be carried out. Intensive research is being conducted to improve the chances of early detection, and pure research will certainly lead to new and improved diagnostic procedures in clinical practice.

What are the long-term consequences of pancreatic cancer and what form of after-care is given?
Many patients show the symptoms of diabetes mellitus before pancreatic cancer is diagnosed. After the operation, a stabilisation in this condition is normally observed, although some patients experience an improvement while for others the diabetes becomes worse. The diabetes is usually treated by following a special diet or taking medication. In a small number of cases, insulin has to be taken (by injection). In exceptional cases where the entire pancreas has been removed, insulin therapy will always be necessary.
Removal of part of the pancreas can lead to the reduced production of digestive enzymes. This results in digestive disorders, flatulence, or diarrhoea. This situation can be treated quite easily by taking tablets (or capsules) which contain pancreatic enzymes.
After a successful operation, the patient must be regularly monitored by means of physical examinations, laboratory tests and sometimes radiological examinations (ultrasound, CAT, magnetic resonance imaging). These tests are normally organised in consultation with the family physician. An additional treatment, using, for example, chemotherapy, is often carried out as part of a study and organised on a case to case basis with the patient, surgeon, oncologist (cancer specialist) and family physician.

What tests and preliminary examinations have to be carried out in the case of cancer of the pancreas?
The careful examination of patients with pancreatic tumours is carried out using the above mentioned special investigation methods, ultrasound, computerised tomography, magnet resonance imaging and ERCP. The choice of which specific method is used depends on the individual case, but a CAT scan of the abdominal cavity in combination with ERCP or MRI normally indicates whether surgery should be carried out or not. What is decisive is the quality of the test, which according to the experience of the staff and the equipment available can vary from one hospital to the next. The results of the investigations must be examined by a team of specialised doctors in order that a decision on an operation can be made.

How is pancreatic cancer treated?
Surgery, i.e. the removal of the tumour, promises the only hope of a cure. A cure is only possible if the cancer cells have not spread to other organs, such as the liver or the lungs. In addition, if the tumour has spread to surrounding vessels, it will not be possible to remove it completely. Experience so far has shown that in approximately 15% to 20% of all patients with pancreatic cancer, the surgical removal of the tumour can be carried out. In the course of the operation, not only the tumour but also the surrounding healthy part of the pancreas and parts of the stomach, the common bile duct, the duodenum and the gall bladder are removed.

If the tumour has reached an advanced stage, it will be impossible in many cases to remove it completely. The aim of the treatment is then to relieve the patient's symptoms. If the bile duct is blocked and the patient is suffering from jaundice, then the flow of bile must be restored. This can be done by inserting an endoscope into the bile duct or by a surgical procedure, known as biliodigestive anastomosis, in which a piece of the intestine is sewn on to the bile duct (Fig. 5), to ensure the flow of bile. If the tumour grows into the duodenum, it can disrupt the passage of food, i.e. food cannot pass from the stomach into the intestine or can only do so with difficulty. An operation, known as a gastroenterostomy, can be performed to join the stomach to the small intestine in order to by-pass the obstruction.

There are still no proven benefits of radiotherapy and/or chemotherapy in the treatment of pancreatic cancer. These forms of therapy therefore play a secondary role in the treatment of the disease. However, efforts are being made to develop new and more effective forms of treatment for pancreatic cancer. A range of new procedures are being tested at the moment in clinical trials.

What are the chances of a cure?
Surgery on the pancreas has in recent years become a very safe procedure. Nevertheless, very few patients who have had a tumour removed survive the first 5 years after the operation. In cases where the tumour cannot be removed, patients seldom survive for more than a year. The enormous efforts that are being put into research give us hope that this situation will improve significantly in the coming years. In relation to this, genetic therapies are worthy of special mention. In recent years, knowledge of the complex factors which cause pancreatic cancer has improved considerably. This knowledge can be combined with genetic therapies to offer the hope of a new start. However, a realistic assessment of the present situation shows that with the exception of a small number of selected patients who are undergoing genetic therapy as part of clinical studies, the research and development of genetic therapies is still taking place in the laboratory alone. Further examination of the molecular-biological changes in pancreatic cancer should lead to a clearer understanding of how tumours develop, and provide new starting points for the gene-based treatment of pancreatic cancer.

After-care
After the operation has been carried out, the patient has to be given regular checks, including physical examinations, laboratory tests and possibly also radiological tests (ultrasound, computerised tomography, magnetic resonance imaging). These follow-up examinations are normally organised in consultation with the patient's family doctor. An additional form of treatment, e.g. chemotherapy, is often carried out as part of studies into the disease, and this is organised on an individual basis between patients and their surgeons, oncologists (cancer specialists) and family doctors.

Part of my pancreas has been removed - what happens now?
Patients who have had a part or the whole of their pancreas removed may experience a reduction in the functioning of their pancreas, dependent on how much of the organ has been lost. This leads to two problems, above all: Too few pancreatic enzymes (leading to digestion problems) Too little insulin (leading to high blood-sugar levels) These deficiencies can be rectified by taking suitable medication.

1. Pancreatic Enzyme Substitution
Nowadays there are excellent, modern preparations on the market which contain substances that replace the pancreatic enzymes (e.g. Creon, Fig. 7). These preparations must be taken with all meals, including fat- or protein-rich snacks. The required dosage varies from patient to patient and is determined by the nature of the food and the symptoms of the patient. It is essential that the therapy eliminates the patient's bloated feeling and the foul-smelling diarrhoea with the fatty deposits. Typically, 2-3 capsules have to be taken with main meals and 1-2 capsules with snacks. It is important that the pancreatic enzymes reach the food so that they can fulfil their function. For this to happen, from 6-12 capsules need to be taken every day. These numbers may be significantly higher or lower, dependent on how well the remaining part of the pancreas functions. These enzyme preparations are normally easily digestible and have virtually no side-effects. In very rare cases, they can cause an allergic reaction.

2. Insulin Substitution
If the pancreatic disorder or operation lead to high blood sugar levels being recorded, the patient will require an appropriate form of blood sugar therapy. To start with, and where the blood sugar levels are not particularly high, the situation can be controlled by following a suitable diet and taking tablets which influence the sugar level. However, where extensive resectioning of the pancreas has been carried out, direct insulin replacement treatment is sometimes required. Various forms of insulin are now available for this treatment. These either come from animals or are manufactured using gene technology. For the most part, these are identical to human insulin and are therefore described as human insulin. All forms of insulin must be injected. The large variety of insulin types allow the therapy to be tailored to the needs of the patient and special attention can be paid to eating habits. The aim of any therapy is to ensure that the patient feels well and the blood sugar levels are kept under control. By doing this, serious damage to the health can be avoided, both in the short and the long term. It is particularly important in the initial phase of treatment that the patient is closely monitored by his family doctor or specialists in the field.

My spleen has been removed - what happens now?
Sometimes the spleen is also removed as part of an operation on the pancreas. It is quite possible to live without a spleen. The spleen plays a certain role in the human immune system. If it is removed, a person is more susceptible to bacterial infections. To provide protection against infection after removal of the spleen, the patient should be given certain inoculations after the operation. According to current guidelines, these inoculations should be repeated every 3 to 5 years. In addition, the patient should always seek medical help if he contracts a serious infection, and tell the doctor that he or she no longer has a spleen. The doctor can then decide whether treatment with antibiotics is required. The removal of the spleen can also lead to a build-up of blood platelets (thrombocytes). It is important to have this situation regularly monitored. If the number of platelets is too high, this can lead to the thickening of the blood and a possible thrombosis. If the level is too high, your doctor will prescribe a temporary course of medication to thin the blood, in order to reduce the risk of thrombosis.

2. Acute Pancreatitis

What is acute pancreatitis?
Acute pancreatitis is an acute, i.e. suddenly occurring, inflammation of the pancreas. It results in damage to the cells of the pancreas, which limits its function for a temporary period. Dependent on the severity of the damage, acute pancreatitis can also lead to the death of pancreatic cells, which results in various harmful substances being secreted into the body, which in turn can cause the patient to become critically ill. As a further consequence, other organs may be attacked and their function affected.
There are basically two forms of acute pancreatitis which can be distinguished:
1. Acute oedematous pancreatitis
2. Acute necrosing pancreatitis

1. Acute oedematous pancreatitis
This is the milder form of acute pancreatitis and around 85% of patients suffer from this form of the disease. It causes temporary damage to the pancreas, but does not normally affect any of the surrounding organs. In most cases, the patient recovers completely from the inflammation and there is no long-term damage to the pancreas.

2. Acute necrosing pancreatitis
Around 15% of patients suffer from this more serious inflammation of the pancreas. It leads to the sudden widespread damage of pancreatic tissue, which subsequently dies off. In addition, it can cause the failure of other organs and can therefore seriously endanger the life of the patient. Even if the patient recovers, the function of the pancreas is permanently reduced in most cases, leading to digestion disorders and/or diabetes. The greater the amount of pancreatic tissue that is destroyed, the more serious the loss of function.

What are the causes of acute pancreatitis?
There is a long list of possible causes of acute pancreatitis. However, in Western Europe, gallstones and excessive alcohol consumption are responsible for 90% of cases. The harmful by-products of alcohol can cause a sudden inflammation of the pancreas. If a gallstone escapes from the gall bladder into the common bile duct, it can block the pancreatic duct, which joins the common bile duct shortly before the duodenum, and this can trigger an attack of acute pancreatitis. In addition to these common causes, there is a whole host of much rarer causes, such as infections, various forms of medication, and congenital defects in the pancreatic ducts. Finally, there is also a small number of cases of pancreatitis where no cause can be found.
What are the symptoms of acute pancreatitis?
Sudden onset
Severe, but dull pain in the upper abdomen (often radiating round to the back, like a belt)
Nausea, vomiting
High temperature

Complications and Risks?
Long-term effects of acute pancreatitis Apart from the functional damage to the pancreas, such as disorders of the digestion due to the under-production of digestive enzymes in the remaining part of the pancreas, or the development of diabetes mellitus due to the under-production of insulin, the following problems can arise:

1. Formation of pseudocysts
Damage to the pancreatic tissue can lead to a tear forming in the pancreatic duct system. The pancreatic juices which leak out gradually gather in or around the pancreas. This accumulation of pancreatic juices is known as a pseudocyst. Often pseudocysts disappear in the course of time without any specific treatment. On the other hand, there are pseudocysts which steadily increase in size and can eventually cause symptoms such as nausea, vomiting, pain and weight loss. In the case of pseudocysts causing these symptoms, an operation is normally required. During the operation, a part of the small intestine is sewn on to the cyst so that its contents can simply drain directly into the intestine.

2. Pancreatic Abscesses
In exceptional cases, after the acute phase of the inflammation has died down, a build-up of pus in the region of the pancreas can occur. This can cause recurrent attacks of fever. Normally it is possible to puncture the abscess under local anaesthetic and closely monitored by ultrasound or CAT, and to inset a catheter to allow the pus to drain away. If this is not successful, an operation will be required. In addition, the patient will be treated for a certain period with antibiotics.

3. Pancreatic fistula
In the course of a severe inflammation of the pancreas or following an operation made necessary by such an inflammation, a so-called fistula can form, which is a passage between the pancreas and another organ (e.g the colon) or to the outside (the skin). This can lead to a leakage of pancreatic fluid, which can continue for a lengthy period of time.

Part of my pancreas has been removed - what happens now?
Patients who have had a part or the whole of their pancreas removed may experience a reduction in the functioning of their pancreas, dependent on how much of the organ has been lost. This leads to two problems, above all: Too few pancreatic enzymes (leading to digestion problems) Too little insulin (leading to high blood-sugar levels) These deficiencies can be rectified by taking suitable medication.

What tests and preliminary investigations must be carried out in the case of acute pancreatitis?
Inflammation of the pancreas can normally be confirmed on the basis of the symptoms and blood analysis. However, the extent and the seriousness of the inflammation must also be established. This is best done between 48 to 72 hours after the symptoms begin by means of computerised tomography. The technique and quality of the CAT must be such that a serious form of the disease, with pancreatic necrosis, can be distinguished from the less serious form of acute oedematous pancreatitis.

Treatment of acute pancreatitis
The treatment of acute pancreatitis is largely determined by the patient's symptoms and differs according to the form of the disease (mild or severe). In general, any patient with acute pancreatitis should be monitored and treated in hospital. There the patient will be given nothing to eat or drink for a number of days in order to allow the pancreas to calm down. The patient will be given painkillers and fluids through an intravenous drip. In addition, the circulatory system, lungs and kidneys will be carefully monitored. Accordingly to the progress of the condition, the patient can sooner or later begin to eat light meals. If the severe form of acute pancreatitis is indicated, the patient will be treated in an intensive care ward. Dependent on the symptoms, treatment will continue for several days or even weeks.

When is an operation required?
On average, every third patient with acute pancreatitis requires an operation. If the patient's condition visibly deteriorates, a test will be carried out in which a fine needle is inserted into the pancreas. The procedure is radiologically monitored. If this "puncture" reveals bacteria or a fungal infection, an operation is necessary. A long central incision is used to open the abdomen, and the infected parts of the pancreas which have died off are removed. Finally, a number of tubes are inserted, through which the area around the pancreas is rinsed out over the next few days in order to prevent further infection. In severe cases of acute pancreatitis, the patient may have to stay in hospital for a number of weeks or even months.

In addition to treating the acute symptoms, the cause of the disease must also be found. If a gallstone is responsible, then an attempt will be made to remove the stone using ERCP as early as possible. This will allow pancreatic enzymes and bile to flow into the duodenum once again and remove the immediate cause of the damage. After a patient has recovered from an attack of acute pancreatitis caused by gallstones, the gall bladder will have to be removed. In most cases, this is done by means of so-called keyhole surgery (laparoscopic cholecystectomy).

When dealing with a case of acute pancreatitis, doctors will always ask the patient about the amount of alcohol he drinks. Where alcohol is the cause, it is not always the case that the patient has been drinking to excess. There are some people who, as a result of increased sensitivity, develop acute pancreatitis after drinking only a moderate amount of alcohol. On the other hand there are people who drink to excess who never develop acute pancreatitis. Whatever the case may be, it is absolutely vital that patients who have suffered an attack of acute pancreatitis limit their alcohol consumption in future or, better still, give up alcohol altogether, even when the cause of the attack is clearly a gallstone or some other more unusual factor. Any recurrence of acute pancreatitis must be regarded as a serious danger to the patient's life.

After Care
A standard form of after care is not normally necessary, especially after an attack of the less serious form of pancreatitis. In the event of complications, such as the formation of pseudocysts or fistulae, however, patients must be given follow-up examinations by a specialised team of doctors. These follow-up examinations normally involve a computerised tomography to help decide if further treatment is required.

 

3. Chronic Pancreatitis

What is Chrnic Pancreatitis?
Chronic pancreatitis is the chronic (long-term) inflammation of the pancreas. Continuous damage to the pancreas results in the slow but certain destruction of its functional cells. These cells are replaced by scar tissue and, as a result, the pancreas cannot fulfil its normal functions.
1. The pancreas can no longer produce the digestive enzymes which are essential for breaking down food so that it can be absorbed into the body. This leads to diarrhoea (often foul-smelling) and in the longer-term to weight loss.
2. The specialised islet cells in the pancreas are also destroyed. As a consequence, less insulin, or no insulin at all, is produced and the sugar metabolism is severely disrupted.

For various reasons, which are still not fully understood, chronic pancreatitis causes increasingly severe pain in the upper abdomen, which often radiates round the back like a belt. This pain is probably caused by changes in the nerve tissue in the pancreas, and/or the blockage of the pancreatic ducts, which cause increasing pressure on the organ. Often the pain is so severe that it cannot be eliminated or relieved, even by taking the strongest painkillers (opiates).

What are the causes of chronic pancreatitis?
In the western world, excessive alcohol consumption is the commonest cause (80%) of chronic pancreatitis. However, not all alcohol-related cases are due to chronic over-consumption of alcohol. As everyone has a different tolerance level for alcohol, there are some cases where the disease is triggered by drinking only a relatively small amount of alcohol. In addition to alcohol consumption, there are other important causes of chronic pancreatitis. These include genetic defects, defects in the pancreatic ducts (pancreas divisum), medication and metabolic disorders. Sometimes, no particular cause can be found.

What are the symptoms of chronic pancreatitis?
Pain
Digestive disorders
Diarrhoea
Weight loss
Diabetes mellitus

What tests and preliminary examinations must be carried out in the case of chronic pancreatitis?
If chronic pancreatitis is suspected, a computerised tomography is normally carried out to obtain information on any changes in the form of the pancreas and any distinctive distension of the ducts. In addition, characteristic calcification in the pancreas will be shown. Early changes in the pancreatic ducts will however be shown best by means of ERCP. This investigation method, together with a high-quality MRI, should be carried out at a specialist centre (such as the Inselspital). The extent of the limitation of the digestive function of the organ and blood sugar regulation is indicated by specific tests.

The Treatment of Chronic Pancreatitis
Treatment is primarily determined by the patient's symptoms. In most cases the main problem for the patient is almost unbearable pain in the upper abdomen. First and foremost, the consumption of alcohol should immediately be reduced, or better still, stopped. Secondly, oral pancreatic enzyme supplements can be taken, which alleviate the condition by suppressing pancreatic secretions and bring about a satisfactory restoration of the digestive process. If these two measures do not bring the pain relief hoped for, different drugs of varying strengths can be used to relieve the pain. If this still fails to result in satisfactory relief, an operation will have to be considered.
If there are indications, such as fatty deposits in the stools and/or foul-smelling diarrhoea, that the pancreas is not producing sufficient digestive enzymes, the enzymes must be supplemented by a regular intake of the appropriate medication (e.g. Creon). Dependent on the fat content of the food, a certain number of capsules containing the required enzymes are taken with each meal. In many cases, to allow the artificial enzymes to have an effect, the acid production in the stomach has to be suppressed by taking acid blockers (e.g. Antra). Finally, patients must be careful to take an adequate supply of fat-soluble vitamins /A, D, E, K). In serious cases, these may have to be administered by injection.
If the blood sugar level rises, this is a sign that the pancreas is not producing enough insulin. As a first step, an attempt can be made to stabilise the blood sugar level by following an appropriate diet. Often though, the sugar level can only be regulated by the administration of regular injections of insulin.

When is an operation required?
For every second patient with chronic pancreatitis, an operation is necessary at some point in the course of the disease. This operation must be performed with the greatest of care, and therefore should only be carried out in specialist hospitals (e.g. the Inselspital). There are two main reasons why an operation may be required:
1. The pain cannot be brought properly under control, even by using the strongest painkillers (opiates).
2. The changes in the pancreas caused by chronic inflammation are having an effect on neighbouring organs, such as the constriction or blockage of the duodenum, the bile duct, the main pancreatic duct and the blood vessels behind the pancreas.

Sometimes, so-called "pseudo-cysts" (fluid-filled sacs) can form. These growths, which are filled with pancreatic juices, form on or just under the surface of the pancreas. Often pancreatic pseudo-cysts disappear by themselves, without any treatment being needed. However, they can become increasingly large and cause nausea, vomiting, pain and weight loss. The best approach is to have them surgically removed.
When best to have the operation has to be discussed with a surgeon who is experienced in the treatment of pancreatic disorders. The early removal of the focus of the inflammation provides a better chance of restoring the functions of the pancreas (digestion, blood sugar control).

What does the operation involve?
Normally, the operation begins by making an incision in the centre of the abdomen from just below the tip of the breastbone to just below the navel. The abdominal wall is pulled apart and tied back in order that the surgeon and his team have a good view of the internal organs. Operations on the pancreas in cases of chronic pancreatitis can be divided into "draining" and "resectioning" procedures. The type of procedure used depends on the changes in the pancreas. In a draining operation, the main pancreatic duct is opened along its entire length and is attached to the small intestine, so that the pancreatic juices can drain directly into the small intestine. If there is a pseudocyst, this can be opened and it can be sewn on to a section of the small intestine so that fluid which has accumulated can flow away.

In most cases, the pancreas has undergone such changes as a result of the inflammation that this procedure can only provide a short-term improvement. Often, the drainage stops after a few months as the ducts become blocked again, and the patient once again experiences pain. In such cases, the removal (resection) of the damaged part of the pancreas is the normal treatment chosen. As inflammation is almost always most severe in the head of the pancreas, this is the part which is normally removed.
Nowadays, every effort is made to perform this operation with the greatest of care. This means that only the most severely damaged pancreatic tissue is removed. The surrounding organs, such as the duodenum, the bile ducts and the stomach are saved (pancreatic head resection preserving duodenum). In rare cases, it may also be necessary to remove these organs (Whipple Operation.
If the focus of the inflammation is mainly to be found in the tail of the pancreas (this is rare), the tail will be removed, and, where possible, the spleen will be saved. For technical reasons, however, the spleen must also be removed in some cases.
After the removal of the pancreatic tissue, a section of small intestine will be sewn on to the remaining part of the pancreas, in order that the digestive juices can again drain away unhindered.

These operations on the pancreas are extremely demanding and should only be performed in major specialist centres by suitably qualified surgeons.

Part of my pancreas has been removed - what happens now?
Patients who have had a part or the whole of their pancreas removed may experience a reduction in the functioning of their pancreas, dependent on how much of the organ has been lost. This leads to two problems, above all: Too few pancreatic enzymes (leading to digestion problems) Too little insulin (leading to high blood-sugar levels) These deficiencies can be rectified by taking suitable medication.

3. Pancreatic Enzyme Substitution
Nowadays there are excellent, modern preparations on the market which contain substances that replace the pancreatic enzymes (e.g. Creon). These preparations must be taken with all meals, including fat- or protein-rich snacks. The required dosage varies from patient to patient and is determined by the nature of the food and the symptoms of the patient. It is essential that the therapy eliminates the patient's bloated feeling and the foul-smelling diarrhoea with the fatty deposits. Typically, 2-3 capsules have to be taken with main meals and 1-2 capsules with snacks. It is important that the pancreatic enzymes reach the food so that they can fulfil their function. For this to happen, 6-12 capsules need to be taken every day. These numbers may be significantly higher or lower, dependent on how well the remaining part of the pancreas functions.

These enzyme preparations are normally easily digestible and have virtually no side-effects. In very rare cases, they can cause an allergic reaction.

4. Insulin Substitution
If the pancreatic disorder or operation lead to high blood sugar levels being recorded, the patient will require an appropriate form of blood sugar therapy. To start with, and where the blood sugar levels are not particularly high, the situation can be controlled by following a suitable diet and taking tablets which influence the sugar level. However, where extensive resectioning of the pancreas has been carried out, direct insulin replacement treatment is sometimes required. Various forms of insulin are now available for this treatment. These either come from animals or are manufactured using gene technology. For the most part, these are identical to human insulin and are therefore described as human insulin. All forms of insulin must be injected. The large variety of insulin types allows the therapy to be tailored to the needs of the patient, and special attention can be paid to eating habits

My spleen has been removed - what happens now?
Sometimes the spleen is also removed as part of an operation on the pancreas.
It is quite possible to live without a spleen. The spleen plays a certain role in the human immune system. If it is removed, a person is more susceptible to bacterial infections. To provide protection against infection after removal of the spleen, the patient should be given certain inoculations after the operation. According to current guidelines, these inoculations should be repeated every 3 to 5 years. In addition, the patient should always seek medical help if he contracts a serious infection, and tell the doctor that he or she no longer has a spleen. The doctor can then decide whether treatment with antibiotics is required.

The removal of the spleen can also lead to a build-up of blood platelets (thrombocytes). It is important to have this situation regularly monitored. If the number of platelets is too high, this can lead to the thickening of the blood and a possible thrombosis. If the level is too high, your doctor will prescribe a temporary course of medication to thin the blood, in order to reduce the risk of thrombosis.

After Care
Following a pancreas operation in the case of chronic inflammation, regular checks on the digestion and level of blood sugar must be carried out. These can normally be done perfectly satisfactorily by the patient's family doctor. A regular examination using radiological procedures (e.g. a CAT scan) is not required. However, the specialist clinic which carried out the surgery should play a role in after care, as problems related to the operation can arise.

 
 

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Quick Reference
Function
Methods of Examination
Major Disorders
1. Pancreatic Cancer
2. Acute Pancreatitis
3. Chronic Pancreatitis