PANCREAS
Pancreas
The pancreas is a yellowish fleshy organ that is about 6- 8 inches long. It is placed horizontally across the upper abdomen, behind the stomach. About 95% of the pancreas is made up of the exocrine gland (which secretes digestive enzymes) and nearly 5 % of it is made up of endocrine glands (which secretes hormones like insulin).
The exocrine glands secrete digestive enzymes, which helps to break down carbohydrates, fats, proteins, and acids. An ideal, healthy pancreas will secrete about 1 liter of these enzymes daily. The endocrine gland secretes hormones such as insulin and glucagon into the bloodstream to regulate the blood sugar level.
Pancreatitis:
The inflammation of the pancreas is called pancreatitis and it is a condition that occurs when the digestive enzymes in the pancreas start digesting itself. The condition can either be acute- when the disease manifests suddenly or chronic- when the disease manifests over the years. Both conditions can cause very serious health issues.
Acute pancreatitis:
Acute pancreatitis is usually caused by gallstones or consumptions of alcohol. Even gallbladder sludge (powder-like material) can also be the cause. Rarely acute pancreatitis results from abdominal trauma, procedures like ERCP (Endoscopic retrograde cholangiopancreatography), drugs like steroids and scorpion bite. Based on the severity it can be classified into mild, moderate and severe variety. Severe acute pancreatitis is a life-threatening condition characterized by persistent organ failure or fluid collection or necrosis (dead tissues) in and around the pancreas. Pancreatic enzymes like amylase/lipase will be elevated in blood investigations.
Symptoms:
Severe epigastric (upper abdominal) pain radiating to back is typical of acute pancreatitis. This is often accompanied by fever, nausea, and vomiting. If the bile duct is blocked, then the patient may have jaundice. Associated organ dysfunction may present with difficulty in breathing and decreased urine output.
Treatment:
Treatment of acute pancreatitis is mainly supportive, using medicines. Mild and moderate acute pancreatitis often improve with this alone. Severe acute pancreatitis patients require a prolonged time to recover fully and usually stay in the hospital for a long duration. If respiratory failure is there, ventilatory support is required. CT scan is done to assess the extent of the damage.
Abstinence from alcohol intake is a must. Those who have common bile ducts have to get it cleared by the endoscopic method (ERCP – Endoscopic retrograde cholangiopancreatography).
ERCP Procedure:
An ERCP (endoscopic retrograde cholangiopancreatography) procedure is done to treat those with bile duct stones. This involves inserting a long tube with a camera at the end down the throat into the duodenum (first part of the small intestine). The bile duct is cannulated and its opening widened by cutting its sphincter muscle (sphincterotomy) and then the stones are removed. Plastic stent (tube) may be inserted to keep the drainage intact. The plastic stent should be removed at a later date.
Gallbladder surgery:
If the pancreatitis is caused by gall bladder stones, then the doctors will suggest a cholecystectomy which is the surgical removal of the gallbladder. Laparoscopic (Keyhole) Cholecystectomy is the gold standard nowadays. Through 4 small holes (two 10mm, two 5mm) the gallbladder can be removed. By this, big scars can be avoided after surgery. The patient can resume normal activity early. However, they may require taking pain-killers (analgesics) for a few days.
Pancreatic Pseudocyst:
A pseudocyst is a collection of pancreatic enzyme-rich fluid in the vicinity. If it is uncomplicated and asymptomatic, it can safely be observed. Symptomatic fluid collections require drainage via endoscopy or surgery.
Pancreatic Necrosis:
Necrotic tissue means dead tissue. Either part of the pancreas or peripancreatic fatty tissue becomes necrotic and can act like a potential nidus for infection to develop. Infected necrotic collection requires drainage either through a small tube (inserted under CT scan or ultrasound scan guidance) or by surgery. Endoscopists, interventional radiologist and surgeons should work together to choose an optimal approach.
Chronic pancreatitis
Chronic pancreatitis usually is a result of regular alcohol intake for a long duration or genetic abnormality. Chronic pancreatitis leads to diabetes and loose stools (steatorrhea) due to inadequate fat digestion. A CT scan or MRI scan (Magnetic resonance cholangiopancreatography – MRCP) is often required to assess the extent of the damage. Pancreatic duct develops strictures (narrowing) at single or multiple places. Pancreatic stones may be located inside the duct as well as parenchyma (functional tissue). Adjacent organs can also get affected as its sequelae. If the splenic vein (blood vessel which carries the blood from spleen to liver) gets blocked, patients develop enlargement of the spleen and dilated blood vessels near the upper part of the stomach (gastric fundal varices). This condition is called left-sided portal hypertension. If the bile duct gets blocked, patients develop jaundice. If the duodenum (first part of the small intestine) gets blocked, patients develop vomiting. Sometimes patients develop inflammatory (non-cancerous) mass near the head of pancreas. This often poses a diagnostic dilemma as it is difficult to differentiate this from pancreatic cancers. Endoscopic ultrasound evaluation along with biopsy may help to confirm the diagnosis.
Symptoms:
- Pain in the upper abdomen radiating to back
- Unintentional weight loss
- Nausea and vomiting
- Fatigue and fever
- Oily and foul bowel movements
- Jaundice
- Blood vomiting
- Melena
Treatment:
Chronic pancreatitis changes cannot be reversed. Treatment is aimed at relieving the symptoms and associated complications. Surgery is required if other less invasive options not working. Removal or clearance of pancreatic stones may not cure the symptoms in all, unlike gallbladder or kidney stones.
Methods to treat pain associated with chronic pancreatitis
- Medicines
- Analgesics (Pain killers)
- Acid suppressants (Proton pump inhibitors)
- Pancreatic enzyme replacement (like lipase)
- Nerve block (blocking the nerves carrying the pain signals from pancreas to central nervous system)
- Endoscopic ultrasound (EUS) guided
- Percutaneous
- Pancreatic duct decompression
- Endoscopic method (ERCP and stenting)
- Surgery (Frey’s procedure)
Total pancreatectomy (complete removal of the pancreas) along with islet cell autologous transplantation has been done for some patients with unrelenting symptoms. Patients with pancreatic head mass with suspicion of malignancy should undergo Whipple’s procedure (Pancreaticoduodenectomy).
Periampullary Cancers
The ampulla of Vater comprises the junction of the biliary and pancreatic ducts and is surrounded by the sphincter of Oddi which is a 1cm long smooth muscle structure. The distal constricted end of the ampulla opens into the posteromedial aspect of the duodenum (proximal part of the small intestine) which is called papilla. Cancers arising at and near ampulla are called periampullary tumors.
It comprises 4 different histological types
- Ampullary carcinoma
- Duodenal carcinoma
- Pancreatic carcinoma
- Distal cholangiocarcinoma
Symptoms:
- Jaundice
- Pruritus
- Loss of weight and appetite
- Fever
- Abdominal pain
- Vomiting
- Dark-colored stool (Melena)
Diagnosis is made from imaging like CT or MRI scans. Side viewing endoscopy and biopsy or Endoscopic ultrasonography (EUS) guided biopsy may be used to get a histological diagnosis. However, even with repeated attempt histological confirmation is not possible in a certain group of patients. There are cases in which we only get a definitive diagnosis after surgery.
Treatment:
Whipple’s procedure (pancreaticoduodenectomy) is the treatment of choice for periampullary cancers. This can be done by open as well as laparoscopic (keyhole) approaches. This is one of the major surgeries performed in the abdomen with associated complications. In patients with severe infection in the bile duct (cholangitis), endoscopic stenting of the bile duct should be done pre-operatively. The patient may require additional therapy like chemotherapy depending on the final biopsy reports.
Pancreatic Cancers
When there is exponential growth, division and spread of the cells in the tissues of the pancreas, the condition is termed as pancreatic cancer. Adenocarcinoma is the commonest type. These are aggressive tumors with poor outcome. Though it is unclear as to how certain people get pancreatic cancer, factors that contribute to it are smoking, obesity, genetic factors, and chronic pancreatitis.
Symptoms:
(depends on the site from where the tumor originates in the pancreas)
- Yellowing of the skin and eyes
- Unintended weight loss
- Pain in the abdomen
- Itchy skin
- Light-colored stools
- Dark-colored urine
- Fatigue
- Loss of appetite
Treatment:
Treatment decisions will be taken in a multidisciplinary meet (MDT). Doctors will suggest a treatment course based on the stage of cancer, location and the physical condition of the patient. Endoscopic ultrasonography (EUS) guided biopsy may be used to prove the diagnosis histologically. However, a positive biopsy is not mandatory before surgery. Surgery is indicated only if the disease is localized without any distant spread (like liver metastasis).
Surgery:
Whipple Procedure (pancreaticoduodenectomy):
This surgery is indicated if the tumor located at the head or uncinate process of pancreas. This can be done by open as well as laparoscopic (keyhole) approaches. This is one of the major surgeries performed in the abdomen with its associated complications. If the patient is having severe infection in the bile duct (cholangitis), endoscopic stenting bile duct should be done pre-operatively. Patient may require additional therapy like chemotherapy depending on the final biopsy reports.
Distal Pancreatectomy:
This surgery is done when the tumor is located in body or tail of the pancreas, often along with spleen to get adequate lymph nodal clearance. This can be done by open as well as laparoscopic (keyhole) approaches.
Total Pancreatectomy:
Surgical removal of the whole pancreas is called total pancreatectomy and is rarely performed. Patients develop diabetes after surgery as there is no insulin secreted in the body.