Frequently Asked Questions About Pancreatic and Biliary Diseases

 

What is the pancreas?

It is a "silent," solid organ positioned behind the stomach in the upper part of the abdomen. The body's main digestive organ, the pancreas is composed of different cells that serve distinct functions. Some cells produce digestive "juices" or enzymes, while the others produce hormones. The pancreatic enzymes break down the three types of nutritional elements: protease digests proteins; lipase digests fat; and amylase digests carbohydrates. Once manufactured, the digestive enzymes empty into channels (ducts), eventually draining into the first part of the small intestine, called the duodenum. Food that passes through the duodenum stimulates the pancreas to produce digestive enzymes. The most important hormone the pancreas produces is insulin, which controls the amount of glucose in our bloodstream. When an insufficient amount of insulin is secreted, the body's cells are unable to take in glucose, which raises glucose levels in the bloodstream and may ultimately lead to diabetes (though it is not the principal cause of diabetes). In addition to insulin, the pancreas makes other hormones, all of which pass into the blood that flows through the organ (not through the ducts used by the enzymes).

 

What are the most common problems that affect the pancreas?

Normally the pancreas does not cause us much trouble, but when it does, the symptoms can be quite bothersome and, in some cases, fatal. Pancreatitis is the most common pancreatic condition, categorized as either acute and chronic. In acute pancreatitis the organ suddenly becomes swollen and releases digestive juices into the bloodstream. Depending on how severe it is, acute pancreatitis can cause pain, fever, shortness of breath or kidney problems, among other symptoms. In rare cases death may result from infection, respiratory failure, bleeding or other complications. Most patients recover without any serious consequences. Still, even mild cases can bring severe pain, nausea and vomiting for a few days.

After an acute attack a patient may either completely recover or have several more episodes, which can lead to chronic pancreatitis. This is characterized by persistent abdominal pain, intolerance of food and sometimes disabling nausea. If it causes permanent scarring or damage to the pancreas, chronic pancreatitis can harm the organ's ability to produce digestive enzymes and hormones, which can lead to diabetes, chronic diarrhea and malnourishment. The vast majority of diabetes cases, however, are not caused by chronic pancreatitis.

Perhaps the most feared condition is pancreatic cancer, since it is almost always fatal. Indeed, it is the most lethal of all cancers, though fortunately, not very common. While no screening is currently available to detect it at earlier, more curable stages, there is hope for one soon. Most pancreatic cancer patients have minimal or no symptoms until later, less curable stages, and the symptoms that do arise are usually the same as those for chronic pancreatitis.

 

What causes these pancreatic conditions?

Acute pancreatitis is usually caused by a gallstone getting stuck in the bile duct on its way from the gallbladder into the small intestine. Since the bile duct shares the same opening with the pancreatic duct, a sudden obstruction of the pancreatic opening will cause pancreatic juices to back up into the pancreas. This leads to the pancreatic duct system becoming swollen and inflamed, potentially causing pancreatic damage. Drinking a large amount of alcohol at one time is another common cause of acute pancreatitis. Furthermore, athletic, automobile and falling injuries can break open or bruise the pancreas, causing acute pancreatitis. Less frequent causes include medications, high triglyceride levels in the bloodstream and a tight pancreatic duct opening. Sometimes a common test used to investigate pancreatic conditions, called endoscopic retrograde cholangiopancreatography (ERCP), can cause acute pancreatitis.

Chronic pancreatitis can be caused by any one of the triggers associated with acute episodes, but the most common one is excessive use of alcohol. Also, a condition arising at birth that leads to a disconnect in the pancreatic duct system, called pancreas divisum, makes some people susceptible to chronic pancreatitis in their adult years. Cystic fibrosis, a very common hereditary disease contracted at birth, may also cause chronic pancreatitis, even if it was a mild case. There is also a rare form of pancreatitis that runs in families.

Pancreatic cancer occurs without any apparent reason, though patients with chronic pancreatitis are more likely to contract it. Smoking seems to be the only known preventable risk factor. Pancreatic cancer is also quite common among patients with the hereditary form of pancreatitis. Diabetes has not been shown to be a risk factor for pancreatic cancer.

 

Can we live without a pancreas?

Many years ago, a patient without a pancreas could not survive because severe diabetes and an inability to digest food would immediately result. Today some patients can function without a pancreas, living fairly normal lives. However, they must take daily injections of insulin and pills that contain digestive enzymes for the rest of their lives. Sometimes pancreatic transplantation is an option for patients whose pancreas does not function normally.

 

What are the warning signs of pancreatic problems?

Pancreatic conditions can produce severe pain or no symptoms at all, and virtually all pancreatic conditions can have the same symptoms. The pain is usually in the upper middle part of the abdomen, but it can also be in the upper left side, upper right side or throughout the abdomen. Pain often travels straight to the mid-back region. Even though most diabetes is unrelated to pancreatic conditions, if it occurs at the onset of upper abdominal pain, then pancreatic problems are the likely source. In addition, if the patient experiences loss of weight, either pancreatitis or cancer should be considered.

 

If I suspect a pancreatic problem, what should I do?

If the symptoms are severe, seek immediate medical help. Severe acute pancreatitis may require hospitalization. At the very least, a series of tests should be performed to establish a diagnosis. A blood test that shows the presence of pancreatic enzymes will suggest acute pancreatitis, but not necessarily chronic pancreatitis. In that case, an ultrasound or computed tomography (CT scan) could indicate if a blockage or high lipids are the cause. Anyone older than 60 or who has suddenly lost weight should have a CT scan and a blood test known as CA19-9 to check for cancer. Recently, more-specific tests have become available that are minimally invasive and can clearly show pancreatic swelling and inflammation. ERCP can examine the bile and pancreatic ducts to check for tumors, a stricture, stones or abnormal anatomy. And ERCP combined with a pressure-measuring device called a manometer is the only test that can diagnose an unusual condition known as papillary stenosis (very tight pancreatic opening). Despite a slight risk of causing pancreatitis, ERCP is one of the best ways to remove stones blocking the ducts.

 

What are some of the other tests and treatments available today to treat pancreatitis and other common problems?

Using ERCP technology, doctors can place stents where there is a stricture or narrowing of the ducts. One of the most exciting new tests is endoscopic ultrasound (EUS) of the pancreas. By placing the ultrasound probe next to the pancreas in the stomach or duodenum, EUS can see inside the pancreas and show much greater detail than any other nonsurgical method. This is probably the most desirable test for investigating possible pancreatic tumors. It is also becoming a standard test for assessing if a patient is a good candidate for cancer surgery.

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