Where exactly is the pancreas located?
The pancreas is an elongated organ and is located in the upper abdomen between the small intestine and spleen, about a hand's breadth above the navel and in front of the spine.
What functions does the pancreas have?
The pancreas produces important digestive juices that contain enzymes and ensure that fats, proteins and carbohydrates can be broken down and digested.
The digestive juices enter the duodenum via a central duct (pancreatic duct). The pancreatic duct has a common end section with the bile duct, via which the bile juices are directed into the duodenum.
Another important function of the pancreas is the production of the hormones insulin and glucagon, which regulate blood sugar levels and can be regarded as antagonists. They are produced in special cells of the pancreas. Diseases of the pancreas can have a variety of causes.
- Inflammation(pancreatitis)
- sudden (acute)
- prolonged (chronic)
- Tumor (carcinoma)
- Cysts (fluid-filled cavities)
- Failure of function (pancreatic insufficiency)
- Digestive disorder (lack of digestive secretions)
- Diabetes(diabetesmellitus)
How does pancreatitis develop?
Inflammation of the pancreas (medically known as pancreatitis) can be caused by an obstruction to the flow of digestive juices . The most common cause of this is a gallstone, for example, which can obstruct the common terminal duct of the pancreas and gallbladder. However, strong stimulation of the cells (e.g. through excessive alcohol consumption) can also result in digestive enzymes not being passed into the intestine. Overproduction of these enzymes has the same effect: some of the digestive enzymes remain in the pancreas and damage or destroy its cells.
The resulting inflammation leads to swelling of the pancreas, which further impairs drainage.
If the inflammation of the pancreas is not stopped, it continues to spread and the aggressive digestive juices can attack and destroy the structures of the pancreas and surrounding structures.
Particularly severe forms of acute pancreatitis (so-called necrotizing pancreatitis) can even take on life-threatening forms.
How is pancreatitis treated?
Treatment is initially conservative, i.e. non-surgical. It is important to abstain from food (i.e. fasting) to prevent further stimulation of pancreatic secretion and to provide sufficient fluids to support the circulation.
In order to prevent an infection of possibly dead tissue, the administration of an antibiotic can be considered as a preventative measure. Pancreatic surgery is only necessary if there is a recognizable infection of dead tissue areas or if pseudocysts form (as described below).
In addition, the cause of the inflammation must be sought so that it can be eliminated. If it is gallstones, for example, these must be removed - it may also be necessary to remove the gallbladder itself.
When does chronic inflammation of the pancreas occur?
Acute inflammation of the pancreas can heal without consequences or lead to cell death with the formation of non-functional scar tissue. If it leads to a narrowing of the pancreatic duct, this scar tissue can make the pancreas susceptible to further inflammation. Chronic pancreatitis is a long-term, recurring inflammation of the pancreas.
Each new bout of inflammation leads to cell death and the associated functional impairment of the pancreas, which can no longer produce sufficient digestive enzymes. As a result, more nutrients enter the large intestine, where they stimulate excessive bacterial growth, leading to diarrhea.
In addition, so-called 'fatty stools' occur because the enzymes to break down the fats are missing. Other symptoms include upper abdominal pain that radiates to the back.
In advanced stages,diabetes mellitus can also develop, as the hormones that regulate blood sugar (insulin and glucagon) are no longer produced in sufficient quantities.
The most common cause of chronic pancreatitis in Western countries is alcohol, although it is not always a case of too much or excessive alcohol consumption, as in some people even small amounts of alcohol are enough to trigger the disease.
Other important causes of chronic pancreatitis are
- Chronic gallstone disease,
- genetic defects,
- congenital malformations of the pancreatic duct and
- metabolic disorders.
In some cases, the cause remains unclear.
How does pancreatic cancer develop?
Adenocarcinoma of the pancreas (glandular tumor) is the most common tumor of the pancreas. Pancreatic cancer is particularly aggressive because the tumor grows quickly and can grow into neighboring tissue. In addition to a hereditary component (genetic predisposition), there are a number of risk factors for the development of pancreatic cancer. Risk factors are
- Nicotine,
- alcohol,
- a diet high in cholesterol and nitrosamines and
- the presence of chronic pancreatitis.
Symptoms usually only occur in more advanced stages and depend on the location of the tumor. If the tumor is located in the head of the pancreas, this leads to a narrowing of the bile duct with increasing size. This leads to a backlog of bile and yellowing of the skin and sclera(jaundice).
If the tumor is located in the middle part or tail of the pancreas, it often causes upper abdominal and back pain because nerve centers located behind the pancreas are irritated. A new onset of diabetes can also indicate a pancreatic tumor.
Pancreatic surgery is still the only treatment that offers the patient a chance of recovery.
Due to its location, the pancreas is difficult to see. The stomach, small intestine, gallbladder and bile ducts are located in the immediate vicinity of the pancreas. This often makes the examination more difficult and makes a recommendation for early detection examinations for tumors in symptom-free people less sensible.
In the case of pancreatic cancer, diagnosis is made more difficult by the fact that it only causes symptoms at a very late stage. And as the pancreas is located directly in front of the spine and the nerve plexus located there, diseases of the organ can also lead to back pain, which makes detection even more difficult.
As a rule, a blood test is carried out to determine the enzymes of the pancreas in the blood and, if a tumor is suspected, the tumor markers (CEA, CA-19-9).
An ultrasound of the pancreas is always performed. As a rule, a computer tomography and an MRCP (magnetic resonance cholangiopancreatography), in which the bile ducts and the pancreatic duct are visualized, are carried out, depending on the issue.
If therapeutic interventions (such as the removal of stones from the bile duct) are highly likely to be necessary, endoscopic retrograde cholangiopancreaticography(ERCP) is the procedure of choice, as treatment can be carried out at the same time as the examination.
What exactly is done during ERCP?
During ERCP, the gallbladder and bile ducts as well as the excretory duct of the pancreas are visualized using a contrast agent and X-rays. If this reveals constrictions or obstructions caused by gallstones, they can be removed immediately. An operation is not initially necessary in such cases. However, once the inflammation has subsided, removal of the gallbladder is recommended if it contains stones. Otherwise, gallstones can pass out of the gallbladder again and again and cause such problems. Life without a gallbladder is possible without any problems.
What is the next step if a malignant pancreatic tumor is suspected?
Confirming a cancer diagnosis before pancreatic surgery by means of a puncture or tissue removal is generally not advisable and sometimes not even possible, as the pancreas is very unfavorably located (far back in the abdomen). In addition, a puncture can lead to bleeding and fistula formation.
For this reason, surgical exposure of the pancreas and complete removal of the tumor focus in the healthy area as part of a pancreatic operation should be the aim.
If the inflammation of the pancreas results in the outflow of pancreatic secretions being impaired, surgery is often the only way to achieve freedom from symptoms in the final stage, in addition to consistent alcohol abstinence, appropriate pain therapy and the intake of digestive enzymes in tablet form. The aim of the operation is to remove the scarred material, mainly in the pancreatic head area, and to create an outlet for the pancreatic secretions. This operation can achieve a significant reduction in pain in 60 to 80 percent of patients. In addition, a worsening of the diabetes can be halted or a new development prevented.
During the operation, the dead tissue must be removed through pancreatic surgery. In addition, the space around the pancreas is flushed out by inserting a drain to prevent further infections. If the symptoms and inflammation are caused by a bile duct stone that is blocking the joint confluence of bile and pancreatic juice in the duodenum, an attempt will be made to remove the bile duct stone using ERCP. Once the acute pancreatitis has healed, it may be necessary to remove the gallbladder completely.
If fluid-filled cavities, so-called pancreatic pseudocysts, have formed, a tube should be inserted into the stomach using endoscopy if the position of the cysts is favorable. This drains the cyst contents into the stomach (drainage) and is not an operation, so no abdominal incision is required, just a gastroscopy.
The drainage is active for around four to twelve weeks, which is usually enough for the cyst to heal.
However, if the cyst is not located near the stomach, a surgical procedure must be performed. A loop of small intestine is removed (i.e. no more intestinal contents flow into it) and stitched onto the cyst. This drains the cyst contents into the intestine without allowing intestinal contents to enter the pancreas.
How does pancreatic surgery for pancreatic cancer work?
In the case of cancer (carcinoma) of the pancreas, pancreatic cancer surgery promises the only chance of a cure. However, a cure is only possible if the tumor has not yet metastasized to other organs.
During the operation, the part of the gland affected by the tumor and parts of the stomach and small intestine are removed. All surrounding lymph nodes must also be removed, otherwise the risk of recurrence is very high.
Sometimes it is also necessary to remove the spleen if it has been infiltrated by tumor growth. Life without a spleen is possible, but people without a spleen are more susceptible to bacterial infections, as the spleen plays an important role in the immune defense.
In addition, an increase in blood platelets can occur after a spleen removal, which may make temporary medication for thrombosis prophylaxis necessary.
Firstly, it is important that chemotherapy is sometimes necessary after pancreatic cancer surgery in order to keep the risk of recurrence as low as possible. Chemotherapy is very stressful for the body, but should definitely be carried out on the recommendation of the treating doctors if necessary. It usually lasts 10-12 weeks and consists of several so-called cycles. Breaks must be taken in between, as otherwise it would be too much of a strain on the body.
Irrespective of any chemotherapy that may still be necessary, a number of special features must be observed. For example, pancreatic enzymes must be taken with meals after the partial removal of sections of the pancreas. The dosage is individual, depending on which parts were removed and to what extent, and how the patient is feeling after pancreatic surgery.
If the spleen was removed during pancreatic surgery, the blood platelets (thrombocytes) must be checked regularly. If there is an increase in platelets, thrombosis prophylaxis may be necessary.
Even if no diabetes is diagnosed at the time of pancreatic surgery and shortly afterwards, it is still advisable to check the sugar metabolism regularly, as diabetes can develop as a result of pancreatic surgery. This can be checked, for example, by means of a daily blood glucose profile carried out once or twice a year or by means of a so-called oral glucose tolerance test.
If nutritional problems occur despite the improved surgical procedures, in which the stomach is no longer removed, nutritional advice can be sought. In the case of a pancreatic tumor that has been removed by pancreatic surgery, regular follow-up examinations are required. In addition to a physical examination, an ultrasound examination of the upper abdomen is carried out. The tumor markers CEA and CA 19-9 in the blood are also checked by taking blood samples at regular intervals.
People who have had pancreatic surgery due to a tumor are initially checked at three-month intervals. Over time, the intervals can be extended in accordance with the guidelines and in close consultation with the attending physicians. Further treatment in the form of chemotherapy should also be carried out in close consultation with an oncologist.
