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Friday, July 2, 2010

Pancreatic Cancer

Overview
The pancreas is a digestive organ located in the upper abdomen behind the stomach on a level with the inverted V where the ribs meet at the front. It is about 15cm (6 inches) long. The large rounded section on the right-hand side of the body is called the head of the pancreas, the middle part is known as the body of the pancreas and the narrow part on the left-hand side of the body is called the tail of the pancreas. The head of the pancreas lies next to the first part of the small intestine, which is called the duodenum.

Pancreatitis
Pancreatitis is an inflammatory condition of the pancreas. It may be acute in onset or may be a chronic inflammatory and fibrotic process in which case it is termed as chronic pancreatitis.

Chronic Pancreatitis
Chronic pancreatitis is a long standing inflammation of the pancreas. Pancreas is involved in many functions such as insulin production and synthesis of digestive enzymes. This inflammation leads to loss of these functional capabilities as well as alteration in the structure of pancreas. People with chronic pancreatitis require ongoing medical care to minimize their symptoms, slow the damage to the pancreas, and address any complications that arise. In most cases, treatment controls but does not cure the underlying problem.

Causes
  • Exess alcohol consumption
  • Hereditary predisposition
  • Hyperparathyroidism which causes hypercalcemia (high calcium levels in blood)
  • Obstruction of pancreatic duct from stones, tumor etc.
  • Hypertriglyceridemia( high fat content in blood)
  • Autoimmune causes and use of drugs such as steroids, estrogens, etc.
  • In some cases, a cause may not be established.
Symptoms
Chronic pancreatitis is more common in men in the 45-54 yrs age group.
  • Pain
Most common symptom of this condition is pain in upper part of abdomen which radiate to the back. Pain at times is excruciating and may be brought upon within 15 - 20 minutes of taking food. It may occur frequently sometimes even 2 -3 times per week or may last 24 hours a day for several days requiring intake of pain killers. Some 20% of patients may never experience any pain at all.
  • Loss of pancreatic function
This is manifested by loss of weight, nausea and foul smelling fatty or greasy stools (steatorrhea) which are difficult to flush. This is due to decreased digestion if fat which leads to weight loss and loss of certain vitamins in the body. Patients may also have a high blood sugar level due to lack of insulin production.

Complications of chronic pancreatitis

Chronic pancreatitis can lead to complications like:
Blockage of the ducts that drain the pancreas and gallbladder, leading to jaundice (yellowing of the skin) and bouts of worsening pancreatitis. Blockage of the upper intestine which may cause pain and vomiting leading to further weight loss. 

Diagnostic tests
The signs and symptoms of chronic pancreatitis can be similar to those caused by other health problems, such as an ulcer, gallstones, irritable bowel syndrome, or even pancreatic cancer and hence it can be a tricky and difficult diagnosis to make in the initial one or two years of the disease 

Blood tests
Tests are done to detect pancreatic enzymes in the blood stream like serum amylase and lipase, but it cannot distinguish between an attack of acute pancreatitis and chronic pancreatitis with conviction. Secretic stimulation test may be done but is also not 100% diagnostic. 

Stool test
Fecal estimation of fat and elastase is also done to diagnose fat malabsorption.
The digestive juices produced by the pancreas flow down a tube (the pancreatic duct) into the duodenum. The bile duct drains bile from the liver, into the duodenum, and joins the pancreatic duct at the sphincter of Oddi just as it enters the duodenum.

It has various types of cells grouped into 2 categories-- exocrine cells which produce several digestive enzymes that drain through the pancreatic duct into the duodenum i.e, the first part of the small intestine; and endocrine cells which are specialized cells producing a number of hormones like insulin, glucagon, gastrin etc which are secreted directly into the blood stream. 

Each type can form different cancerous and non cancerous (benign) tumors. In addition, tumors can spread to the pancreas from other organs. Newer advanced imaging techniques, like 64- slice multidetector CT scan, 3-Tesla MRI scanner, Octreotide nuclear scans has helped in acurately diagnosing and staging pancreatic tumors and thus helping in planned surgery which augments favourable outcome.

Exocrine Cell Tumors

Pancreatic exocrine cells commonly arise from the pancreatic duct and form adenocarcinomas which comprise 95% of all pancreatic exocrine cancers. Other less common types of exocrine cell cancers include:
  • Mucinous noncystic carcinoma
  • Adenosquamous carcinomas
  • Mucinous cyst adenocarcinoma
  • Intraductal papillary mucinous carcinoma
Our main concern in treating pancreatic cancer revolves around the extent of tumor spread rather than its type. Benign tumors of pancreas include cystadenomas like serous cystadenoma, mucinous cystadenoma, etc.

Endocrine Cell Tumors
Neuroendocrine tumors arise from hormone producing cells (endocrine cells) of the pancreas are more commonly non cancerous than cancerous. They may or may not be hormone producing tumors.

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