Diseases of the pancreas

A cyst of the pancreas (pancreatic cyst) is a bubble-like, closed tissue cavity within the glandular tissue, which is usually filled with fluid. Possible fluids in a cyst are tissue water, blood and/or pus. The typical cyst of the pancreas is divided into two classes, the true cyst and the so-called pseudocyst.

A true pancreatic cyst is lined with epithelium and usually does not contain natural enzymes of this glandular organ (lipase, amylase). The pseudocyst often develops in connection with an accident in which the pancreas is bruised or torn. In contrast to the real cyst, pseudocysts are not enclosed by epithelial but by connective tissue.

Since the enzymes of the pancreas contribute to a self-digestion process when released within the tissue, this form of cyst is particularly dangerous. Typical fluids inside the cyst are blood and/or dead cell remains. A cyst of the pancreas is an extremely painful affair.

The perceived pain is not limited to the area of the upper abdomen but usually radiates into the back, especially at the level of the lumbar spine. Especially the occurrence of unexplainable back pain is a clear indication of the presence of a cyst. They also manifest themselves as colicky pain.

This means that they are similar to contractions during childbirth, do not get better or worse through certain movements or relieving postures, and the condition of the affected patient constantly changes between being free of pain and severely restricted by the pain. A cyst of the pancreas can be visualised by means of ultrasound as well as by computer tomography (CT). After successful diagnosis, the condition of the gland is first observed.

This is useful because many cysts in the pancreatic tissue regress spontaneously and do not require treatment. If the symptoms are extremely severe, a drainage can provide relief. The doctor treating the patient will gain access to the pancreas by making a hole in the stomach or intestinal wall, opening the pancreatic cyst and inserting a small plastic tube (stent).

This allows the fluid collected inside the cyst to drain away. The stent is removed after approximately 3 to 4 months. Possible complications of a pancreatic cyst include bleeding, the formation of an abscess, water retention in the abdomen (ascites) and/or narrowing of the drainage channels of the gallbladder.

The latter often leads to a phenomenon known as “jaundice” (icterus). The main cause of inflammation of the pancreas is chronic excessive or acute alcohol consumption. Pancreatitis is also a complication of the so-called ERCP, a pancreatic diagnostic examination method.

In this procedure, contrast medium is injected into the pancreatic duct through an endoscopic examination. In some cases, this can lead to pancreatitis, which must then be treated quickly. The first symptoms of pancreatitis are girdle-like pains that extend from the abdomen above the navel to the back.

The abdomen is very painful under pressure, the pain character is dull. The main point of pain lies between the navel and the lower edge of the sternum at the level of the stomach. Patients are sometimes very severely affected by the pain and are no longer able to perform normal movements such as turning or bending forward or backward without pain.

In addition to the pain, the patients are in a sometimes very poor general condition, sometimes even the pale grey skin colour of the patient indicates that he or she is suffering from a serious, sometimes life-threatening disease. A frequent accompanying symptom is also the fever, which can be 39-40 degrees in some patients and must be reduced urgently. Depending on the severity of the pancreatitis, the organ may already be releasing insufficient enzymes, which in turn can have serious effects on digestion and sugar metabolism.

This can lead to fatty stools and diarrhoea, since food can no longer be properly broken down and processed as long as the pancreas is in a highly inflamed state. It can also lead to severe hyperglycaemia because the pancreas does not secrete enough insulin. In addition to the symptoms, a detailed interview with the patient can substantiate the suspicion of pancreatitis.

It is therefore essential to ask patients whether they consume alcohol regularly or excessively or whether they have had to undergo a pancreatic examination in the last few months or weeks. The background to this is that the cause of pancreatitis is often alcohol abuse, and in a so-called ERCP (endoscopic retrograde cholangiopancreaticography – examination of the gall bladder, bile ducts and pancreas) the pancreas can become inflamed by the contrast medium injected. The diagnosis is made, among other things, by means of an ultrasound examination.

A cloudy, distended pancreas can be seen. In addition to a strict alcohol and 24-hour food restriction, antibiotic treatment is one way to make the patient soon free of symptoms. In some severe cases parts of the pancreas have to be surgically removed.

Pain from the pancreas can manifest itself in different ways. They are often not clearly recognizable as such. Depending on the cause and severity of the disease causing the pain, it can radiate into the entire abdominal area.

However, they can also be felt locally. Mostly they occur in the area of the upper abdomen (also called epigastrium) and radiate belt-shaped over the entire upper abdomen up to the back. It can also happen that only pain in the back or on the left side at the level of the pancreas is felt.

The pain has a different character depending on the cause. With more acute illnesses, such as inflammation, they are usually rather stabbing; with chronic illnesses, such as tumorous changes, the pain is described as dull. Since the pain in the pancreas as such is often recognized late, it is important to act quickly when it occurs.

If such pain persists over a longer period of time, it should always be clarified by a doctor. Why does a diseased pancreas cause back pain? Pancreatic diseases often cause pain in the back.

This can be explained by the position of the pancreas in the upper abdomen. It is located in the back of the abdominal cavity at the level of the lower thoracic vertebrae. Due to its anatomical proximity to the spinal column in the area near the back, many pathological changes in the pancreas manifest themselves as back pain at this level.

Back pain is usually belt-shaped and radiates over the entire back at this height. It should be remembered that back pain can only be an expression of a slight irritation of the pancreas, but can also be an expression of a serious disease of the pancreas. As this is often difficult to differentiate, a doctor should be consulted in the case of long-term back pain.

You can find more information on the topic “Pain through the pancreas” under Inflammation of the pancreasA weakness of the pancreas means that the pancreas is unable to perform its functions adequately. This is particularly evident in digestion: the pancreas is responsible for the production of most digestive enzymes. These are needed to break down the various components of food, i.e. proteins, fats and sugars, so that they can then be absorbed in the intestines and stored in the body.

If the pancreas is weakened, digestive enzymes such as trypsin or cholesterol esterase can only be released in a reduced form and have a reduced effect. This is particularly evident in the form of flatulence, loss of appetite and food intolerances. However, since these symptoms also indicate other causes, such as an irritable bowel or a gall bladder problem, pancreatic insufficiency as such is rarely diagnosed.

Pancreatic insufficiency also often causes so-called fatty stools. An overactive pancreas is an extremely rare and hardly ever occurring clinical picture. Depending on the part of the pancreas affected, there is an excessive production of various enzymes for digestion (in the case of exocrine hyperfunction) and of insulin (in the case of endocrine hyperfunction).

Depending on the extent of the excessive function, the latter can manifest itself as hypoglycaemia. This can be prevented by taking regular small meals. A fatty pancreas can develop as a result of various diseases.

One of the more common and well-known causes is excessive consumption of alcohol. This leads to an acute inflammation of the pancreas. Over the course of many years, the tissue of the pancreas can become damaged and perish.

In some patients, this is manifested by increased fat accumulation in the area of the pancreas. Another possible cause of a fatty pancreas is the subsequent inflammation due to an inflammation of a different origin, i.e. an inflammation caused by a cause other than excessive alcohol consumption. This can be an inflammation caused by a bile problem with backflow of bile into the pancreas.

Alternatively, certain medications, diabetes mellitus or yellowing (icterus) caused by the liver can lead to inflammation of the pancreas, which, once the disease has healed, accumulates fat. A stone in the pancreas is usually rather rare, but all the more dangerous. This is a gallstone that can migrate through the common orifice of the bile ducts and the pancreatic outlet into the pancreas.

This prevents the secretion of the pancreas from flowing into the intestine. Instead, it accumulates and begins to digest its own glandular tissue instead. This is therefore an acute, very dangerous clinical picture that manifests itself as acute pancreatitis and should be treated as soon as possible.

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Complications of an inflammation of the gall bladder Calcifications in the pancreas often occur in the context of a chronic inflammation. This leads to long-term changes in the glandular tissue. These include deposits of the digestive secretions produced and secreted by the pancreas.

If this cannot flow properly into the intestine, residues remain in the ducts, which can accumulate over a longer period of time. The resulting calcifications can be seen by the doctor during an ultrasound examination, depending on their severity. Pancreatic cancer is a malignant new formation of the pancreas.

Causes can include chronic alcohol consumption and recurrent pancreatitis. As a rule, pancreatic cancer is diagnosed at a very late stage, as it causes symptoms late in the patient’s life. As a rule, patients do not experience any pain but complain of darkening of the urine and lightening of the stool.

In some cases there may be a yellowing of the skin and conjunctiva. Since the pancreas is also responsible for the production of insulin, the organ may not be able to produce enough insulin when cancer is diagnosed. This leads to an increase in sugar in the blood, which is often diagnosed routinely.

If a malignant new formation (tumour) of the pancreas is suspected, an ultrasound examination is first carried out. However, it is not always possible to see whether a malignant neoplasm is present. A CT or MRI of the pancreas can provide more reliable information as to whether such a disease is present.

Only a puncture, which is often CT-guided, can tell with certainty whether a malignant neoplasm is present in the pancreas. In the case of pancreatic cancer in particular, punctures are often not carried out because metastasis can be triggered by the puncture. The treatment options for pancreatic cancer are rather limited.

Chemotherapy can be used to try to stop the progression of the disease, often a so-called Whipple operation is used, in which parts of the pancreas are removed. The prognosis of healing and survival depends on the diagnosis of pancreatic cancer, especially the stages. For example, a so-called staging is necessary to check how far the tumour has already spread in the body of the affected person.

The most important thing is whether the tumour has spread beyond the tissue of the pancreas and has affected surrounding tissue. It is also very important to find out whether there are already distant metastases in other organs and whether the lymph nodes of the body are already affected. Depending on how this staging occurs, a longer or shorter statistical survival time can be assumed.

In oncology, prognoses and chances of survival are described by the so-called 5-year survival rate. It is expressed as a percentage and indicates how many of the average affected patients are still alive after a period of 5 years. It says nothing about the quality of life or possible complications, but only whether someone is still alive.

If the pancreatic cancer has spread beyond the borders of the organs and infiltrated surrounding organs, and if it has also affected the lymph vessel system and the bile ducts are already narrowed, a decision is usually made against curative surgery and only a palliative approach is used. A palliative treatment concept is not a curative approach but a pain-relieving approach. In this case the disease is unstoppable and inevitably leads to death.

If such a treatment concept is chosen, the 5 year survival rate is 0%, i.e. after 5 years no patient is alive anymore. If a curative approach is chosen, i.e. if measures such as surgery or chemotherapy are taken, the chances of survival increase. In this case, one speaks of an approximately 40% 5-year survival rate.

After 5 years, 40% of the intensively treated patients are still alive. Also not how many patients are still alive after 6-10 years. The fact that more than half of the treated patients have died after 5 years clearly shows how severe this disease is.

There is also an average 5 year survival rate, which indicates all survival rates of a disease as an average. Since there are some treatment methods that are also applied individually, the averaged prognosis is not too meaningful. The average 5-year survival rate for pancreatic cancer is 10-15%.

This means that only 10-15% of patients on average survive the disease for 5 years. The signs of pancreatic cancer are difficult to detect, partly because the first symptoms appear very late. If pancreatic cancer is diagnosed early, it is usually a matter of routine examinations, the secondary findings of which show conspicuous values, e.g. in the blood count or also in the ultrasound image.

The first symptoms, which is why a doctor is usually consulted, can be back pain, which is either beltlike at the level of the pancreas, or abdominal pain that extends into the back. Since these are completely unspecific symptoms, the first suspicion will probably never be pancreatic cancer, which is why valuable time can pass. Mostly, however, patients come to the doctor with an unclear so-called icterus, a yellowing of the skin and conjunctiva.

An icterus is completely painless and only indicates that there is either a problem with the blood pigment bilirubin, for example if the liver is damaged, or if there is a bile flow problem in the area of the bile ducts or pancreas. In the case of an icterus, it is essential to have a closer look at the pancreas in addition to the liver. Sometimes it happens that patients become conspicuous due to a sudden sharp increase in blood sugar.

As a rule, these patients are diabetic mellitus and are treated with insulin accordingly. In this case, however, the pancreas should definitely be examined. The background is that the pancreas produces the vital substance insulin.

If the work of the pancreas is impaired by a tumour, it is possible that too little insulin is produced and released into the blood, which can then lead to an increased blood sugar level. Since there are only a handful of correct symptoms that are not pancreas-specific, if these symptoms are present, they should be followed closely in order not to overlook this life-threatening disease. Another important and trend-setting first symptom of a pancreatic disease is a change in stool and a conspicuous urine.

Thus, the majority of those affected whose pancreatic duct is obstructed by an inflammation or the corresponding tumour show a lightening of the stool. At the same time the urine also becomes darker. The reason is that the substances that are released by the pancreas for digestion to make the bowel movement darker no longer reach the digestive tract but are excreted through the urine.

This is why the colouring does not take place in the stool but in the urine. Patients who have such complaints should definitely be examined more closely. Although there is not always a malignant disease history behind it, the suspicion of a disorder of the bile ducts or pancreas is very high.

If treatment is decided upon, it depends on whether it is a curative treatment (i.e. a curative approach) or a palliative approach (palliative treatment). In palliative treatment, measures are used that do not unnecessarily weaken the patient but are intended to have a soothing effect on him or her. In most cases in patients undergoing palliative treatment, the tumour has already affected large parts of the pancreas and the drainage of bile acids is disturbed, which leads to severe symptoms and yellowing of the skin.

In this case, a small tube is usually inserted into the pancreatic duct by means of an endoscopic procedure to ensure that the bile ducts can drain away immediately and can once again actively participate in digestion. In the case of progressive pancreatic cancer, it is usually the case that the initially complete painless tumour attack becomes increasingly painful as it progresses. For this reason, an important palliative treatment concept, regardless of the type of tumour, is to ensure freedom from pain.

In most cases, highly potent analgesics are chosen, which are very quickly highly dosed in order to guarantee the corresponding freedom from pain. If a curative, i.e. curative treatment approach is chosen, surgical measures or combined surgical and chemotherapeutic measures are usually used. Depending on the spread of the tumour, it may be necessary to start chemotherapy before an operation.

This is usually carried out if the tumour is very large and a chemotherapeutic reduction would make a gentler operation possible. It may also be necessary to carry out chemotherapy after an operation in order to subsequently kill any remaining tumour cells. Exclusive surgical treatment is rarely performed.

During surgery, the affected pancreas is operated on as gently as possible. Parts of the unaffected pancreas are left standing so that the corresponding functions can be maintained. Almost always, however, the gallbladder and parts of the stomach and duodenum are removed and the remaining ends reattached.

This procedure, also known as Whipple surgery, is now a standardised treatment method for pancreatic cancer. There is also a modified surgery in which larger parts of the stomach are left standing and the result is the same as the Whipple surgery. As a rule, patients suffering from pancreatic cancer are older.

However, since severe alcoholism with recurrent pancreatitis is considered a risk factor, it can also happen that patients of younger age are affected by pancreatic cancer. In Germany, 10 people per 100,000 inhabitants per year are newly diagnosed with pancreatic cancer. The main age group is between 60 and 80 years.

It is not so easy to diagnose pancreatic cancer. The first important thing is to raise suspicion, which must then be substantiated. If there is a suspicion of a malignant event in the area of the pancreas, imaging procedures are used in addition to blood tests.

In the blood, above all the enzymes produced by the pancreas are determined. A sharply increased increase indicates a general disease in the pancreas. However, it can also be an inflammation of this gland.

For this reason, it is important to perform imaging. In most cases, an ultrasound of the abdomen is performed first, in which the pancreas is attempted to be imaged. Large tumours, which are located in the area of the gland, can sometimes already be seen.

Even if a mass is seen in the ultrasound, a computed tomography of the abdomen is usually followed. Here the suspicious area can be examined more closely, usually with a contrast medium. Experienced radiologists can often already guess from the CT image whether it is a benign disease, such as a particularly pronounced inflammation, or a malignant disease.

Another important diagnostic imaging measure is ERCP. In this procedure, a gastroscopy is performed and a small catheter is inserted into the bile ducts and the pancreatic duct at the level of the duodenum. A contrast medium is injected through this catheter, which is then scanned using X-rays.

This shows the pancreas with an exact view of the duct. It can be seen whether the duct is compressed at any point and if so, by what. Even after this also as endoscopic retrograde cholangiopancreaticography, it is not possible to clarify with certainty whether it is a malignant tumour that compresses the bile duct.

The more the suspicion of a pancreatic tumour is confirmed, the consideration of a sample collection must be made, which will then provide definitive information about the histological development of the tumour. Sampling can be carried out by the described ERCP if the tumour already reaches far into the pancreatic duct or also from the outside by needle puncture. Since the pancreas is a relatively small organ surrounded by important structures, it is particularly important not to injure any of the surrounding tissue such as nerves or vessels.

For this reason, the puncture is usually controlled by CT. The patient lying in a CT machine is placed in the pancreas with a needle under external control after the radiologist has located the exact position of the pancreas using CT. The procedure takes only a few minutes, the sample is minimal, but gives the decisive indication of the development of the tumor and the necessary next therapeutic steps.

The sample is then sent to the microbiology laboratory, where the cells are treated with a special staining procedure. The samples are then examined by a pathologist and an appropriate diagnosis is made. So-called false positive results, i.e. that a cancer is seen but in reality a benign new formation is present, only exist if the samples are mixed up.

A false negative result, i.e. that the pathologist does not see any malignant tumour tissue although it is cancerous, may be more frequent. Mostly it is because the biopsy, which was carried out precisely and under CT control, and hit parts of the pancreas, penetrated right next to the malignant cells and therefore only hit benign cells. The pathologist then sees only benign cells under his microscope. If the microscopic findings contradict the CT image (typical CT image but inconspicuous microscopic findings), the biopsy should be considered again. Biopsy