Answers to frequently asked questions

The pancreas fulfills two main functions:

1. it is important for digestion (exocrine function).

2. it controls the regulation of blood sugar (endocrine function).

Digestion: The pancreas produces digestive enzymes that are used to break down nutrients ingested with food, namely carbohydrates (amylase), fats (lipase) and proteins (protease). The pancreas releases these digestive enzymes to the duodenum in the form of a clear, transparent secretion called pancreas. Furthermore, the pancreas produces bicarbonate to neutralize the acidic gastric juice.

The composition of the pancreas is controlled by hormones and regulated according to the fat content and acidity of the food. The amount of secretion is also influenced by the food consumed and ranges from 1500 ml to 3000 ml per day. This secretion is very active in digestion. In order to prevent the gland from damaging itself during its formation, precursors that are not yet effective are produced in the organ and only acquire their potency in the small intestine.

In acute pancreatitis (acute inflammation of the pancreas) and after operations on the pancreas, there is a risk that the secretion in the pancreas itself may become active or enter the abdominal cavity. In the process, the secretion can disintegrate the tissue with which it comes into contact.

Blood glucose regulation: Scattered throughout the pancreas are groups of cells called islets of Langerhanns, in which hormones, messenger substances of the organism, are formed. These hormones, insulin and glucagon, are mainly used for carbohydrate metabolism. They do not enter the intestine via the secretion, but are transported via the blood to all organs (liver, brain, heart) in which glucose is converted as an essential source of energy for the cells.

Without insulin from the pancreas, diabetes, the diabetes disease, develops. Besides insulin and glucagon, other hormones are produced in the pancreas, such as somatostatin and pancreatic polypeptide. All these hormones are involved in metabolism.

The pancreas produces important enzymes. It produces 1.5 - 3 l of enzyme-containing secretion daily. In the process, 60 g of protein are converted in the gland. This is a large metabolic output. This digestive secretion is produced by specialized cells throughout the gland. Initially, an ineffective precursor is produced, which is directed into a widely branched ductal system and finally collected in a main duct, the so-called "ductus pancreaticus", and released into the duodenum. Just before entering the duodenum, this pancreatic secretion is joined by bile, which comes from the liver. These secretions are passed into the duodenum, and the site of the orifice is called the papilla Vateri. In the duodenum, the pancreatic enzymes are activated, i.e. converted into their effective form. Now the food coming from the stomach can be digested.

The pancreas produces more than 20 different digestive enzymes that break down food into its smallest building blocks. This is the only way they can be absorbed from the intestine into the blood. However, these enzymes are not converted to perform their task until they reach the duodenum. This prevents these enzymes from digesting the pancreas itself. The three most important enzymes of the pancreas are called:

• Amylase digests carbohydrates
• Trypsin digests proteins
• Lipase digests fats

The breakdown of food components into smallest pieces is necessary so that the body can absorb them through the intestines. If the pancreatic enzymes are missing, the carbohydrates (starch, etc.), proteins and fats are not broken down properly and the intestine is not able to transport the nutrients into the blood. As a result, undigested food continues to be transported in the intestines. This leads to diarrhea, flatulence and also abdominal cramps. In addition, due to the lack of absorption of food into the body, there is a steady weight loss, the lack of essential vitamins and dysfunction of other organs because they lack energy.

In addition to digestive enzymes, the pancreas also produces an important hormone, insulin. This is produced in special islet cells, which are found in small groups throughout the gland. These so-called islets of Langerhann account for only about 2.5 g of the 80-120 g gland. Approximately 1.5 million islets are found in the pancreas. From there, insulin is released directly from the pancreas into the blood. This hormone is crucial for blood sugar control.

In a sense, it opens the doors to all the body's cells for the sugar. Of the various sugar molecules, glucose is the most important. All cells depend on glucose. Without it, cell function is lost. After absorption from the intestine into the blood, insulin enables glucose to pass from the blood into the body's cells.

If there is too little or no insulin, the glucose cannot pass from the blood into the body's cells. As a result, blood glucose rises, which has life-threatening consequences for humans. Diabetics have such a more or less pronounced lack of insulin.

The pancreas produces another important hormone, glucagon. It is also produced in the islet cells. Glucagon is the antagonist of insulin. When low blood sugar causes danger to the function of cells, glucagon releases glucose from reserves in the body, especially in the liver, and blood sugar rises. In the absence of the pancreas, this important safety hormone is absent. This must be taken into account in the treatment of pancreas-operated patients.

The production of pancreatic enzymes and insulin are largely independent of each other. If damage to the pancreas occurs for any reason, both functions can be disrupted independently of each other.

Most often, abdominal pain occurs, which is belt-shaped or also radiates to the back (the pancreas is located in the back of the abdomen, hence back pain). The pain may be quite sudden and severe (acute pancreatitis) or recurrent (chronic pancreatitis) or slowly increasing (pancreatic tumor).

Other symptoms of pancreatic disease include diarrhea, bloating and flatulence (indigestion) or diabetes (diabetes).

Pain in the upper abdomen and middle of the abdomen with radiation to the flanks (girdling) and back.

What should I do if something is wrong with my pancreas?

Visit your family doctor right away and tell him about your symptoms, he will examine you and arrange for further tests - such as laboratory control and ultrasound examinations.

This is a pancreatic cancer. It is a very serious disease that needs to be treated very quickly. The earlier you detect the disease, the better you can help.

In addition to the discussion with the physician and the physical examination, laboratory tests, ultrasound, computer tomography (X-ray), magnetic resonance imaging (MRI) and also a reflection of the duodenum with X-ray imaging of the bile and pancreatic ducts (ERCP) come into question. If no certainty can be achieved in this way, clarification must be obtained via laparoscopy or trial surgery.

What is the medical treatment for pancreatic carcinoma?

A carcinoma can only be cured surgically by removing it. This is accompanied by treatment of the symptoms and the consequences of the disease (pain management, improvement of digestion, insulin therapy, etc.) Chemotherapy and radiation treatment do not cure the disease, but prolong and improve the quality of life.

You can find out more about this under Pancreatic Cancer

Acute inflammation of the pancreas, often caused by gallstones blocking the pancreatic duct or by too much alcohol damaging the cells of the pancreas.

Acute pancreatitis is always a dangerous disease, it should be treated in hospital. Due to inflammation, the organ swells, bleeding, self-digestion and involvement of other organs may occur. 85% of acute pancreatitis is mild, 15% is life-threatening.

You can find out more about this under acute pancreatitis

An inflammation of the pancreas that usually progresses with severe pain over a period of years, triggered by alcohol in 80% of cases. Repeated episodes of inflammation lead to an increasing loss of function and a lack of digestive enzymes, vitamins and insulin. The pancreas is severely altered over the years, hardening and even calcification occur. Cancer can then also develop.

You can find out more about this under chronic pancreatitis

In acute pancreatitis only in case of complications, in chronic pancreatitis in the late course (after 3 to 5 years) in case of tumors in all early stages and in middle stages without distant metastases (liver, lung).

The risks of surgery are low if the surgery is done in a center with great experience. They are higher if it is done in a hospital with low frequency of pancreas surgery.

Only in young diabetics if severe renal dysfunction is also present. All other patients are treated with insulin.

Yes! But that alone is no reason to take on the transplant risks.

Yes.

No, only when more than 60 to 90% of the pancreas is gone, or when the gland is already damaged by chronic inflammation, diabetes develops.

As a rule, you can eat normally. One should eat more than three, preferably 5 - 6 meals a day. After major pancreas surgery, one must limit fat consumption or adjust it to tolerance and take digestive enzymes with each meal. However, the quality of life is good after pancreas surgery.

Until the operation, yes. After that, only rarely.

The Pancreas Center has all the specialists who have been dealing with pancreatic diseases for many years and have the indispensable experience in all areas. Especially the surgical experience is enormously important for good long-term results.

As a rule, the health insurance company. The European Pancreas Center will help you with this.

Send us an email at pankreas@med.uni-heidelberg.de. You will receive a message from us within 24 hours!

Also if you have a personal question, send us an email: pankreas@med.uni-heidelberg.de. Your question will be answered quickly and confidentially.

Chronic pancreatitis is a chronic (over a long period of time) inflammation of the pancreas. Persistent and recurrent episodes of inflammation of the pancreas result in the slow destruction of the functional cells in the gland. These are replaced by scar-like tissue. As a result, the pancreas can no longer adequately perform its normal function:

1. the production of digestive enzymes, which are responsible for allowing food to be broken down into smaller units, and thus absorbed from the intestines into the body, dries up. Diarrhea (often foul-smelling), weight loss and vitamin deficiencies result.

2. The islet cells of the pancreas, are also destroyed. As a result, less or no insulin is produced, glucose metabolism is disturbed, diabetes mellitus develops.

One of the main symptoms of chronic pancreatitis is severe upper abdominal pain, which is often belt-shaped and can radiate to the back. They probably originate from changes in the nervous tissue in the pancreas and obstruction of outflow from the pancreatic ducts. This results in an ever-increasing pressure in the organ. Pain can also result from obstruction of the passage of food through the stomach and intestines or massive flatulence. This pain often cannot be relieved even by the strongest painkillers.

In Western countries, alcohol consumption is the most common cause (80%) of chronic pancreatitis. However, this does not always have to be a case of persistent overconsumption of alcohol. Rather, there are different "tolerance limits" for alcohol, so that in some people even a relatively small amount of alcohol is enough to trigger the disease.

In addition to this most common one, there are other important causes of chronic pancreatitis: chronic gallstone disease, genetic defects, special anomalies of the pancreatic ducts (pancreas divisum), medications, and metabolic disorders. Sometimes no cause is found.

What are the most common signs of chronic pancreatitis?

• Pain
• Flatulence, bloating
• Diarrhea
• Weight loss
• Diabetes mellitus (diabetes)

Therapy is based primarily on the patient's complaints. Often, the patient's main problem is the barely tolerable upper abdominal pain. First of all, all alcohol consumption should be stopped. Secondly, one will try to reduce the secretion of the gland by taking pancreatic enzyme preparations, thus immobilizing it and at the same time restoring sufficient digestive capacity.

If these two measures do not lead to the desired pain relief, painkillers will be used. If this does not provide sufficient pain relief, surgery must be considered.

If fat deposits in the stool and/or diarrhea show that the pancreas is no longer producing enough digestive enzymes, these must be replaced by regular administration of appropriate medication (e.g., creon). This can also be confirmed by determining an enzyme produced in the pancreas, elastase, in the stool. Depending on the fat content of the meal, more or fewer capsules containing the appropriate enzymes must be taken with the meal. Often, in order for the enzymes to exert their effect, acid production in the stomach must be inhibited by so-called acid blockers.

Finally, care must be taken to ensure sufficient intake of fat-soluble vitamins (A, D, E, K). In severe cases, these must be given by injections into the muscles. This necessity can be investigated by measuring vitamin levels in the blood.

If the glucose in the blood rises, this is a sign that too little insulin is being produced in the pancreas. Rarely, diet can be used to normalize blood glucose levels. As a rule, the patient needs adjustment of blood glucose by regular administration of insulin.

In every second patient with chronic pancreatitis, surgery becomes necessary in the course of the disease. This must be performed very carefully and should therefore be done in specialized clinics. There are several reasons why surgery is necessary:

1. the pain cannot be brought under control even with painkillers.

2. due to the chronic inflammatory changes of the gland, there are effects on the surrounding organs, such as constriction or obstruction of the duodenum, bile duct, main pancreatic duct and vessels behind the pancreas.

3. uncertainty as to whether a tumor is hidden behind the changes.

Sometimes, the formation of so-called "pseudocysts" (fluid-filled cavity created by the inflammation) may also occur. The structure filled with pancreatic secretion is located in or on the pancreas.

Often, pancreatic pseudocysts disappear on their own without any treatment. However, occasionally they become larger and larger, leading to local problems. The best therapy then is surgical removal or drainage. (For more on this, see the page "Acute pancreatitis).

The best time for surgery must be discussed with an experienced pancreatic surgeon. Early surgical removal of the inflammatory focus can help preserve pancreatic functions (digestion, blood sugar control).

Operations on the pancreas for chronic pancreatitis can be divided into "draining" and "resecting" operations. Which procedure is used depends on the changes in the pancreas. In draining operations, the main pancreatic duct is opened along its entire length and connected to the small intestine, allowing pancreatic secretions to drain directly into the intestine. If a pseudocyst is present, it is opened, then a piece of small intestine is sutured to this opening to allow the stagnant fluid to drain.

Often the pancreas is already so inflamed that these procedures only improve the situation for a short time. If pain recurs, removal (resection) of the damaged portion of the pancreas is usually the treatment of choice. Since the inflammation is almost always most pronounced in the pancreatic head, this is then removed.

Today, attempts are made to perform these operations as gently as possible. This means that only the most severely damaged pancreatic tissue is resected. The surrounding organs, such as the duodenum, the bile ducts and the stomach are spared and not removed.

In special cases, it may be necessary to remove these organs as well. If the focus of inflammation is located primarily in the tail of the pancreas, it is removed, sparing the nearby spleen if possible. After resection of the diseased pancreatic tissue, a piece of small intestine is sewn onto the rest of the gland in such a way that the digestive juices can flow out unhindered.

These operations on the pancreas are very demanding and technically difficult. They should only be performed at specialized large centers by appropriately trained surgeons.

Patients who have had part or even all of their pancreas removed may experience functional impairment of the pancreas, depending on the extent of the removal. The following two problems are in the foreground:

• too little pancreatic enzymes (leads to digestive problems)
• too little insulin (leads to high blood sugar)

These deficiencies can be substituted with appropriate medications.

1. pancreatic enzyme substitution

Today there are preparations on the market that replace the pancreas' own enzymes (e.g. Creon). These enzyme preparations must be taken with all main meals and also with snacks in between meals ("snacks"). The necessary dosage varies from patient to patient and depends on the type of food and ultimately on the patient's symptoms. The decisive factor is that a feeling of fullness and diarrhea with fat deposits disappear under this therapy. Typically, more capsules need to be taken at the main meals than at the meals in between. It is important that the pancreatic enzymes come into contact with food so that they can fulfill their effect. Thus, between 6-12 capsules are needed per day. However, the number can also be significantly higher or lower, depending on the remaining pancreatic function and the preparation, which is offered in very different enzyme contents.

These preparations are usually very well tolerated and have practically no side effects. Very rarely, an allergic reaction may occur.

2. insulin substitution

In case of high blood sugar levels after pancreatic disease or surgery, it is necessary to perform appropriate blood sugar therapy. Initially, and if blood glucose levels are not greatly elevated, this can be done with the help of adjusted food intake and tablets that affect glucose levels. However, the loss of insulin-producing cells often makes insulin treatment necessary. Today, a wide variety of insulin types are available for insulin treatment, allowing therapy to be highly individualized. Special attention can be paid to dietary habits. The goal of every therapy is personal well-being and a good adjustment of the blood glucose level. In this way, serious consequential damage in the near and distant future can be avoided. Especially in the initial phase, close supervision by the family doctor or specialist is necessary.

It is possible that the spleen had to be removed as part of a pancreas operation.

It is quite possible to live without a spleen. The spleen plays a certain role in the human immune system. Without a spleen, one is more susceptible to bacterial infections. These can become life-threatening diseases. To protect patients from infections, one should receive appropriate vaccination after surgery. Here, the pneumococcal infection vaccination should be mentioned in particular. According to current guidelines, these vaccinations must be repeated after about 3 to 5 years. Furthermore, when an infectious disease occurs, the patient should visit the family doctor and draw his attention to the fact that he no longer has a spleen. He will then decide whether antibiotic therapy is necessary.

Furthermore, after a splenectomy there may be an increase in blood platelets (thrombocytes). It is important to check these regularly. If the increase in platelets is too high, there is a tendency to thrombosis. If the increase is too high, your doctor will temporarily prescribe medication to reduce the risk of thrombosis.

In its development, the pancreas arises from two parts that normally merge during the growth period of the embryo.

In the process, these two parts of the gland, including the separate ducts, merge into one organ as the more anterior (ventral) part migrates posteriorly.

In the course of embryonic development, the merging of the pancreas may be disturbed, which in some cases may lead to diseases.

1. anulare pancreas

In this case, during the early phase of development, the migration of the ventral part of the pancreas causes a part of the duodenum to be wrapped around above the papilla, thus obstructing the passage of the food.

The first signs of the disease occur either in early childhood or in the adult. They are characterized by vomiting and pain in the upper abdomen; icterus (yellow discoloration of the skin) is also rarely observed. Acute or chronic pancreatitis may occur due to obstruction of pancreatic outflow.

2. pancreas divisum

In this anomaly, the two ductal systems of the pancreas do not fuse together while the actual tissue does. Thus, two ducts opening into the small intestine remain.

Secretions from the posterior (dorsal) larger portion are drained through the so-called ductus Santorini via a "minor papilla". The anterior smaller (ventral) section empties its secretion via the ductus Wirsungianus via the "major papilla". The bile duct (ductus choledochus) also empties into this section.

The frequency of this variation is variously reported between 3 and 10% in the general population. As a rule, this is of no importance. Only if the minor papilla has an excessively narrow outflow duct in the papillary region does this lead to obstruction of pancreatic outflow, which can result in acute or chronic pancreatitis.

Treatment consists of widening the excretory duct. Initially, this is attempted by means of an endoscopic papillary incision, often with the insertion of a tube (stent or prosthesis), but in most cases this is not a permanent solution.

Today, it is possible to widen this ductal stenosis with a papilloplasty operation without having to remove the pancreas or parts of it.