Pancreatic Diseases

Image 1. Anatomic relation of the pancreas with the adjacent organs.

Image 2. Pancreatic Anatomy

Pancreatic Cancer

The pancreas is a long flat organ, located behind the stomach in the upper abdomen. Pancreatic cancer is a cancerous growth in the pancreas.There are several types of pancreatic cancer but more than 9 in 10 of all cases are caused by a pancreatic adenocarcinoma.Pancreatic cancermainly occurs in people over 60 years old.

Image 3. Pancreatic Head Tumor invading the duodenum and compressing the distal bile duct.

The cause of pancreatic cancer is not well known. There are though specific risk factors for developing pancreatic cancer including ageing, smoking, chronic pancreatitis, diet, diabetes, chemicals, genetic and hereditary factors.

Pancreatic cancer can be found in all parts of the pancreas including the head, body or tail of pancreas. A small tumour often causes no symptoms at first. Pancreatic head tumours can present with jaundice (yellowness in the eyes and skin) secondary to blockage of the bile duct. Abdominal or back pain can also be symptoms of pancreatic cancer commonly related to perineural invasion. Vomiting, loss of appetite, weight loss and new onset of diabetes may also be present.

Diagnosis and staging of pancreatic cancer is made with imaging including CT scan, MRI/MRCP, endoscopic ultrasound and PET- CT scan. All this exams can assess the local extend of the tumour and rule out distant metastasis. Biopsy is required only in those cases where the radiological imaging is inconclusive or prior to oncological treatment (both neoadjuvant or palliative).

Treatment options that may be considered include surgery, chemotherapy and radiotherapy. The treatment advised for each case depends on various factors, such as how large the cancer is and whether it has spread (the stage of the cancer) and your general health. Surgery is the only available treatment with a curative intent. Surgical resection of pancreatic cancer could be offered only if there are no distant metastasis or local involvement of vascular structures that cannot be removed or reconstructed with clear margins.

If a pancreatic cancer is diagnosed and treated at an early stage then there is a modest chance of a cure with surgery. As a rule, the smaller the tumour, and the earlier the tumour is diagnosed, the better the outlook. Some tumours which develop in the head of the pancreas are diagnosed very early, as they block the bile duct and cause yellow skin (jaundice) fairly early on. This obvious symptom is then investigated and surgery to remove a small tumour may be curative. However, most pancreatic cancers are advanced upon diagnosis. A cure is unlikely in most cases. However, treatment may slow down the progression of the cancer.

Dr Papoulas is one of the most experienced pancreatic surgeons in Cyprus. His expertise and clinical practice in both surgical oncology and transplantation have given him the ability to perform the most demanding pancreatic resections including vascular resections and reconstructions.

Acute Pancreatitis

The pancreas is a long flat organ, located behind the stomach in the upper abdomen. The pancreas produces enzymes that help digestion and hormones that help regulate the way your body processes sugar (glucose). Pancreatitis is defined as inflammation of the pancreas which can be acute or chronic. Acute pancreatitis appears suddenly and lasts for days whereas chronic pancreatitis occurs over many years.

Mild cases of pancreatitis may go away without treatment, but severe cases can cause life-threatening complications. The most common symptoms of acute pancreatitis are epigastric pain radiating to the back, nausea or vomiting, diarrhoea and fever. Jaundice (yellowness in the eyes and skin) and deranged liver function tests may be present especially in cases where the pancreatitis is secondary to gallstones.

The most common causes of acute pancreatitis are gallstones and alcohol consumption. Other causes have also been described such as drugs, viruses, autoimmune conditions, injury to the abdomen, increased triglycerides or calcium levels in the blood and iatrogenic. Sometimes no cause can be identified. Diagnoses of acute pancreatitis can be suspected from the clinical picture and the history of the patient. Further test to confirm the diagnosis include blood tests showing increased levels of the pancreatic enzymes (amylase and lipase), US abdomen and CT scan showing oedematous and swollen pancreas or peripancreatic fluid accumulation. In cases of severe pancreatitis, there may be areas of organ hypo-perfusion, necrosis on imaging.

Acute pancreatitis can be a very serious condition requiring multidisciplinary approach and expert treatment in high volume centers. Complications related to acute pancreatitis include pancreatic infection, pseudocyst formation (cystlike fluid filled pockets around the pancreas), kidney failure, acute respiratory distress syndrome, diabetes and malnutrition. The treatment of pancreatitis is mainly conservative and supportive. Dr Papoulas and his colleagues including intensive care doctors, interventional radiologists and gastroenterologists can offer the best and most comprehensive treatment of patients with acute and complicated pancreatitis.

Chronic Pancreatitis

In chronic pancreatitis the pancreas has become permanently damaged from inflammation over many years.Chronic pancreatitis can affect people of any age, but it usually develops between the ages of 30 and 40 as a result of heavy drinking over many years. It’s more common in men. Patients present with chronic pain, diabetes and malabsorption leading to weight loss. Long-standing pancreatic inflammation caused by chronic pancreatitis is a risk factor for developing pancreatic cancer.

Once diagnosed with chronic pancreatitis, you should be followed up by gastroenterologist, endocrinologist, dietitian and hepatobiliary surgeon. Treatment can help control the condition and manage any symptoms. You will be usually advised to make lifestyle changes, such as stopping drinking alcohol and stopping smoking. You will also be given medicine to relieve pain and also pancreatic enzyme supplements to help your digestion.

Patients with symptomatic pancreatic duct stones can be treated with endoscopic removal (ERCP) and lithotripsy. This treatment may improve pain to some extent, but the benefit may not be permanent.In cases where specific parts of the pancreas are inflamedcausing severe pain, they can be surgically removed. This is called pancreatic resection aiming to improve the drainage of the remaining pancreas. In those rare cases where the whole pancreas is chronically inflammed causing significant symptoms not alleviating conservatively, a total pancreatectomy may be considered.

Pancreatic Cysts

Pancreatic cysts are saclike pockets of fluid on or in your pancreas. Pancreatic cysts are typically found during imaging testing for another problem (incidentally).The main categories of pancreatic cysts can be divided into two groups, nonneoplastic or neoplastic cysts. Each group includes many different subtypes of cysts, such as pseudocysts, serous cystadenomas and mucinous cystic neoplasms. Most aren’t cancerous, and many don’t cause symptoms. However, some pancreatic cysts can be or can become cancerous.

Diagnosis of those cysts requires a CT scan and MRI/MRCP. In some cases, endoscopic ultrasound can also be performed in order to further assess the lesion and also obtain fluid for biochemical analysis or tissue for biopsy. The majority of those lesions will require a routine annual follow up. Only a minority of the pancreatic cystic lesions will need intervention or surgery.

Dr Papoulas is an expert in pancreatic diseases including management of pancreatic cystic lesions. Visit Dr Papoulas in order to get an expert opinion.

Image 4. Illustration of pancreatic cystic lesions.