Unlovely but essential: why the pancreas is so important

by Symptom Advice on May 14, 2012

What do you think this is?” a surgical registrar once asked me. we were standing over the blue-draped abdomen of a 60-year-old man, peering into the hole the registrar had made. The brown bulk of the liver was obvious – it is massive, relative to everything else, with a clearly defined bottom edge, like the hull of a boat. I could see the gall bladder, clinging to the liver’s underside like a greenish blob of sea anemone. The surgeon had worked her way deeper towards the spine and was poking at a knobbly piece of tissue with her forceps. “Think of the pictures you’ve seen in books: think what is related to what.”

Looking for a landmark, I finally saw a bit of the duodenum, the first part of the gut, which curves in the shape of a C. The unidentified organ had one end buried in the curve. It was the pancreas. in anatomical drawings the pancreas looks weightless: an elegant plume like the feather sticking out of a cavalier’s hat, with its broad end (the “head”) nestled against the duodenum and its “tail” pointing across the top of the abdomen towards the spleen. you could see how its name is derived from the Greek words meaning “all flesh”; it is lumpy and blobby, unlovely but essential.

The pancreas has several functions. It is both an endocrine gland (producing hormones that are secreted into the internal environment: the pancreas secretes insulin and glucagon into the bloodstream), and an exocrine gland (producing substances released into the exterior; the pancreas makes enzymes to help us digest our food and secretes them into the gut, and so, eventually, the outside world). when the endocrine cells malfunction, diabetes results: a common, harmful but treatable illness. For some reason, the other serious diseases affecting the pancreas have a much lower profile. Pancreatic cancer, like the other so-called “silent” cancers (ovarian is another), tends to present late, which accounts for its poor prognosis. A small tumour in the pancreas is rarely painful or disruptive, especially if it grows in the tail. By the time it has grown large enough to cause symptoms, such as nausea, weight loss, pain or jaundice (from a tumour blocking the common bile duct), it has often invaded nearby structures, or spread elsewhere in the body – as happened to the actor Patrick Swayze. Once it has spread, the disease is inoperable.

Pancreatic cancer is a very nasty disease, but it actually kills fewer people than a less well-known illness, pancreatitis – inflammation of the pancreas. At its most severe, acute pancreatitis has a mortality rate of 10 per cent. (You can also get a lingering, chronic form of the disease, which is painful and difficult to treat, but less immediately dangerous.) Many things can provoke an acute (or sudden) inflammation of the pancreas, but the most common are excessive alcohol and gallstones (if you are a medical student these sensible causes unfortunately desert you and you will only be able to summon up “scorpion venom” – true, but unhelpful in a British context).

Alcohol acts as an irritant (a single binge can be enough to trigger a severe episode), and gallstones can fall out of the gallbladder and block the common bile duct, obstructing the drainage route from the pancreas to the gut. whatever the trigger, the results are the same. instead of pouring its enzymes into the small bowel to help process food, the pancreas sequesters them instead, digesting itself. as the students inevitably ask, “you mean it eats itself?” It does, with life-threatening consequences.

Sophie Harrison is a hospital doctor in South Yorkshire

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