University of
Leicester
The pancreas
“The shape and size of a kipper”
Ashley Dennison
University of Leicester
Exploring the Science of Digestion
Birmingham Town hall
Tuesday 6th December,2016
University of
Leicester
History of the pancreas
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The pancreas was first identified by a Greek anatomist
Herophilus in 335–280 BC
Another Greek anatomist and physician Ruphos of
Ephesus in the late 1st century AD gave the pancreas its
name.
Etymologically, the term "pancreas“ is a modern Latin
adaptation of the Greek πάγκρεας, πᾶν "all", "whole",
and κρέας "flesh", originally meaning
sweetbread although literally meaning all-flesh,
presumably because of its fleshy consistency
University of
Leicester
The pancreas is essential
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Pancreatic tissue is present in all vertebrates
Can be up to three pancreas’s but fused into one in
humans
Sometimes no discrete pancreas with tissue distributed
in the mesentery of the bowel and other organs such as
the liver and spleen
University of
Leicester
Studies on the pancreas
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The study of the pancreas began on March 2, 1642,
when a German émigré, Johann Georg Wirsüng,
discovered the pancreatic duct in the San Francisco
Monastery in Padua, Italy. Wirsüng was murdered by a
student the year after the discovery.
1671 Regnier de Graaf investigated the physiological
functions of the pancreas by examining the juice in
dogs
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Leicester
Where is the pancreas
• Shape and size of a kipper with a head,
neck, body and tail
• At the back of the upper abdomen
• Six inch's long weighing 60-100g
• Draped over the blood vessels at the
back of the abdomen
• Has a duct like the backbone of a kipper
• Connected to the first part of the bowel
after the stomach, the duodenum
University of
Leicester
Anatomy of the pancreas
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Leicester
Under the microscope
University of
Leicester
Function remained a mystery
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The digestive enzymes, (amylase, lipase, trypsin, etc), secreted by
the pancreas into the intestine, were discovered in the mid to late
19th century.
In 1889 Oscar Minkowski discovered that removing the pancreas
from a dog caused it to become diabetic.
In 1921 insulin was discovered by Frederick Banting and Charles
Best
Beginning in 1898 surgeons started to operate on the pancreas
Codivilla (1898) and Halsted (1898), Kausch (1909), Hirschel (1913),
Tenani (1918), and Whipple (1934-1940) who performed the first
successful one-stage resection of a cancer of the pancreas in New
York City on March 6, 1940.
University of
Leicester
Main functions of the pancreas
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Digestion of food by producing
enzymes (exocrine) such as lipase,
protease and amylase
Blood sugar control and metabolism
(endocrine) by hormones (insulin,
glucagon, somatostatin and pancreatic
polypeptide).
Control of the function of the bowel
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Leicester
What can go wrong
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Tumours
Cancer
Other tumours
Inflammation
Acute
Chronic
University of
Leicester
Pancreas cancer
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Common disease – 9,000 per year in UK; 5th commonest fatal cancer
85-90% inoperable at presentation
Only 20% of the remainder cured by surgery
97% will die of the disease
8,500 deaths per year
Incidence approximates to mortality
University of
Leicester
Signs and symptoms
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Painless jaundice
Pale stools (clay coloured) and
dark (tea coloured) urine
Back pain (depends on the
position of the tumour)
Weight loss
University of
Leicester
Outlook of pancreas cancer
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Locally advanced cancer: median
survival without treatment about 6
months
Disseminated disease: median
survival without treatment ~3
months
With standard chemotherapy
(gemcitabine) 18% survive one year;
2% without.
Results have not improved
significantly for 30 years
University of
Leicester
Other pancreas tumours
Neuroendocrine tumours (NET’s)
University of
Leicester
Acute Pancreatitis
“Acute pancreatitis is an acute inflammatory process of the
pancreas with variable involvement of other regional tissues
or remote organ systems”
In 1925 Sir Berkeley Moynihan wrote “acute pancreatitis is
the most terrible of all calamities that occur in connection
with the abdominal viscera. The suddenness of its onset, the
illimitable agony which accompanies it and the mortality
attendant upon it render it the most formidable of
catastrophes.”
University of
Leicester
Causes of acute pancreatitis
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Gallstones
Alcohol
Trauma
High lipids and calcium
Infection
Drugs
Cancer
Pregnancy
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Leicester
Causes cell damage
Intracellular oedema
Cell membrane
destruction
University of
Leicester
Incidence in the UK
“There have been sharp increases in the incidence of acute pancreatitis over
the last 30 years in the UK and other European or western countries. These
include studies in Croatia, Denmark, Finland, Germany, Ireland, Norway,
Sweden, the Netherlands, and the USA”
“From 1999-2010 the incidence of acute pancreatitis was 30.0 per 100 000
population overall, mortality was 6.4% at 60 days. Incidence increased
significantly from 27.6 per 100 000 in 1999 to 36.4 in 2010 (average annual
increase = 2.7% per year).”
University of
Leicester
Effects of acute pancreatitis
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Mild attack in 80-90% but severe in 10-20%
Overall mortality 6-8% but 25-40% when severe
Recurrent episode within 3 years in 16.5-25%
Mortality has steadily fallen over the last 30 years
Pancreatic necrosis in 10-20%
Infected pancreatic necrosis 20-30% (of patients with
necrosis)
University of
Leicester
Acute pancreatitis is very expensive
In an American study;
“The estimated total cost for acute pancreatitis admissions was $2.2B at a mean cost
per hospitalization of $9870 and a mean cost per hospital day of $1670. Costs per
hospitalization were higher in urban hospitals, teaching hospitals, and for patients
older than 65 years, based on a longer length of stay.”
In a European study;
“The overall hospital cost and cost for loss of production was per person in mean
€5,100 for mild acute pancreatitis and €28,200 for severe acute pancreatitis. The costs
for treating AP during the two-year-long study period were on average €9,762 per
patient. Extrapolated to a national perspective, the annual financial burden for AP in
Sweden would be €38,500,000; corresponding to €4,100,000 per million inhabitants”
University of
Leicester
Chronic pancreatitis
Chronic pancreatitis (CP) is an inflammatory disease that causes
progressive damage to the pancreatic parenchyma with irreversible
morphological changes and fibrotic replacement of the gland
• In the UK ~50% caused
by alcohol
• ~50% idiopathic
(unknown)
• Small number due to
genetic causes
University of
Leicester
Chronic pancreatitis damage
Normal pancreas
Chronic pancreatitis
University of
Leicester
Symptoms of chronic pancreatitis
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Severe unremitting abdominal
pain
Back pain
Malabsorption (loose motions
due to steatorrhoea; offensive
smell)
Weight loss
University of
Leicester
Conclusions
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The pancreas is a complex organ
Prone to a number of problems
Pancreas cancer has a very poor outlook
Pancreatitis, both acute and chronic, is potentially fatal
and very costly