Pancreatic Diseases

Introduction
Signs and Symptoms
Causes
Risk Factors
Screening and Diagnosis
Treatment
Preventions

The pancreas is a narrow, flat organ about six inches long, with a head, middle, and tail section. It is located below the liver, between the stomach and the spine, and its head section connects to the duodenum (first part of the small intestine). Inside the pancreas, small ducts (tubes) feed fluids produced by the pancreas into the pancreatic duct. This larger duct carries the fluids down the length of the pancreas, from the tail to the head, and into the duodenum. The common bile duct also runs through the head section of the pancreas, carrying bile from the liver and gall bladder into the small intestine. The bile duct and the pancreatic duct usually join just before entering the duodenum and so have a common opening into the small intestine.

The pancreas consists of two kinds of tissues:

• Exocrine - which make powerful enzymes to digest fats, proteins, and carbohydrates. The enzymes normally are created and carried to the duodenum in an inactive form, then activated as needed. Exocrine tissue also makes bicarbonates that work to neutralize stomach acids.
• Endocrine - which produce the hormones insulin and glucagon and release them into the blood stream. These hormones regulate glucose transport into the body's cells and are crucial for energy production.

The primary diseases of the pancreas are pancreatitis, which may be classified as acute pancreatitis or chronic pancreatitis, and cancer of the pancreas.

Pancreatitis is an inflammation of the pancreas. It is caused when the digestive enzymes from the exocrine pancreas become activated inside of the pancreas, instead of in the duodenum, and start “digesting” the pancreas itself. It usually presents with abdominal pain and can cause nausea and vomiting.

• Acute pancreatitis may be a single or a recurring event, and it usually occurs suddenly. The abdominal pain in acute pancreatitis is often severe. The disease may even lead to internal bleeding and infection and can be life-threatening. The most common cause of acute pancreatitis is blockage of the pancreatic duct by gallstones. Secretions can back up in the pancreas and cause permanent damage in just a few hours. Acute pancreatitis often presents with raised levels of pancreatic enzymes in the blood. These enzymes can circulate to other body organs, causing shock and organ failure. Other causes may include biliary tract disease (obstruction, gallstones or sludge), alcohol excess, physical trauma to the abdomen, hyperlipidemia and hypercalcemia.
• Chronic pancreatitis is characterized by chronic or persistent abdominal pain and may or may not present with raised pancreatic enzymes. It develops gradually, often results in slow destruction of the pancreas, and can lead to other problems, such as pancreatic insufficiency (see below), bacterial infections, and type 2 diabetes. The main causes of chronic pancreatitis are gall bladder disease (ductal obstruction) and alcoholism. Other causes of chronic pancreatitis include cystic fibrosis, hypercalcemia, hyperlipidemia, some drugs, and autoimmune conditions.

Cancer of the pancreas is the fourth leading cause of cancer death in the United States, killing about 32,000 people a year. Risks include smoking, age, gender (more common in men), chronic pancreatitis, and exposure to some industrial chemicals. Most (95%) pancreatic cancers are adenocarcinomas, developing in the exocrine tissues. Pancreatic cancer is very difficult to detect in the early stages because symptoms are either absent or nonspecific: abdominal pain, nausea, loss of appetite, and sometimes jaundice. Only about 10% of the cancers are still contained within the pancreas at the time of diagnosis.

Pancreatic insufficiency is the inability of the pancreas to produce and/or transport enough digestive enzymes to break down food in the intestine and allow its absorption. It typically occurs as a result of progressive pancreatic damage - damage that may be caused by a variety of conditions. It is most frequently associated with cystic fibrosis in children and with chronic pancreatitis in adults; it is less frequently but sometimes associated with pancreatic cancer.

Many people who have pancreatic cysts, including pseudocysts, have no symptoms. When signs or symptoms do occur, they typically include:

• Persistent abdominal pain, which may radiate to the back
• A mass you can feel in the upper abdomen, where the pancreas is located
• Nausea and vomiting

Acute pancreatitis comes on suddenly, usually with mild to severe pain in your upper abdomen that may radiate to your back and occasionally to your chest. The pain may be nearly constant for hours or even days and is likely to become worse when you drink alcohol or eat. Bending forward or curling into a fetal position may provide temporary relief.

Other signs and symptoms of acute pancreatitis include:

• Nausea and vomiting
• Fever
• Rapid pulse
• Swollen, tender abdomen
• In severe cases, dehydration and low blood pressure, internal bleeding, and shock

You may have repeated episodes of acute pancreatitis and recover fully from each one. Still, every attack is a serious illness that can damage your pancreas and cause life-threatening complications.

Chronic pancreatitis



Ongoing damage to your pancreas can lead to a chronic condition that destroys the pancreas and nearby tissues, although it may be years before signs and symptoms appear. A few people with chronic pancreatitis never experience discomfort, but most have intermittent bouts of abdominal pain that can be severe. The pain may also become constant.

In addition to pain, you may experience the following with chronic pancreatitis:

• Nausea and vomiting
• Fever
• Weight loss, even when your appetite and eating habits are normal
• Oily, malodorous stools resulting from poor digestion and malabsorption of nutrients, particularly fats (steatorrhea)
• Diabetes

Hereditary pancreatitis
The inherited form of pancreatitis is marked by recurrent attacks of pain, nausea, vomiting and fever lasting anywhere from two days to two weeks. In the majority of cases, the acute bouts progress to chronic pancreatitis. Although the genetic defect that causes the condition is present at birth, pancreatitis symptoms often don't appear until the first or second decade of life. However, most people with hereditary pancreatitis will develop pancreatitis before the age of 20.

Signs and symptoms of pancreatic cancer often don't occur until the disease is advanced. When symptoms do appear, they may include:

• Upper abdominal pain that may radiate to your middle or upper back. Pain is a common symptom of advanced pancreatic cancer. Abdominal pain occurs when a tumor presses on surrounding organs and nerves. Pain may be constant or intermittent and is often worse after you eat or when you lie down. Because many conditions other than cancer can cause abdominal pain, be sure to discuss your symptoms carefully with your doctor.
• Loss of appetite and unintentional weight loss. Unintended weight loss is a common sign of pancreatic cancer. Weight loss occurs in most types of cancer because cancerous (malignant) cells deprive healthy cells of nutrients, and this is especially true in pancreatic cancer.
• Yellowing of your skin and the whites of your eyes (jaundice). About half of people with pancreatic cancer develop jaundice, which occurs when bilirubin, a breakdown product of worn-out blood cells, accumulates in your blood. Normally, bilirubin is eliminated in bile, a fluid produced in your liver. But if a pancreatic tumor blocks the flow of bile, excess pigment from bilirubin may turn your skin and the whites of your eyes yellow. In addition, your urine may be dark brown and your stools white or clay-colored. Although jaundice is a common sign of pancreatic cancer, it's more likely to result from other conditions, such as gallstones or hepatitis.
• Itching. In the later stages of pancreatic cancer, you may develop severe itching when high levels of bile acids, another component of bile, accumulate in your skin.
• Nausea and vomiting. In advanced cases of pancreatic cancer, the tumor may block a portion of your digestive tract, usually the upper portion of your small intestine (duodenum), causing nausea and vomiting.
• Digestive problems. When cancer prevents pancreatic enzymes from being released into your intestine, you're likely to have a hard time digesting foods - especially those high in fat. Eventually, this may lead to significant weight loss - as much as 25 pounds or more - and malnutrition.

In many cases, the cause of a particular pancreatic cyst is unknown. Some cysts are associated with rare illnesses - such as von Hippel-Lindau disease, which is a genetic disorder that can affect the brain, retina, adrenal glands, kidneys and pancreas.

Pseudocysts often follow a bout of pancreatitis, a painful condition in which the pancreas' digestive enzymes become active prematurely and digest some of the pancreas itself. Pseudocysts can also result from blunt trauma to the abdomen.

The pancreas serves two distinct and vital functions. It produces digestive juices and enzymes that help break down proteins, carbohydrates and fats in your small intestine. It also secretes the hormones insulin and glucagon, which regulate the way your body metabolizes sugar (glucose).

Most of your pancreas is composed of cells called exocrine cells that produce digestive enzymes. These cells are arranged in clusters and connected to a series of small ducts. Pancreatic enzymes and juices flow from the cells through the ducts into the main pancreatic duct, which leads to your duodenum. The last portion of the bile duct, which carries bile from your liver and gallbladder, joins with the pancreatic duct just before it empties into your small intestine.

Your pancreas also contains small "islands" of endocrine cells located within the exocrine tissue. These cells, called the islets of Langerhans, secrete insulin and glucagon, along with another hormone, somatostatin, into your bloodstream.

What happens in pancreatitis
Mild acute pancreatitis usually doesn't permanently affect digestion or blood sugar levels, although a single severe attack can damage your pancreas and trigger chronic pancreatitis, which destroys the cells that produce both enzymes and insulin.

Ongoing damage to enzyme-producing tissue in chronic pancreatitis leads to poor absorption (malabsorption) of nutrients, especially fats, to weight loss, and to oily, malodorous stools. And damage to or destruction of insulin-producing cells means blood sugar isn't metabolized properly, often leading to diabetes.

Contributing factors
A combination of environmental and genetic factors likely plays a role in the development of most cases of pancreatitis. Nevertheless, long-term alcohol abuse remains a leading cause of both acute and chronic pancreatitis in industrialized nations.

It's not clear in all instances just how alcohol affects the pancreas. But scientists do know that alcohol causes digestive enzymes to be released sooner than normal. It also increases the permeability of the small ducts that convey enzymes within the pancreas, which allows digestive juices to leak into and damage healthy tissue. What's more, excessive alcohol intake leads to the formation of protein plugs - precursors to small stones - that block parts of the pancreatic duct.

Gallstones also can block the pancreatic duct and are another leading cause of acute pancreatitis. Formed when bile in your gallbladder becomes chemically unbalanced, gallstones sometimes migrate from the gallbladder to the common bile duct, which merges with the pancreatic duct near the entrance to your small intestine. There the stones can block the flow of pancreatic juices into the duodenum. As a result, digestive enzymes become active in your pancreas, where they "digest" healthy tissue, rather than in the duodenum, where they normally break down food.

Other factors that can cause or contribute to pancreatitis include:

• Increased blood levels of fats called trigylcerides (hyperlipidemia) or of calcium (hypercalcemia)
• Certain medications, including corticosteroids and nonsteroidal anti-inflammatory drugs, blood pressure lowering drugs (thiazides), antibiotics such as tetracyclines and sulfonamides, and medications that suppress the immune system such as azathioprine and 6-mercaptopurine
• Surgery, usually of the abdomen
• Structural abnormalities of the pancreas or the common bile duct
• Abdominal trauma, which can compress the pancreas against your spine
• Viral infections, including mumps, hepatitis and Epstein-Barr virus
• Bacterial infections
• Pancreatic cancer, which can obstruct the flow of pancreatic enzymes
• Some inherited diseases, especially cystic fibrosis
• Gene abnormalities, leading to a hereditary form of the disease

Your pancreas is about 6 inches long and looks something like a pear lying on its side. The wider end (head) is located near the center of your abdomen next to the upper part of your small intestine (duodenum). The main part (body) of the pancreas stretches behind your stomach, and the narrow end (tail) is on your left side, next to your spleen.

A part of your digestive system, your pancreas performs two essential functions:

• It produces digestive juices and enzymes that help break down proteins, carbohydrates and fats so the food you eat can be digested in your small intestine.
• It secretes the hormones insulin and glucagon that regulate the way your body metabolizes sugar (glucose).

Most of your pancreas is composed of cells that produce digestive enzymes and juices. Pancreatic juices flow into the main pancreatic duct, which leads to your small intestine (duodenum). The pancreatic duct joins up with the tube leading from your gallbladder to form the common bile duct, which then empties into the small intestine. Your pancreas also contains small "islands" of cells that secrete the hormones insulin and glucagon, along with somatostatin.

Types of pancreatic cancer
Most pancreatic tumors originate in the duct cells or in the cells that produce digestive enzymes (acinar cells). Called adenocarcinomas, these tumors account for nearly 95 percent of pancreatic cancers.

Tumors that begin in the islet cells (endocrine tumors) are much less common. When they do occur, they may cause the affected cells to produce too much hormone. For example, tumors in glucagon cells (glucagonomas) might cause excess amounts of glucagon to be secreted, while tumors in insulin cells (insulinomas) may lead to an overproduction of insulin.

Tumors can also develop in the ampulla of Vater - the place where your bile and pancreatic ducts empty into your small intestine. Called ampullary cancers, these tumors often block the bile duct, leading to jaundice. Because even a small tumor can obstruct the bile duct, signs and symptoms of ampullary cancer usually appear earlier than do symptoms of other pancreatic cancers.

Why pancreatic cancer occurs
Healthy cells grow and divide in an orderly way. This process is controlled by DNA - the genetic material that contains the instructions for every chemical process in your body. When DNA is damaged, changes occur in these instructions. One result is that cells may begin to grow out of control and eventually form a tumor - a mass of malignant cells.

Researchers don't know exactly what damages DNA in the vast majority of cases of pancreatic cancer. But it is known that a small percentage of people develop the disease as a result of a genetic predisposition. These people who have a close relative, such as a parent or sibling, with pancreatic cancer have a higher risk of developing pancreatic cancer themselves.

In addition, a number of genetic diseases have been associated with an increased risk of pancreatic cancer, including familial adenomatous polyposis, nonpolyposis colon cancer, familial breast cancer associated with the BRCA2 gene, hereditary pancreatitis, and familial atypical multiple mole-melanoma syndrome - a serious type of skin cancer. This means that people who have a hereditary predisposition to develop these cancers are also more likely to develop pancreatic cancer.

Yet only about 10 percent of pancreatic cancers result from an inherited tendency. A greater number are caused by environmental or lifestyle factors, such as smoking, diet and chemical exposure.

Heavy alcohol use and gallstones are risk factors for pancreatitis, and pancreatitis is a risk factor for pseudocysts - the most common type of pancreatic cyst.

One of the primary risk factors for pancreatitis is long-term alcohol abuse, though not everyone with alcoholism develops this disease. For that reason, researchers believe that more than one factor may be involved in pancreatitis, including:

• Gallbladder disease. Gallstones that lodge in the lower portion of the bile duct can block the pancreatic duct, causing digestive juices to back up into the pancreas, where they destroy healthy tissue.
• Ethnicity. Black Americans are more likely to develop acute pancreatitis than white Americans are.
• Your sex. Pancreatitis occurs more frequently in men, possibly because men are more likely to abuse alcohol than are women.
• Genetic mutations. Abnormalities in one or more genes may predispose some people to pancreatitis.
• Other medical conditions. Certain inherited diseases, particularly cystic fibrosis, increase your risk of pancreatitis.

The vast majority of pancreatic cancers occur in people older than 65. Other important risk factors include:

• Race. Black men and women have a higher risk of pancreatic cancer.
• Sex. More men than women develop pancreatic cancer.
• Cigarette smoking. If you smoke, you're two to three times more likely to develop pancreatic cancer than nonsmokers are. This is probably the greatest known risk factor for pancreatic cancer, with smoking associated with almost one in three cases of pancreatic cancer.
• Abnormal glucose metabolism. Having diabetes may increase your risk of pancreatic cancer. Insulin resistance or high insulin levels may also be risk factors for pancreatic cancer.
• Hereditary pancreatitis. Your chances of developing pancreatic cancer increase if you have hereditary chronic pancreatitis. Hereditary pancreatitis (HP) is a rare genetic condition marked by recurrent attacks of pancreatitis - a painful inflammation of your pancreas.
• Excess weight. People who are very overweight or obese may have a greater risk of developing pancreatic cancer than do people of normal weight.
• Diet. A diet high in animal fat and low in fruits and vegetables may increase your risk of pancreatic cancer.
• Chemical exposure. People who work with petroleum compounds, including gasoline and other chemicals, have a higher incidence of pancreatic cancer than people not exposed to these chemicals.

Most pancreatic cysts can be detected by ultrasound, computerized tomography (CT) or magnetic resonance imaging (MRI) scans. Your doctor may also order an endoscopic ultrasound to visualize the cyst and to obtain fluid from the cyst for analysis. In this study, an endoscope is passed through your mouth and into your stomach and upper small intestine. The scope is equipped with ultrasound to image the cyst and a needle to obtain fluid from the cyst.

While the majority of pancreatic cysts are benign pseudocysts, doctors may suspect another type of cyst if it occurs with no previous history of pancreatitis or abdominal injury or if it has internal walls.

In some cases, the location of the cyst in the pancreas - along with your age and sex - can help doctors pinpoint what type of cyst you have.

• Mucinous cystadenoma. These cysts are usually located in the body or tail of the pancreas and occur most often in middle-aged women. Most of these are cancerous.
• Mucinous duct ectasia. More common in men, these cysts consist of dilated ductal segments, usually within the head of the pancreas. Also known as intraductal papillary mucinous neoplasms, these growths are often cancerous.
• Serous cystadenoma. These growths can become large enough to displace nearby organs, causing such symptoms as abdominal pain and a feeling of fullness. They occur most frequently in middle-aged women and become cancerous very rarely.
• Papillary cystic tumor. The least common of the nonpseudocysts, papillary cystic tumors - also known as papillary cystic neoplasm or solid and pseudopapillary neoplasm - occur most often in young women and are usually located in the body or tail of the pancreas. They are usually cancerous.

Islet cell tumors, also known as neuroendocrine tumors, are less common and more likely to be benign. Normally, the pancreas' islet cells produce insulin and other hormones. Islet cell tumors can also produce these hormones.

Because diagnosing pancreatitis can be difficult, you're likely to have several tests to help pinpoint the problem. The type of test may depend on whether your pancreatitis is acute or chronic.

Acute pancreatitis
If your doctor suspects that you have acute pancreatitis, a sample of your blood may be analyzed for abnormalities such as:

• Elevated levels of the pancreatic enzymes, amylase and lipase
• Elevated white blood cell count
• Elevated liver enzymes and bilirubin, a substance that results from breakdown of red blood cells
• High blood sugar (hyperglycemia)
• Low calcium level - high calcium levels can cause pancreatitis, but low levels of calcium in the blood, called hypocalcemia, are a common result

Because laboratory tests can't confirm a diagnosis of acute pancreatitis, your doctor may request an ultrasound or computerized tomography (CT) scan of your abdomen to examine your pancreas and to check for gallstones, a duct problem, or destruction of the gland. You may also have X-rays of your abdomen and chest to rule out other reasons for your symptoms.

Chronic pancreatitis
Diagnosing chronic pancreatitis can be challenging because some tests may yield normal results, even though you have the disease. It can also be difficult to distinguish acute from chronic pancreatitis. Even so, certain tests can help rule out other problems and aid in the diagnosis. These include:

• Blood tests. These tests can identify abnormalities associated with chronic pancreatitis and help rule out acute inflammation.
• Stool test. This measures the fat content in your feces. Chronic pancreatitis often causes excess fat in your stool because the fat isn't digested and absorbed normally by your small intestine.
• Ultrasound. In standard (external) ultrasound, a wand-like device (transducer) is placed on your body. It emits inaudible sound waves that are reflected to the transducer and then translated into a moving image by a computer. Endoscopic ultrasound may provide images of your pancreas and bile and pancreatic ducts that are superior to those produced by standard ultrasound. In endoscopic ultrasound, your doctor uses a thin, flexible tube with a light (endoscope) to thread a small ultrasound device through your stomach. The device then generates a detailed image on a computer screen.
• X-ray of bile and pancreatic ducts. In a procedure called endoscopic retrograde cholangiopancreatography, your doctor gently threads an endoscope down your throat and through your stomach to the opening of the bile and pancreatic ducts in your duodenum. A dye passed through a thin, flexible tube (catheter) inside the endoscope allows for X-ray images of the ducts.
• Pancreatic function test. If you've lost weight or your doctor suspects a malabsorption problem, you may have a pancreatic function test. Several tests exist, but all measure the ability of your pancreas to secrete enzymes or other substances necessary for digestion.

You may need additional tests if your doctor is concerned about the possibility of other diseases, such as pancreatic cancer. Chronic pancreatitis puts you at a slightly higher risk of pancreatic cancer.

Detecting pancreatic cancer in its early stages is difficult. Signs and symptoms usually don't appear until the cancer is large or has spread (metastasized) to other tissues. And because your pancreas is relatively hidden - tucked behind your stomach and inside a loop of your small intestine - small tumors can't be seen or felt during routine exams.

For this reason, and because pancreatic cancer spreads so quickly, researchers have focused on finding a reliable screening test. At one time, scientists thought a substance called CA 19-9 was the answer. CA 19-9 is produced by pancreatic cancer cells and can be detected by a blood test. But by the time blood levels are high enough to be measured, the cancer is no longer in its early stages. Currently there is no effective screening test for pancreatic cancer.

If your doctor suspects pancreatic cancer, you may have one or more of the following tests to diagnose the cancer:

• Ultrasound imaging. In this test, a device called a transducer is placed on your upper abdomen. High-frequency sound waves from the transducer reflect off your abdominal tissues and are translated by a computer into moving images of your internal organs, including your pancreas. Ultrasound tests are safe, noninvasive and relatively brief - a typical test takes less than an hour.
• Computerized tomography (CT) scan. This imaging test allows your doctor to visualize your organs, including your pancreas, in two-dimensional slices. Split-second computer processing creates these images as a series of very thin X-ray beams pass through your body. Sometimes you may have a dye (contrast medium) injected into a vein before the test. The clearer images produced with the dye make it easier to distinguish a tumor from normal tissue. A CT scan exposes you to more radiation than do conventional X-rays, but in most cases, the benefits of the test outweigh the risks.
• Magnetic resonance imaging (MRI). Instead of X-rays, this test uses a powerful magnetic field and radio waves to create images of your pancreas. During the test, you're placed in a cylindrical tube that can seem confining to some people. The machine also makes a loud thumping noise you might find disturbing. In most cases you'll be given headphones for the noise.
• Endoscopic retrograde cholangiopancreatiography (ERCP). In this procedure, a thin, flexible tube (endoscope) is gently passed down your throat, through your stomach and into the upper part of your small intestine. Air is used to inflate your intestinal tract so your doctor can more easily see the openings of your pancreatic and bile ducts. The bile ducts are thin tubes that carry bile, a fluid produced in your liver that helps digest fats. These ducts are often the site of pancreatic tumors. A dye is then injected into the ducts through a small hollow tube (catheter) that's passed through the endoscope. Finally, X-rays are taken of the ducts. Your throat may be sore for a time after the procedure, and you may feel bloated from the air introduced into your intestine.
• Endoscopic ultrasound (EUS). In this test, an ultrasound device is passed through an endoscope into your stomach. The device directs sound waves to your pancreas. A computer then translates the sound waves into close-up images of your pancreas and your bile and pancreatic ducts. The images are superior to those produced by standard ultrasound and are particularly useful for detecting small pancreatic tumors.
• Percutaneous transhepatic cholangiography (PTC). In this test, your doctor carefully inserts a thin needle into your liver while you lie on a movable X-ray table. A dye is then injected into the bile ducts in your liver, and a special X-ray machine (fluoroscope) tracks the dye as it moves through the ducts. Any obstructions should show up on the X-ray. The table is rotated several times during the procedure so you can assume a variety of positions. During the test, you may have a feeling of pressure or fullness, or have slight discomfort in the right side of your back.
• Biopsy. In this procedure, a small sample of tissue is removed and examined for malignant cells under a microscope. It's the only way to make a definitive diagnosis of cancer. Biopsies of the pancreas and bile ducts can be performed in several ways. If you have a mass that can be reached with a needle, your doctor may choose to perform a fine-needle aspiration (FNA) - a procedure in which a very thin needle is inserted through your skin and into your pancreas. An ultrasound or CT scan is often used to guide the needle's placement. When the needle has reached the tumor, cells are withdrawn and sent to a lab for further study. Tissue samples can also be removed during ERCP or EUS. Sometimes, in a procedure similar to ERCP, your surgeon uses an endoscope to pass a catheter into your bile duct where it empties into your small intestine. But instead of injecting dye, your surgeon uses a small brush introduced through the catheter to scrape cells and bits of tissue from the lining of the duct.
• Laparoscopy. This procedure uses a small, lighted instrument (laparoscope) to view your pancreas and surrounding tissue. The instrument is attached to a television camera and inserted through a small incision in your abdomen. The camera allows your surgeon to clearly see what's happening inside you. During laparoscopy, your surgeon can take tissue samples to help confirm a diagnosis of cancer. Laparoscopy may also be used to determine how far cancer has spread. Risks include bleeding and infection and a slight chance of injury to your abdominal organs or blood vessels.

Staging pancreatic cancer
Staging tests help determine the size and location of cancer and whether it has spread. They're crucial in helping your doctor determine the best treatment for you. Pancreatic cancer may be staged in several ways. One method is to use these terms:

• Resectable. All the tumor nodules can be removed.
• Locally advanced. Because the cancer has spread to tissues around the pancreas or into the blood vessels, it can no longer be completely removed.
• Metastatic. At this stage, the cancer has spread to distant organs, such as the lungs and liver.

Your doctor may also refer to your cancer as stage 1, 2, 3, or 4:

• Stage 1 pancreatic cancer is confined to the pancreas.
• Stage 2 pancreatic cancer has spread somewhat, possibly to the lymph nodes, but not into large blood vessels nearby.
• Stage 3 pancreatic cancer has invaded large blood vessels, may be in the lymph nodes, but hasn't spread to distant sites.
• Stage 4 means the cancer has spread to a distant site or sites in your body.

Appropriate treatment differs depending on the type of cyst and whether it causes symptoms. Sometimes, no treatment is necessary.

A benign pseudocyst - even a large one - can be left alone as long as it isn't causing significant symptoms or enlarging. A pseudocyst that is causing symptoms or growing larger may be drained with a needle or surgically removed.

Because a serous cystadenoma so rarely evolves into cancer, it also can be left alone unless it causes symptoms or enlarges. Your doctor may want to follow its size over time by checking repeat scans, especially if a precancerous cyst can't be ruled out. Most other types of lesions in the pancreas should be surgically removed, because of the risk of cancer.

Acute pancreatitis
Severe acute pancreatitis usually requires a hospital stay. If you have complications, you may be admitted to the intensive care unit. Treatment goals include controlling the pain, allowing the pancreas to rest and restoring a normal balance of pancreatic juices.

Because the pancreas goes into action whenever you eat, you won't be able to eat or drink for a few days. Instead, you'll receive fluids and nutrition through a vein (intravenously). Your doctor may also feed you through a tube that's been passed into your stomach and intestine so that it goes past the pancreas. Placing the tube in the bowel beyond the pancreas ensures that the pancreas is not stimulated, yet you can still receive the nutrition you need.

Longer term treatment includes therapy for alcohol abuse, chemical dependency or smoking if these factors play a role in your pancreatitis. A team approach involving a chemical dependency counselor and a psychologist trained in cognitive therapy may be the most helpful.

When gallstones block the pancreatic duct, your doctor may recommend a procedure to remove the stones. You may eventually need surgery to remove your gallbladder if gallstones continue to pose problems.

Mild cases of acute pancreatitis generally improve in a week or less. Moderate to severe cases take longer.

Chronic pancreatitis
The main goals of treatment for chronic pancreatitis are to help stop alcohol and drug abuse, control pain and improve malabsorption problems.

• Therapy for alcohol dependency. This may be the most important step in treating alcohol-related pancreatitis. In the early stages of the disease, simply stopping drinking may relieve even severe pain. As pancreatitis progresses, continuing to use alcohol greatly increases the risk of complications and death - people who don't stop drinking have a significantly higher chance of dying of pancreatitis.
• Pain relief. Unlike acute pancreatitis, in which the pain often disappears within a few days to weeks, chronic pancreatitis pain can linger. However, conventional pain relievers can be ineffective and pose a real risk of addiction. Using potent pancreatic enzymes to treat pain has proved effective for some people. Enzyme therapy works by increasing the levels of enzymes in the duodenum, which in turn decreases the secretion of enzymes by the pancreas. This is thought to reduce secretion pressure - and hence, pain - within the pancreas. For severe pain that can't be controlled, treatment options include surgery to remove damaged tissue or procedures to block pain signals or deaden the nerves transmitting the pain.
• Enzyme therapy for malabsorption. Enzyme supplements such as pancrelipase (Pancrease, Viokase) can help treat malabsorption problems. By replacing missing enzymes, these tablets help restore normal digestion and improve steatorrhea, leading to weight gain and enhanced well-being. These supplements are generally taken before and during meals and snacks.
• Dietary changes. Your doctor may recommend eating smaller meals and limiting fats, which will help reduce your need for as many digestive enzymes.

Treatment for diabetes
Chronic pancreatitis can cause diabetes in some people. Treatment usually involves maintaining a healthy diet and getting regular exercise. Some people also need insulin injections, although insulin must be used cautiously because of the risk of low blood sugar (hypoglycemia). Your doctor will talk with you about how to manage diabetes, recognize symptoms of high and low blood sugar, and prevent complications.

Treatment for pancreatic cancer depends on the stage and location of the cancer as well as on your age, overall health and personal preferences. Especially when cancer is advanced, choosing a treatment plan is a major decision, and it's important to carefully evaluate your choices.

You may also want to consider seeking a second opinion. This can provide additional information to help you feel more certain about the option you're considering.

The first goal of treatment is always to eliminate the cancer completely. When that isn't possible, the focus may be on preventing the tumor from growing or causing more harm. In some cases, an approach called palliative care may be best. Palliative care refers to treatment aimed not at removing or slowing the disease, but at helping relieve symptoms and making you as comfortable as possible.

Surgical options
The only way to eliminate pancreatic cancer is an operation to remove the tumor. Unfortunately, this is possible only in a small percent of people. Once the cancer has spread beyond the pancreas to other organs, lymph nodes or blood vessels, surgery is usually no longer an option. When surgery is possible, your surgeon may use one of the following procedures, depending on the extent and location of the tumor:

• Whipple procedure (pancreatoduodenectomy). This is the most common procedure for treating pancreatic cancer, including resectable cancers of the ampulla of Vater. In general, the Whipple procedure involves removing the wide end (head) of your pancreas. To do that, your surgeon must also remove your duodenum, gallbladder and the end of the common bile duct. Sometimes part of your stomach is removed as well. The end of your bile duct and remaining part of your pancreas are then connected to your small intestine so that bile and pancreatic enzymes continue to reach the small intestine. The procedure has risks, including infection and bleeding.
• Total pancreatectomy. In this procedure, your surgeon removes your entire pancreas as well as your bile duct, gallbladder and spleen; part of your small intestine and stomach; and most of the lymph nodes in the area. After a total pancreatectomy, you'll need insulin injections and pancreatic enzymes, and the operation presents serious risks. Total pancreatectomy isn't often used for people with pancreatic cancer because there doesn't appear to be enough benefit from the procedure to justify the risks.
• Distal pancreatectomy. In this procedure, which is primarily used to treat islet cell cancers, only the tail - or the tail and a small portion of the body of your pancreas - is removed. Sometimes your spleen may also be removed.

Operations for pancreatic cancer are complex. The most successful outcomes generally occur when these procedures are performed in cancer centers by highly experienced surgeons.

Radiation therapy
Radiation therapy uses high-energy X-rays to destroy cancer cells. You may receive radiation treatments before or after cancer surgery, often in combination with chemotherapy. Or, your doctor may recommend a combination of radiation and chemotherapy treatments when your cancer can't be treated surgically.

Radiation that comes from a machine outside your body (external beam radiation) is generally used to treat pancreatic cancer. Side effects of radiation therapy may include a burn on your skin similar to sunburn where the radiation enters your body, nausea, vomiting and fatigue.

Doctors at some cancer centers are studying a new approach to radiation therapy, called intraoperative electron beam radiation. In this procedure, a type of external beam radiation that uses high-energy particles (electrons) is directed at your pancreas during surgery. This allows doctors to treat a pancreatic tumor with a high dose of radiation while sparing nearby organs.

Chemotherapy
Chemotherapy uses drugs to help kill cancer cells. Injected into a vein or taken orally, these drugs travel through your bloodstream. For that reason, they're often used to treat cancers that have spread. Chemotherapy, or chemotherapy in combination with radiation, is the usual treatment for pancreatic cancers that have spread to nearby tissues or distant organs. Although chemotherapy won't eliminate the cancer, it may help relieve symptoms. It may also help improve survival when used as an adjuvant therapy after an operation to remove a tumor in the pancreas.

Chemotherapy drugs affect normal cells as well as malignant ones, especially fast-growing cells in your digestive tract and bone marrow. For that reason, side effects - including nausea and vomiting, mouth sores, an increased chance of infection due to a shortage of white blood cells, and fatigue - are common. Not everyone experiences side effects, however, and there are new and better ways to control them if you do. Be sure to discuss any questions you may have about side effects with your treatment team.

Clinical trials
If you have advanced pancreatic cancer, you may want to consider participating in a clinical trial. This is a study that is used to test new forms of therapy - typically new drugs, different approaches to surgery or radiation treatments, and novel methods such as gene therapy. If the therapy being tested proves to be safer or more effective than current treatments, it will become the new standard of care.

Remember that the treatments used in clinical trials haven't yet been shown to be effective. They may have serious or unexpected side effects, and there's no guarantee you'll benefit from them.

On the other hand, cancer clinical trials are closely monitored by the federal government to ensure they're conducted as safely as possible. And they offer access to treatments that wouldn't otherwise be available to you.

Palliative procedures
If your cancer has spread too far to be completely removed by an operation, the primary goal will be to relieve your signs and symptoms. Treatments that focus on making you more comfortable include:

• Surgical bypass. Tumors that block your bile duct, pancreatic duct or duodenum can cause pain, digestive difficulties, nausea, vomiting, jaundice and severe itching. To help ease some of these symptoms, you may have an operation to reroute the flow of bile by going around (bypassing) the tumor.
• Stent insertion. When a bypass operation isn't an option, your surgeon may place a stainless steel or plastic tube (stent) in the bile duct to keep it open. A stent is usually the best choice for people who have metastatic cancer or who are very weak.
• Pain management. Tumors pressing on surrounding nerves can cause severe pain, especially in the later stages of the disease. Although pain is a real concern for people with pancreatic cancer, treatment with morphine or similar medications can provide relief in many cases. Long-lasting forms of morphine that need to be taken only once or twice a day may be especially helpful. When medication isn't enough, your doctor may discuss other options with you, such as cutting some of the nerves that transmit pain signals or injecting alcohol into these nerves to block the sensation of pain.
• Pancreatic enzyme tablets. By replacing the digestive enzymes your pancreas no longer produces, these tablets can improve your body's ability to absorb nutrients and may help reduce diarrhea and weight loss.
• Insulin therapy. When pancreatic cancer affects insulin production, you may need insulin injections to help control your blood sugar levels.

New treatments
Researchers are studying a number of other approaches to treating pancreatic cancer, including:

• Anti-angiogenesis factors. Cancer cells need angiogenesis factors to produce new blood vessels so they can grow and spread. Scientists have developed drugs that stop this process.
• Farnesyl transferase inhibitors. Most people with pancreatic cancer have cells that contain a specific genetic mutation. In order to function, the mutated cells need an enzyme called farnesyl transferase. Now researchers have developed drugs that block the action of farnesyl transferase, causing the mutated cells to die. Studies of these drugs are under way.
• Growth factor inhibitors. Growth factor receptors help some malignant cells grow. Drugs that block these receptors, such as cetuximab, may help fight pancreatic cancer.

The best way to avoid pseudocysts is to avoid pancreatitis, which is usually caused by gallstones or heavy use of alcohol. If your pancreatitis is due to alcohol abuse, you need to abstain from alcohol. If gallstones are triggering pancreatitis, you may need to have your gallbladder removed.

Although pancreatitis isn't always preventable, you can take steps to reduce your risk:

• Avoid excessive alcohol use. Overuse of alcohol is the leading cause of chronic pancreatitis and a contributing factor in many acute attacks.
• Stop smoking. Tobacco use increases your risk of pancreatitis, especially if you also drink alcohol.
• Limit fat. Eating a high-fat diet can raise your blood-fat levels and increase your risk of gallstones - both risk factors for pancreatitis. A healthy diet emphasizes fresh fruits and vegetables, whole grains, and lean protein, and limits fats, especially saturated fats such as butter.

Although it's not always possible to prevent pancreatic cancer, these lifestyle changes may help reduce your risk:

• Quit smoking. Cigarette smoke contains carcinogens that can damage the DNA that regulates cell growth. Talk to your doctor about the best ways to quit, or contact the American Cancer Society or American Lung Association for more information.
• Maintain a healthy weight. Being overweight increases your risk of pancreatic cancer. If you need to lose weight, keep in mind that a slow, steady loss is the healthiest way to reach your goals. Aim for no more than 1 to 2 pounds a week. Add 30 minutes or more of aerobic exercise - such as walking, jogging or biking - on most days, and you can increase the amount of weight you lose.
• Exercise regularly. Experts believe that getting even a moderate amount of exercise every week can cut your risk of pancreatic cancer. For overall health, aim for 30 minutes of exercise on most days. If you're not used to exercising, start out slowly and work up to your goal.
• Eat a healthy diet. A diet high in fruits and vegetables and low in animal fat can reduce your risk of pancreatic cancer.