The pancreas is 14–18cm long and weighs 70–80g. It is a gland with exocrine and endocrine features.

head of pancreas with the uncinate process

body of pancreas

tail of pancreas

pancreatic duct (Wirsung)

accessory pancreatic duct (Santorini)

The pancreas is a secondarily retroperitoneal organ. It lies on the median line roughly at the level L1 – L2, with the head lower than the tail: the axis of the body is inclined toward the upper left approximately 30° to the horizontal line.

The accessory pancreatic duct, if present, enters the duodenum 2–3 cm above the major duodenal papilla.

duodenum

L2–L3 (head of pancreas), covered by the right crus of the diaphragm

common bile duct

aorta

inferior vena cava

left renal vein

Fig. 10.1 Topographic relationships of the pancreas.

superior mesenteric artery and vein

duodenojejunal flexure

omental bursa

stomach

kidneys

transverse mesocolon (divides the pancreas into a suband a supramesocolic part)

transverse colon

left colic flexure

splenic vein

peritoneum

spleen

lesser omentum

portal vein

organ pressure

turgor

attachments of connective tissue in the retroperitoneal space

pancreaticosplenic ligament

retropancreatic fascia (Treitz)

transverse mesocolon

duodenum

superior mesenteric artery

gastroduodenal artery (from the common hepatic artery)

splenic artery

superior mesenteric vein

portal vein (from the splenic vein and pancreaticoduodenal veins)

direct lymphatic connections to nearby organs (duodenum)

via celiac lymph nodes to the gastric and hepatic lymph nodes on the left side of the body

mediastinal and cervical lymph nodes

pancreaticolienal lymph node and pylorus

mesenteric and periaortal lymph nodes

sympathetic nervous system from T5 to T9 (sometimes also T10 and T11) via the major splanchnic nerve, with switching in the celiac plexus

vagus nerve

Maximal time: 9–11 a.m.

Minimal time: 9–11 p. m.

Due to the good fascial anchoring in the retroperitoneal space, it is impossible to detect a separate mobility. Nevertheless, the movements of the neighboring organs and the diaphragm cause pushing and pulling on the pancreas.

With a hand that rests on the projection of the pancreas on the abdomen (fingers pointing to the tail, thenar lies above the head), we can detect a wave from the heel of the hand to the fingertips during exhalation. During inhalation, the wave runs in the opposite direction.

The pancreas is a gland with exocrine and endocrine features. The endocrine parts, the islets of Langerhans, are distributed throughout the entire pancreas with accumulations in the body and tail. The cells in the islets of Langerhans produce the hormones that are responsible for regulating blood sugar: insulin, glucagon, and somatostatin.

Insulin is synthesized in the β cells of the islets of Langerhans (approximately 2mg/day) and lowers the blood sugar level by making the cell wall of each body cell permeable to glucose. In addition, insulin assists in the uptake of different amino acids into the cell.

glycogen synthesis and inhibition of glycogenolysis

synthesis of lipids and inhibition of lipolysis

inhibition of protein breakdown

Glucagon is produced in the a cells of the islets. It is the “insulin antagonist”: by promoting glycogenolysis and gluconeogenesis in the liver, it raises the blood sugar level.

The δ cells synthesize this hormone. It suppresses the release of insulin and glucagons, and decreases digestive activity by reducing intestinal peristalsis and inhibiting the secretion of digestive juices. Its function is to maintain the glucose level as much as possible.

The exocrine gland part of the pancreas secretes juice into the pancreatic duct. As a result of its activity, approximately 1–1.5 L of “abdominal saliva” thus reaches the duodenum per day.

This secretion consists of:

bicarbonate to neutralize the acidic chyme from the stomach

trypsinogen and chymotrypsinogen (enzymes for digesting protein)

α-amylase (also present in the saliva of the mouth) for cleaving carbohydrates

lipase (enzyme for cleaving fat)

The enzymes of this “abdominal salivajanu” are not yet activated in the pancreas. It is only after contact with bile or the enterokinase in the duodenal juice that they are activated and begin working. If this activation takes place in the pancreas, it results in autodigestion and the symptoms of acute pancreatitis.

Definition. Inflammation of the pancreas with disturbance of exocrine and endocrine functions.

biliary tract disorders (40–50%)

alcohol abuse (30–40%)

idiopathic (10–30%)

Rare causes include:

medications (diuretics, β blockers, glucocorticoids, antibiotics, nonsteroidal antirheumatics)

trauma

infections (mumps, Coxsackievirus)

hypercalcemia (e.g., hyperparathyroidism)

hyperlipoproteinemia

papillary stenosis

guiding symptom: severe upper abdominal pain, arising approximately 8–12 hours after a large meal or alcohol abuse, with pain radiating into the back and ringlike to the left around the torso

shock

Definition. Chronic inflammation of the pancreas is characterized by persistent or recurrent pain with usually irreversible morphologic changes in the pancreatic parenchyma and functional disturbances in the pancreas.

alcohol (70–90%)

idiopathic (10–25 %)

Rare causes include:

anomalies in the pancreatic duct system

hyperparathyroidism

trauma

abuse of analgesics

upper abdominal pain

nausea, vomiting

icterus

depression

diabetes mellitus

constipation

thrombophlebitis

excretory insufficiency

weight loss

steatorrhea

diarrhea

meteorism

edemas

When approximately 90% of pancreatic tissue is destroyed, we see steatorrhea as a sign of maldigestion, as well as symptoms of fat-soluble vitamin deficiency (night blindness, clotting disorders, osteomalacia).

Definition. Malignant tumor of the pancreas, usually originating in the epithelium of the duct system.

Causes. Unknown genesis. Under discussion are alcohol, nicotine, and coffee consumption as predisposing factors.

Clinical. No early symptoms.

weight loss

recurrent thrombophlebitis

back pain

obstructive icterus