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THE PANCREAS


The pancreas is located in the abdomen, tucked behind the stomach.
between the upper part of your small intestine (duodenum) and the
spleen. It is shaped somewhat like a tadpole - fat at one end and
slender at the other - and is around 25cm in length.
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The pancreas serves two distinct and vital functions;

1. The exocrine pancreas

Once food has been mulched and partially digested by the stomach,
it is pushed into the duodenum (first part of the small intestine). The
pancreas helps to digest food, particularly protein. Most of the
pancreas is compose of cells called exocrine cells that produce
digestive enzymes. Pancreatic enzymes flow from these cells through
small ducts into the main pancreatic duct, which leads to the
duodenum. Pancreatic juices contain enzymes that only become
activated once they reach the duodenum. This is to prevent the
protein-digesting enzyme trypsin from 'eating' the protein-based
pancreas or its duct. Other enzymes produced by the pancreas
include amylase (to break down carbohydrate) and lipase (to break
down fats).
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The exocrine pancreas also makes sodium bicarbonate, which helps
to neutralise stomach acid entering the duodenum.


2. The endocrine pancreas

The pancreas makes the hormone insulin, which helps to control
blood sugar levels. Insulin is manufactured by a small clump of
pancreatic cells called the 'islets of Langerhans'. High blood sugar
levels prompt the release of insulin, so that the sugars can pass into
cells. The endocrine pancreas also
makes glucagon, another hormone involved in the regulation of blood
sugar.

DIAGNOSIS OF PANCREATIC DISEASE

Diagnostic methods depend on the disorder under investigation, but
may include:

   General tests - such as blood tests, physical examination and
    x-rays.
   Ultrasound - sound waves form a picture of the pancreas.
   Computerised tomography (CT) scan - a specialised x-ray
    takes three-dimensional pictures of the pancreas.
   Magnetic resonance imaging (MRI) - similar to a CT scan, but
    magnetism is used to build three-dimensional pictures.
   Endoscopy (ERCP) - a thin telescope is inserted down the
    throat. This device may be used to inject contrasting dye into
    the pancreatic duct prior to x-rays.
   Laparoscopy - the pancreas is examined through a slender
    instrument
    inserted into the abdomen.
   Biopsy - a small tag of pancreatic tissue is taken out with a
    needle and examined in a laboratory.




PANCREATITIS
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The pancreas plays important roles in both digestion and metabolism.
These functions may be affected by pancreatitis, an inflammatory
condition that occurs when pancreatic digestive enzymes become
active within the gland and attack the pancreas itself.

Pancreatitis can be acute — appearing suddenly and lasting for a few
days — or it can be chronic, developing gradually and persisting over
many years. Both acute and chronic pancreatitis are marked by mild
to severe abdominal pain, often with nausea, vomiting and fever.
Both can lead to serious complications.

Heavy alcohol use and gallstones are the primary causes of
pancreatitis, but other factors, including certain medical conditions,
some drugs and genetic mutations also can lead to the disorder.
Sometimes the cause is never found..




ACUTE PANCREATITIS




 Acute pancreatitis is inflammation of the pancreas. This is a medical
emergency and requires prompt treatment. It occurs when the
pancreas suddenly becomes inflamed - the enzymes can't leave the
pancreas and so cause irritation and burning. Enzymes may also
leech into the abdominal cavity.




The two most common causes for pancreatitis are:

    Drinking too much alcohol
    Gallstones
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Other causes include:

    Medications such as corticosteroids, nonsteroidal anti-
     inflammatory drugs, thiazides used for blood pressure lowering,
     antibiotics including tetracyclines and sulphonamides and
     immunosuppression with azathioprine and 6-mercaptopurine.
    Increased levels of triglycerides (fats) or calcium in the blood.
    Viral infections including mumps
    Damage or trauma to the pancreas
    Pancreatic cancer




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

Apart from pain the presentation may feature:

      Nausea and vomiting
      Fever
      Rapid pulse
      Swollen, tender abdomen

When severe, dehydration, internal bleeding, low blood pressure or
shock

DIAGNOSIS


If acute pancreatitis is suspected, the doctor will arrange blood tests
to look for:

    Elevated levels of pancreatic enzymes—amylase or lipase
    Elevated white cell count
    High blood sugar
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   Elevated liver enzymes and bilirubin
   Low calcium levels
   Oxygen status

Because laboratory tests can't confirm a diagnosis of acute
pancreatitis, the 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.



COMPLICATIONS

Severe cases of acute pancreatitis may lead to a number of
complications:



   Infection A damaged pancreas may become infected with
    bacteria that spread from the bowel into the inflamed pancreas.
    The infection may also spread to the blood-stream. Signs of
    infection include fever and an elevated white blood cell count.
    Pancreatic infections can be fatal without intensive treatment
    which may include drainage and surgical removal to remove
    infected and/or dead tissue. Sometimes multiple such
    operations are needed. Multi-organ failure may also occur.
   Pseudocysts These are collections of pancreatic fluid and
    tissue debris that form within the pancreas or in an obstructed
    duct. If small no specific treatment may be necessary but if
    large, bleeding or infected then urgent measures are needed.
   Abscess A collection of pus in or near the pancreas.
    Treatment involves drainage by needle, catheter or surgery.
   Respiratory failure Chemicals circulating in the blood can
    effect lung function, causing the level of oxygen in the blood to
    fall to low levels.
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TREATMENT

Acute pancreatitis usually requires admission to hospital. Severe
cases or those with complications often need admission to an
Intensive Care Unit. Treatment goals include controlling the pain,
allowing the pancreas to rest, careful fluid balance and maintaining
full respiratory function.

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.

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.
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CHRONIC PANCREATITIS


Chronic pancreatitis means recurring bouts of inflammation, even
when known triggers (such as alcohol) are eliminated. Alcoholics are
at increased risk of developing this condition. The relentless
inflammation eventually damages or destroys parts of the pancreas,
reducing its function. Symptoms include digestive upsets and passing
fatty, foul-smelling stools.

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

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

DIAGNOSIS

Diagnosing chronic pancreatitis can be challenging because some
tests may yield normal results. 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.
    Stool test. This measures the fat content in feces. Chronic
     pancreatitis often causes excess fat in the stool because the fat
     isn't digested and absorbed normally by the small intestine.
    Pancreatic function test. If there is weight lost or the doctor
     suspects a malabsorption problem, a pancreatic function test
     can be used. Several tests exist but are not commonly used.
    Ultrasound. In standard (external) ultrasound, a wand-like
     device (transducer) is placed on the body. It emits inaudible
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    sound waves that are reflected to the transducer and then
    translated into a moving image by a computer.
   Endoscopic ultrasound may provide images of the pancreas
    and bile and pancreatic ducts that are superior to those
    produced by standard ultrasound.
   ERCP (X-ray of bile and pancreatic ducts). The doctor gently
    threads an endoscope down the throat and through the
    stomach to the opening of the bile and pancreatic ducts in the
    duodenum. A dye passed through a thin, flexible tube (catheter)
    inside the endoscope allows for X-ray images of the ducts.

The complications common to acute pancreatitis can also occur in the
chronic form of the disease. In addition, chronic pancreatitis can lead
to:

   Bleeding. Ongoing inflammation and damage to the blood
    vessels surrounding the pancreas can cause potentially fatal
    bleeding.
   Malnutrition and weight loss. Lack of digestive enzymes
    prevents your body from absorbing nutrients from food. The
    result is often unintended weight loss and malnutrition.
   Diabetes. Damage to insulin-producing cells can lead to
    diabetes, a disease that affects the way your body uses blood
    sugar.
   Drug addiction. Because medical treatments for severe
    pancreatic pain aren't always effective, people with pancreatitis
    may become addicted to pain medications.
   Pancreatic cancer. Long-term inflammation of the pancreas
    increases your risk of pancreatic cancer, one of the most
    serious of all malignancies.

TREATMENT


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

. Pain relief. Unlike acute pancreatitis, in which the pain often
disappears within a few days to weeks, chronic pancreatitis pain can
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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. Enzyme supplements such as pancreatic lipase
(Pancrease) 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.

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).

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.
People who don't stop drinking have a significantly higher chance of
dying of pancreatitis
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CANCER OF THE PANCREAS
Pancreatic cancer develops when cancerous cells form in the tissues
of the pancreas. The pancreas secretes enzymes that aid digestion
and hormones that help regulate the metabolism of carbohydrates.

Pancreatic cancer spreads rapidly and is seldom detected in its early
stages, which is a major reason why it's a leading cause of cancer
death. Signs and symptoms may not appear until the disease is quite
advanced. By that time, the cancer is likely to have spread to other
parts of the body and surgical removal is no longer possible.

CLINICAL PRESENTATION


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 the middle or upper back.
Pain may be constant or intermittent and is often worse after eating or
when you lie down.

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.

Jaundice (Yellowing of the skin) About half of people with
pancreatic cancer develop jaundice, which occurs when bilirubin, a
breakdown product of worn-out blood cells, accumulates in the blood.
Normally, bilirubin is eliminated in bile, a fluid produced in the liver. If
a pancreatic tumor blocks the flow of bile, excess pigment from
bilirubin may turn the skin and the whites of the eyes yellow. In
addition, the urine may be dark brown and the 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.
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Itching. In the later stages of pancreatic cancer, severe itching may
develop when high levels of bile acids, another component of bile,
accumulate in the skin.

Nausea and vomiting. In advanced cases of pancreatic cancer, the
tumor may block a portion of the digestive tract, usually the upper
portion of the small intestine (duodenum), causing nausea and
vomiting.

Digestive problems. When cancer prevents pancreatic enzymes
from being released into the intestine, there will be problems
digesting foods — especially those high in fat. Eventually, this may
lead to significant weight loss and even malnutrition



TYPES OF PANCREATIC CANCER


Most pancreatic tumours originate in the duct cells or in the cells that
produce digestive enzymes (acinar cells). Such tumours are called
Adeno-carcinomas, These account for nearly 95 percent of
pancreatic cancers.

Tumours 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, tumours in insulin cells
(insulinomas) may lead to an overproduction of insulin. While tumours
in glucagon cells (glucagonomas) might cause excess amounts of
glucagon to be secreted, while Tumors can also develop in the
ampulla of Vater — the place where the bile and pancreatic ducts
empty into the 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.
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Why pancreatic cancer occurs


Healthy cells grow and divide in an orderly way. This process is
controlled by DNA. When DNA is damaged, changes occur. One
result is that cells may begin to grow out of control and eventually
form a tumour — a mass of malignant cells. Researchers don't know
exactly what damages DNA in the vast majority of cases of
pancreatic cancer.



RISK FACTORS



Risk factors include:.

Age: Most occur in people older than 65.

Sex. More men than women develop pancreatic cancer.

Cigarette smoking. Smokers are 2 to 3 times more likely to develop
pancreatic cancer than nonsmokers. This is probably the greatest
known risk factor for pancreatic cancer, with smoking associated with
almost one in three cases of pancreatic cancer.

Diabetes. Having diabetes may increase the risk of pancreatic
cancer. Insulin resistance or high insulin levels may also be risk
factors for pancreatic cancer.

Hereditary pancreatitis. Hereditary pancreatitis (HP) is a rare
genetic condition marked by recurrent attacks of pancreatitis and has
an increased risk of developing pancreatic cancer.

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 the risk of pancreatic cancer.
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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.



DIAGNOSIS

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 the pancreas is
relatively hidden — tucked behind the stomach and inside the loop of
duodenum — small tumors can't be seen or felt during routine exams.

CA 19-9 is produced by pancreatic cancer cells and can be detected
by a blood test. 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 pancreatic cancer is suspected, the doctor may order:

Ultrasound imaging. In this test, a device called a transducer is
placed on the upper abdomen. High-frequency sound waves reflect
off abdominal tissues and are translated by a computer into moving
images of internal organs, including the pancreas. Ultrasound tests
are safe and

Computerized tomography (CT) scan. This imaging test allows the
doctor to visualize the pancreas, in two-dimensional slices.

Magnetic resonance imaging (MRI). Instead of X-rays, this test
uses a powerful magnetic field and radio waves to create images of
the pancreas.

Endoscopic retrograde cholangiopancreatiography (ERCP). In
this procedure, a thin, flexible tube (endoscope) is gently passed
down the throat, through the stomach and into the upper part of the
small intestine. The bile ducts are thin tubes that carry bile, a fluid
produced in the liver that helps digest fats. These ducts are often the
site of pancreatic tumors. A dye is then injected into the ducts through
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a small hollow tube (catheter) that's passed through the endoscope.
Finally, X-rays are taken of the ducts.

Endoscopic ultrasound (EUS). In this test, an ultrasound device is
passed through an endoscope into the stomach. The device directs
sound waves to the pancreas. 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 the liver. A dye is then
injected into the bile ducts in the liver, and a special X-ray machine
(fluoroscope) tracks the dye as it moves through the ducts.

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 the mass can be
reached with a needle, the doctor may choose to perform a fine-
needle aspiration (FNA) — a procedure in which a very thin needle is
inserted through the skin and into the 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.

Laparoscopy. This procedure uses a small, lighted instrument
(laparoscope) to view the pancreas and surrounding tissue. The
instrument is attached to a television camera and inserted through a
small incision in the abdomen. The camera allows the surgeon to
clearly see what's happening inside. During laparoscopy, the 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.
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STAGING PANCREATIC CANCER


Staging tests help determine the size and location of cancer and
whether it has spread. They're crucial in helping the doctor determine
the most appropriate treatment. Pancreatic cancer may be staged in
several ways. Some terms used are:

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.

COMPLICATIONS

The pancreas produces a number of enzymes that break down food
so the body can absorb nutrients. Pancreatic tumors often interfere
with the production or flow of these enzymes. As a result, the gut
cannot easily absorb nutrients, which can leads to diarrhea and
weight loss.

Other complications of pancreatic cancer include:

Problems with glucose metabolism. Tumors that affect the ability
of your pancreas to produce insulin can lead to problems with
glucose metabolism, including diabetes.

Jaundice, sometimes with severe itching. When a pancreatic
tumor blocks the bile duct, the thin tube that carries bile the your liver
to the duodenum, jaundice(yellowing of the skin and eyes) occurs.
The yellow color comes from excess bilirubin. Bile acids may cause
intense itching when they build up in the skin.

Pain. Large pancreatic tumors may press on surrounding nerves,
leading to back or abdominal pain that may sometimes be severe.
When medications aren't enough, cutting or injecting alcohol into
some of the affected nerves may be an option.
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Metastasis. This is the most serious complication of pancreatic
cancer. The pancreas is surrounded by a number of vital organs,
including your stomach, spleen, liver, lungs and intestine. Because
pancreatic tumors are rarely discovered in the early stages, they
often have time to spread to these organs or to nearby lymph nodes.

TREATMENT

Treatment for pancreatic cancer depends on the stage and location of
the cancer as well as on age, overall health and personal
preferences. Especially when cancer is advanced, choosing a
treatment plan is a major decision, and it's important that all choices
are discussed by the patient and their doctor.

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.

Surgery
The only way to eliminate pancreatic cancer is an operation to
completely 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, the surgeon,
depending on the extent and location of the tumor will consider one of
the following procedures,

Whipple procedure (pancreatoduodenectomy). This procedure
involves removing the wide end (head) of the pancreas. To do that,
the surgeon must also remove the duodenum, gallbladder and the
end of the common bile duct. Sometimes part of thestomach is
removed as well. The end of the bile duct and remaining part of the
pancreas are then connected to the small intestine so that bile and
pancreatic enzymes continue to reach the small intestine.

Total pancreatectomy. In this procedure, the surgeon removes your
entire pancreas as well as the bile duct, gallbladder and spleen; part
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of the small intestine and stomach; and most of the lymph nodes in
the area.

Total pancreatectomy isn't because there doesn't appear to be
enough benefit from the procedure to justify the serious 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 the spleen may
also be removed.

Operations for pancreatic cancer are complex and carry significant
risks including infection, bleeding and death. 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.
Radiation treatments may be recommended before or after cancer
surgery, often in combination with chemotherapy. The doctor may
recommend a combination of radiation and chemotherapy treatments
when the cancer is not suitable for surgery

Side effects of radiation therapy may include a burn on the skin
similar to sunburn where the radiation enters the body, nausea,
vomiting and fatigue.

Chemotherapy
Chemotherapy uses drugs to help kill cancer cells. Injected into a
vein or taken orally, these drugs travel through the 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.

Fluorouracil (5-FU) was the only chemotherapy option for people with
pancreatic cancer.. Now doctors are having more success with a
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newer drug, gemcitabine. Doctors are also testing a number of other
new medications and new combinations of older medicines.

Chemotherapy drugs affect normal cells as well as malignant ones,
especially fast-growing cells in the 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. 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 the bile duct, pancreatic duct or
duodenum can cause pain, digestive difficulties, nausea, vomiting,
jaundice and severe itching. To help ease some of these symptoms,
a surgeon can reroute the flow of bile by going around (bypassing)
the tumor.

Stent insertion. When a bypass operation isn't an option, a stainless
steel or plastic tube (stent) can be placed in the bile duct to keep it
open.

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, the doctor may discuss other options, 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 the
body's ability to absorb nutrients and may help reduce diarrhea and
weight loss.

Insulin therapy. When pancreatic cancer affects insulin production,
insulin injections may be needed to help control blood sugar levels.

				
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