Pancreatic cancer
Pancreatic cancer: Excerpt from Handbook of Diseases
A deadly GI cancer, pancreatic cancer progresses rapidly. Pancreatic tumors are almost always adenocarcinomas and most arise in the head of the pancreas. Tumors of the body and tail of the pancreas and islet cell tumors are rare. The two main tissue types are cylinder cell and large, fatty, granular cell.
Causes
Pancreatic cancer, the fourth leading cause of cancer-related death in the United States, is slightly more common in men than in women; risk increases with age. Almost one-third of cases result from cigarette smoking; some cases are related to hereditary syndromes.
Possible predisposing factors are chronic pancreatitis, diabetes mellitus, and chronic alcohol abuse.
Signs and symptoms
The most common features of pancreatic cancer are weight loss, anorexia, abdominal or low back pain, jaundice, diarrhea, steatorrhea, fluid and electrolyte imbalances, and bleeding tendencies. If the islets of Langerhans are affected, signs and symptoms of diabetes may be present. (See Types of pancreatic cancer, page 598.)
Other signs and symptoms include fever, skin lesions (usually on the legs), and emotional disturbances, such as depression, anxiety, and premonition of fatal illness.
Diagnosis
Definitive diagnosis requires a laparotomy with a biopsy. Other tests used to detect pancreatic cancer include:
❑ ultrasound — can identify a mass but not its histology
❑ computed tomography scan — similar to ultrasound but shows greater detail
❑ angiography — shows vascular supply of tumor
❑ endoscopic retrograde cholangiopancreatography — allows visualization, instillation of contrast medium, and specimen biopsy
❑ magnetic resonance imaging — shows tumor size and location in great detail.
Laboratory tests that can help support this diagnosis include serum bilirubin level (increased), serum amylase and serum lipase levels (sometimes elevated), prothrombin time (prolonged), and aspartate aminotransferase and alanine aminotransferase levels (elevations indicate necrosis of liver cells).
Additional pertinent studies include alkaline phosphatase level (marked elevation occurs with biliary obstruction), plasma insulin immunoassay (shows measurable serum insulin in the presence of islet cell tumors), hemoglobin level and hematocrit (may show mild anemia), fasting blood glucose level (may indicate hypoglycemia or hyperglycemia), and stool analysis (occult blood may signal ulceration in the GI tract or ampulla of Vater).
Treatment
Treatment of pancreatic cancer is rarely successful because this disease has usually metastasized widely by the time it’s diagnosed.
Therapy consists of surgery and, possibly, radiation and chemotherapy. Small advances have been made in the survival rate with surgery:
❑ Total pancreatectomy may increase survival time.
❑ Cholecystojejunostomy, choledochoduodenostomy, and choledochojejunostomy have partially replaced radical resection to bypass obstructing common bile duct extensions, thus decreasing the incidence of jaundice and pruritus.
❑ Whipple’s operation, or pancreatoduodenectomy, has a high mortality but can produce wide lymphatic clearance, except with tumors located near the portal vein, superior mesenteric vein and artery, and celiac axis. This procedure removes the head of the pancreas, the duodenum, gall bladder, end of the common bile duct, and possibly portions of the body and tail of the pancreas and stomach.
❑ Gastrojejunostomy is performed if radical resection isn’t indicated and duodenal obstruction is expected to develop later.
If the tumor is confined to the pancreas and can’t be removed, a combination of radiation and chemotherapy may be used. If the tumor has metastasized to other organs such as the liver, chemotherapy is usually the lone treatment. Gemcitabine is the standard agent and produces improvement in 50% of patients.
Other medications used in the treatment of pancreatic cancer include:
❑ anticholinergics (particularly propantheline) — to decrease GI tract spasm and motility and reduce pain and secretions
❑ antacids (oral or by nasogastric [NG] tube) — to decrease secretion of pancreatic enzymes and suppress peptic activity, thereby reducing stress-induced damage to gastric mucosa
❑ insulin — to provide adequate exogenous insulin supply after pancreatic resection
❑ narcotics — to relieve pain, but only after analgesics fail because morphine, meperidine, and codeine can lead to biliary tract spasm and increase common bile duct pressure
❑ pancreatic enzymes (average dose is 0.5 to 1 mg with meals) — to assist in the digestion of proteins, carbohydrates, and fats when pancreatic juices are insufficient because of surgery or obstruction.
Special considerations
Before surgery:
❑ Ensure that the patient is in stable condition, particularly regarding nutrition (this may take 4 to 5 days). If the patient can’t tolerate oral feedings, provide total parenteral nutrition and I.V. fat emulsions to correct deficiencies and maintain positive nitrogen balance.
❑ Give blood transfusions (to combat anemia), vitamin K (to overcome prothrombin deficiency), and antibiotics (to prevent postoperative complications) and perform gastric lavage (to maintain gastric decompression), as necessary.
❑ Tell the patient about postoperative procedures and adverse effects of radiation and chemotherapy.
After surgery:
❑ Watch for and report complications, such as fistula, pancreatitis, fluid and electrolyte imbalance, infection, hemorrhage, skin breakdown, nutritional deficiency, hepatic failure, renal insufficiency, and diabetes.
❑ If the patient is receiving chemotherapy, treat adverse effects symptomatically.
Throughout this illness, provide meticulous supportive care as follows:
❑ Monitor fluid balance, abdominal girth, metabolic state, and weight daily. With weight loss, replace nutrients I.V., orally, or by NG tube; with weight gain (due to ascites), impose dietary restrictions, such as a low-sodium or fluid-retention diet, as required. Maintain a 2,500-calorie diet.
❑ Serve small, frequent, nutritious meals by enlisting the dietitian’s services. Administer an oral pancreatic enzyme at mealtimes, if needed. As necessary, give antacids to prevent stress ulcers.
❑ To prevent constipation, administer laxatives, stool softeners, and cathartics as required; modify diet; and increase fluid intake. To increase GI motility, position the patient properly at mealtime, and help him walk when he can.
❑ Administer pain medication, antibiotics, and antipyretics, as necessary. Note time, site (if injected), and response.
❑ Watch for signs of hypoglycemia or hyperglycemia; administer glucose or an antidiabetic as necessary. Monitor blood glucose and urine acetone levels.
CLINICAL TIP: Prevent excoriation in a pruritic patient by clipping his nails and having him wear cotton gloves.
❑ Watch for signs of upper GI bleeding; test stools and vomitus for occult blood, and keep a flow sheet of hemoglobin level and hematocrit.
❑ To prevent thrombosis, apply antiembolism stockings and assist in range-of-motion exercises. If thrombosis occurs, elevate the patient’s legs, and give an anticoagulant or aspirin, as required.
Pictures
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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» Next page: Pancreatitis (Handbook of Diseases)
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