The Pancreas: Anatomy and Functions 

Anatomy of the pancreas:

The pancreas is an elongated, tapered organ located across the back of the abdomen, behind the
stomach. The right side of the organ (called the head) is the widest part of the organ and lies in
the curve of the duodenum (the first section of the small intestine). The tapered left side extends
slightly upward (called the body of the pancreas) and ends near the spleen (called the tail).

The pancreas is made up of two types of tissue:

 exocrine tissue
The exocrine tissue secretes digestive enzymes. These enzymes are secreted into a
network of ducts that join the main pancreatic duct, which runs the length of the
pancreas.
 endocrine tissue
The endocrine tissue, which consists of the islets of Langerhans, secretes hormones into
the bloodstream.
Functions of the pancreas:

The pancreas has digestive and hormonal functions:

 The enzymes secreted by the exocrine tissue in the pancreas help break down
carbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel down the
pancreatic duct into the bile duct in an inactive form. When they enter the duodenum,
they are activated. The exocrine tissue also secretes a bicarbonate to neutralize stomach
acid in the duodenum.
 The hormones secreted by the endocrine tissue in the pancreas are insulin and glucagon
(which regulate the level of glucose in the blood), and somatostatin (which prevents the
release of the other two hormones).
Pancreas

Structure of the Pancreas

The pancreas is an elongated organ that lies behind and below the stomach. This mixed gland
contains both exocrine and endocrine tissues. The predominant exocrine part consists of grape-
like clusters of secretory cells that form sacs known as acini, which connect to ducts that
eventually empty into the the first portion of the intestine called duodenum. The smaller part of
the gland consists of isolated islands of endocrine tissue known as islets of Langerhans which are
dispersed throughout the pancreas.

Hormones Secreted by the Pancreas

The most important hormones secreted by the pancreas are insulin and glucagon. Both play a
role in proper metabolism of sugars and starches in the body. Insulin promotes the movement of
glucose and other nutrients out of the blood and into cells. When blood glucose rises, insulin,
released from the beta cells causes glucose to enter body cells to be used for energy. Also, it
sometimes stimulates conversion of glucose to glycogen in the liver. Another pancreatic
hormone, glucagon, promotes the movement of glucose into the blood when glucose levels are
below normal. It causes the breakdown of stored liver glycogen to glucose, so that the sugar
content of blood leaving the liver rises.

Function of the Pancreas

The pancreas is largely responsible for maintaining blood glucose levels. The normal clinical
range of blood glucose levels is 70 to 150 mg/dL (milligrams per deciliter). The pancreas can
measure blood sugar and if it is high or low, the pancreas releases a hormone to correct the level.
Blood glucose must be maintained at a certain level for cells to neither gain or lose water.

Digestive Enzymes Secreted by the Pancreas

The exocrine pancreas secretes the pancreatic juice consisting of two components:

 Pancreatic enzymes actively secreted by the acinar cells that form the acini. These
pancreactic enzymes are very important because they can almost completely digest food
in the absence of all other digestive secretion.
 An aqueous alkaline solution rich in sodium bicarbonate (NaHCO3) actively secreted
by the duct cells that line the pancreatic ducts. Sodium bicarbonate neutralizes the acidity
of the chyme so that won't burn the intestines.
Pancreatic Enzymes

The acinar cells secrete three different types of enzymes:

1. Proteolytic enzymes for protein digestion

2. Pancreatic amylase for carbohydrate digestion
3. Pancreatic lipase for fat digestion3

Pancreatic Diseases

 Cystic Fibrosis
 Exocrine Pancreatic Insufficiency
 Nesidioblastosis
 Pancreatic Cyst
o Pancreatic Pseudocyst
 Pancreatic Fistula
 Pancreatic Neoplasms
o Islet Cell Adenoma
 Insulinoma
o Islet Cell Carcinoma
 Gastrinoma
 Glucagonoma
 Somatostatinoma
 Vipoma
o Pancreatic Ductal Carcinoma
 Pancreatitis
o Acute Necrotizing Pancreatitis
o Alcoholic Pancreatitis
o Chronic Pancreatitis
o Graft Pancreatitis4

References:
1.Image credit: University of Colorado at Boulder
2. The Language of Medicine. Davi-Ellen Chabner
3. Human Physiology: From Cells to Systems. Lauralee Sherwood
4. National Library of Medicine - Medical Subject Headings
ETIOLOGY

Modifiable Risk Factors

Accumulating research shows there are a number of factors that contribute to a person’s overall
likelihood of developing type 2 Diabetes and heart disease. 

Modifiable risk factors include:

 Overweight/Obesity
 High Blood Glucose
 Hypertension
 Abnormal Lipid Metabolism
 Inflammation & Hypercoagulation
 Physical Inactivity
 Smoking

Overweight/Obesity

Two out of three Americans are now overweight or obese, which poses a threat to their
cardiometabolic health. But for many patients, weight loss can be a struggle because it means
substantial changes in eating and exercising habits. These can be some of the hardest habits to
change, and there is no "one size fits all" or quick fix. If they have other cardiometabolic risk
factors, they should know that losing weight can help manage blood pressure and cholesterol,
among others.

Clinical Intervention:

Measure BMI routinely at each regular check-up.

BMI 18.5-24.9 = normal

BMI 25-29.9 = overweight

BMI of 30 or greater = obesity

Recommend & counsel for lifestyle modification

Reduce calorie intake

Increase physical activity

Remind patients that even a small calorie deficit will lead to weight loss. A deficit of 100
calories per day leads to a 10lb weight loss over a year.

Consider pharmacologic treatment

If your patients are interested in calculating their own BMI, they may enjoy our patient-friendly
BMI calculator.

High Blood Glucose

Insulin resistance and high blood glucose are substantial risk factors for diabetes and in the long
run, heart disease and stroke.    ADA uses the fasting plasma glucose (FPG) test to determine if
patients' glucose levels are too high.

Healthy blood glucose FPG under 100  

Pre-diabetes  FPG 100 - 125

Diabetes  FPG more than 125
 

Clinical Intervention:

 Treat IFG and IGT with aggressive lifestyle modification

 For certain patients with both IFG and IGT consider metformin

Hypertension

Hypertension leads to elevated risk for myocardial infarction, stroke, eye problems and kidney
disease. Often a silent disease, many patients won't know they have high blood pressure until
informed by their health care provider.

For patients without diabetes:

 Blood Pressure should be measured at each regular visit or at least once every 2 years if it
is less than 120/80 mmHg
 Blood Pressure should be measured  while seated after 5 min rest in office

For patients with diabetes:

  Blood Pressure should be measured at each regular visit
 Blood Pressure should be measured while seated after 5 minutes rest in office
 Patients with ;::1 30 or ;;:80 mmHg should have Blood Pressure confirmed on a separate
day

Clinical Intervention:

DASH (Dietary Approaches to Stop Hypertension) diet

High in whole grains, fruits, vegetables, and low-fat dairy

Low in saturated and trans fat, cholesterol

Physical Activity

Weight loss, if applicable

If Blood Pressure ;::140/ ;;:90 mm Hg, drug therapy is indicated

 Combination therapy often necessary

 Treatment should include ACE or ARB
 Thiazide diuretic may be added to reach goals
 Monitor renal function and serum potassium

Abnormal Lipid Metabolism

Inform patients of the health risks of both high LDL cholesterol and low HDL cholesterol, as
well as triglycerides. Patients should also be aware that modest weight loss and increased
physical activity can have a beneficial effect on lipid management.

Clinical Intervention:

 In adults (> 19 years) without diabetes, test at least every 5 years, including adults with
low-risk values. Low-risk values are:
o LDL <100 mgdL
o HDL >40 mgdL for men and
o >50 mgdL for women
o Triglycerides <150 mgdL)

Inflammation & Hypercoagulation

Proinflammatory/prothrombotic factors are known to underlie cardiometabolic risk.
Inflammation is a major component of atherogenesis and other cardiometabolic problems.
Creactive protein (CRP), an emerging marker of inflammation, may provide useful information
to assess CVD risk, but trials documenting its clinical utility have not been completed. This may
give a more complete picture of risk.

High-sensitivity CRP (hs-CRP) tests may be used to further evaluate patients' underlying risk,
especially for patients otherwise at indeterminate risk.

Relative risk categories for hs-CRP levels:

 Low risk <1 mg/L

 Average risk 1-3 mg/L
 High risk> 3 mg/L

Patients with hs-CRP levels in the high end of the normal range have 1.5 to 4 times the risk of
having MI than those with CRP values at the low end of the normal range. Weight loss, aspirin
and statins have been shown to reduce CRP levels, however, at this point, no controlled
prospective trials have shown the benefit of CRP lowering.

More research is needed to establish hypercoagulation as a solid indicator of risk, to determine

the positive predictive value of the test, and to standardize assays.

Physical Inactivity

35% of coronary heart disease deaths in the United States can be attributed to an inactive
lifestyle, and consistent exercise can reduce CVD risk.

Staying active can:

 Increase insulin sensitivity

 Improve lipid levels
 Lower blood pressure
 Aid weight management
 Improve blood glucose management in type 2 diabetes \ Lower risk of CVD

Clinical Intervention:

 Encourage your patients to find ways to fit activity into their daily routine. Examples
include taking the stairs, parking further away, taking the stairs instead of elevator, or
walking to another bus stop.
 Encourage patients to aim for at least 150 minutes/week of moderate aerobic exercise.
This can be broken down into multiple spurts of activity each day. If they are just starting
out, encourage them to start with just 5 or 10 minutes, 3x per day and build from there.
  Many patients are motivated by wearing a pedometer and tracking their steps. Encourage
them to join a walking group and challenge each other to more and more steps. A good
online group exists at diabetes.org/ClubPed

Smoking

Most patients know smoking is bad for their health, but quitting is often easier said than done. If
you have patients who smoke, be sure to emphasize not only the grave dangers of continuing
smoking, but also the tremendous benefits of quitting.

Clinical Intervention:

 Obtain documentation of history of tobacco use

 Ask whether smoker is willing to quit
 If no, initiate brief, motivational discussion regarding:
o The need to stop using tobacco
o Risks of continued use
o Encouragement to quit, as well as support when ready
 If yes, assess preference for and initiate either minimal, brief, or intensive cessation
counseling.

Non Modifiable Risks Factors For Diabetes Mellitus

There are numerous non modifiable risks for diabetes mellitus and these should be clear
to everyone suffering from or with the potential to contract the disease.
Today there are more than eighteen million Americans dealing with both Type 1 and
Type 2 diabetes and both are linked to non modifiable risks for diabetes. As far as
illnesses are concerned, diabetes (especially Type 2 diabetes) is unique because so many
of the risks associated with diabetes can be controlled. For example, diabetes Type 2 has
definitely been linked to obesity. Consequently much of the advice is to lose weight and
exercise as a way of reducing your chances of developing this condition