10 The Pancreas
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.
L2-L3 (head of pancreas), covered by the right crus of the diaphragm
common bile duct
inferior vena cava
left renal vein
superior mesenteric artery and vein
transverse mesocolon (divides the pancreas into a suband a supramesocolic part)
left colic flexure
attachments of connective tissue in the retroperitoneal space
retropancreatic fascia (Treitz)
superior mesenteric artery
gastroduodenal artery (from the common hepatic 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
Maximal time: 9–11 a.m.
Minimal time: 9–11 p.m.
For basic information, see page 34.
First back tooth in the lower jaw, right side
First molar in the upper jaw on the right side
Movement Physiology according to Barral
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.
In the liver, it initiates a variety of metabolic processes:
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 saliva” 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.
Symptoms that Require Medical Clarification
Pain in the depth of the upper abdomen with back pain in the area of the lower thoracic spinal column, radiating beltlike from the back to the front
Definition. Inflammation of the pancreas with disturbance of exocrine and endocrine functions.
biliary tract disorders (40–50%)
alcohol abuse (30–40%)
Rare causes include:
medications (diuretics, β blockers, glucocorticoids, antibiotics, nonsteroidal antirheumatics)
infections (mumps, Coxsackievirus)
hypercalcemia (e.g., hyperparathyroidism)