Disorders of the Pancreas

Located just behind the stomach, your pancreas releases hormones—such as insulin—that control how your body uses the sugar, fats, and protein consumed in your diet. The most common disorders of the pancreas are diabetes and pancreatitis (see page 277). Cancer also can affect the pancreas.

Diabetes

Diabetes is a serious, chronic condition that affects an estimated 16 million Americans. Up to 95 percent of people with diabetes have type 2 diabetes, also referred to as adult-onset or non-insulin-dependent diabetes. One-third of these people do not know they have the disease because type 2 diabetes seldom causes symptoms in the early stages.

When you have diabetes, the amount of glucose (a simple sugar that is the body's main source of fuel) in your blood is too high. Your blood always has some glucose in it, but excessive amounts are not good for your health.

Diabetes affects the way your body uses food for energy and growth. Most of the food you consume is broken down into glucose, which passes into the bloodstream and is transported throughout the body for use by the cells. To get inside the cells, a hormone called insulin must be present. Insulin is produced by the pancreas.

When you eat, the pancreas normally produces the proper amount of insulin to allow glucose to enter your cells. But in people with diabetes, either the pancreas produces insufficient insulin or the cells do not respond to the insulin produced. Glucose builds up in the blood and overflows into the urine. During urination, the body loses its vital source of energy.

Diabetes is widely recognized as one of the leading causes of death and disability in the United States. It can produce serious, long-term complications that affect every major part of the body. Some of these complications are heart disease, stroke, nerve damage, blindness, kidney failure, and amputations.

Type 1 Diabetes Type 1 diabetes, the less common form of the disorder, occurs when the body's immune system (see page 376) attacks the insulin-producing

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Concerns cells in the pancreas and destroys them. The pancreas then loses its ability to produce an adequate supply of insulin.

Type 1 diabetes is sometimes referred to as insulin-dependent diabetes because people who have it need daily injections of insulin to stay alive. If the person's insulin level is not sufficient, symptoms appear quickly, including increased thirst, feeling hungry, frequent urination, weight loss, blurred vision, irritability, and extreme fatigue. Without insulin these symptoms worsen, and the person can lapse into a life-threatening coma.

At present, the cause of type 1 diabetes is unknown, but both a person's genetic makeup and environmental factors such as viruses may have a role in the development of the disorder. Type 1 diabetes accounts for 5 to 10 percent of all cases of diagnosed diabetes in the United States. It most often develops in children and young adults, but it can appear at any age. This type of diabetes occurs equally among men and women. Type 1 diabetes most frequently occurs in whites.

To diagnose type 1 diabetes, your doctor will give you a thorough physical examination and will ask you questions about your symptoms, your family health history (see page 80), and your personal health history (see page 82). He or she will order blood tests to measure the level of glucose in your blood. Your blood also will be tested for changes in levels of electrolytes such as sodium and potassium. The doctor may also order a urine test that can detect the presence of substances known as ketones that accumulate in your urine if your body does not produce enough insulin.

To treat this type of diabetes, the doctor will teach you how to give yourself daily injections of insulin. He or she may recommend an insulin pump, which is implanted just under the skin on the abdomen and provides insulin continuously 24 hours a day according to a plan programmed just for you. The steady infusion of insulin keeps your blood glucose level in the healthy range between meals and overnight. When you eat, you program the pump to deliver an extra dose of insulin based on the amount of food you eat.

You will also learn how to test your blood glucose level at home using a home glucose meter that measures the amount of glucose present in a small drop of blood taken from your finger. (Newer monitors are available that allow you to measure the blood glucose level without sticking your finger.) Frequent monitoring of your blood glucose level can help you gauge how often to take your insulin injections or how well your insulin pump is working.

Diet is a key component of diabetes management. A dietitian will help you to plan meals that are tailored to your individual needs. The diet plan will tell you not only what types of food to eat—mostly complex carbohydrates and highfiber foods—but also when to eat, because it is important to balance your insulin injections with your food intake. This balance will ensure that you keep your blood glucose level as close to normal as possible.

Regular exercise actually helps to reduce the level of glucose in your blood by 367

improving your body's ability to convert the food you eat into energy. Exercise Endocrine also strengthens your heart and blood vessels, which can be adversely affected system by uncontrolled diabetes. Work with your doctor to plan an exercise program that fits your schedule and includes activities you like. Be sure to plan your exercise sessions around your mealtimes and insulin injections so you can keep your blood glucose level within the normal range.

Type 2 Diabetes The more common form of diabetes is type 2 diabetes. Ninety to 95 percent of people with diabetes have this form. In people with type 2 diabetes, the pancreas produces insulin, but the body's cells cannot effectively use it. The end result is the same as that in type 1 diabetes: an unhealthy buildup of the sugar glucose in the blood and the body's inability to make efficient use of its main source of fuel.

The symptoms of type 2 diabetes develop very gradually and are barely noticeable at first. Over time, however, people with type 2 diabetes may feel tired, urinate frequently (especially at night), be unusually thirsty, lose weight, and have blurred vision. Eventually, they may develop frequent infections—especially of the skin—and sores that are slow to heal.

Type 2 diabetes usually develops in adults over age 40 and is most common over age 55. About 80 percent of people with this form of diabetes are overweight, and obesity is an important risk factor for type 2 diabetes. It is more common in older women than in older men. In contrast with type 1, the incidence of type 2 diabetes is about 60 percent higher in African Americans and up to 120 percent higher in Hispanic Americans than it is in whites. Native Americans have the highest incidence of diabetes in the world. People who have family members with type 2 diabetes are at greater risk of developing the disease.

Doctors use a number of tests to diagnose type 2 diabetes. If you have a family history of type 2 diabetes or are otherwise at risk of developing it, you will be given a screening blood test to measure the level of glucose in your blood. A high or a low glucose level in a screening blood test will warrant a fasting blood glucose test, which measures the glucose level in your blood after you have fasted for 10 to 12 hours, usually overnight. Blood glucose levels of 125 mg/dL (milligrams of glucose per deciliter of blood) or more on two or more fasting blood glucose tests show that you have diabetes. If your blood glucose levels fall between 105 and 124 mg/dL, or if your fasting blood glucose levels are normal but you have symptoms of diabetes, the doctor may recommend an oral

Warning Signs of Type 1 Diabetes

Symptoms of type 1 diabetes appear suddenly and develop most often in children and young adults. See your doctor right away if you have any of the following symptoms:

• increased thirst

• frequent urination

• constant hunger

• abdominal pain

• blurred vision

• fatigue glucose tolerance test. Before taking this test, the doctor will ask you to eat a carbohydrate-rich diet for a few days and then to fast overnight. You will then receive a glucose-containing liquid to drink, and your blood glucose level will be monitored for 2 hours through blood tests taken every 30 minutes. High levels (over 200 mg/dL) of glucose in the blood indicate that you have type 2 diabetes. Moderately high levels show that you have a condition called impaired glucose tolerance, which places you at an increased risk of developing type 2 diabetes and at an increased risk of developing heart disease.

A test called a glycosylated hemoglobin test measures the percentage in your blood of a particular type of hemoglobin (the substance in red blood cells that carries oxygen). If you have too much glucose in your blood, the extra glucose forms a link with (glycosylates) the hemoglobin. The blood test can determine the average level of glucose in your blood over the past 120 days. In a person who does not have diabetes, about 6 percent of all hemoglobin is glycosylated. In a person whose diabetes has been poorly controlled for a long time, the level of glycosylated hemoglobin can be as high as 25 percent. If you are diagnosed with diabetes, your doctor is likely to recommend that you have a glycosylated hemoglobin test twice a year to monitor the effectiveness of your treatment.

Obesity is the number one cause of type 2 diabetes, so weight reduction is the primary goal of treatment. A balanced weight-loss diet and regular exercise are often all that are needed to reach and maintain a normal blood glucose level. If not, your doctor will prescribe oral medication (including sulfonylureas such as glipizide or glyburide, or other medications such as metformin or acarbose) that reduces the level of glucose in your blood. Although most people with type 2 diabetes take oral medication, some people who have the disorder need to take daily injections of insulin. The doctor will probably recommend that you routinely check your blood glucose level at home using a simple test so that you can determine whether your program of diet, exercise, and medication is working.

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Warning Signs of Type 2 Diabetes

Type 2 diabetes is the more common form of the disease. The symptoms of type 2 diabetes develop gradually and are not as noticeable as those of type 1 diabetes. See your doctor right away if you experience any of the following symptoms:

• frequent urination, especially at night

• unusual thirst

• blurred vision

• frequent infections

• slow healing of sores

Managing Diabetes Before the discovery of insulin in 1921, people with type 1 diabetes died within a few years after getting the disease. Insulin is not considered a cure for the disease, but daily injections of the hormone help the affected person live a normal life. The insulin injections have to be balanced with diet, proper timing of meals, and exercise. Frequent blood glucose testing helps to monitor the level of glucose in the blood. Diet, exercise, and blood glucose testing also are indispensable for the management of type 2 diabetes. Some people with this form of diabetes also take drugs or insulin to lower their blood 369

glucose level. Endocrine

People who have either type of diabetes must take responsibility for their own system day-to-day care to keep their blood glucose level from getting too low or too high. If the blood glucose level drops too low, usually because the person has taken too much insulin or oral medication or has not balanced the insulin or medication with the proper food intake, a condition known as hypoglycemia occurs. Hypoglycemia causes the person to tremble and become weak, confused, hungry, and dizzy. Pale skin, headache, irritability, sweating, rapid heartbeat, and a cold and clammy feeling are additional symptoms of hypoglycemia. In severe cases the person can lose consciousness and even lapse into a coma. The symptoms of low blood glucose can be mistaken for those of other conditions, such as anxiety or overindulgence in alcohol. The best way to correct a low blood glucose level is to eat or drink something—such as hard candy, soda pop, or orange juice—that contains sugar. Many people with diabetes carry glucose tablets for just such an emergency. A person who has diabetes should always wear a medical identification bracelet or necklace and carry a wallet card containing up-to-date personal medical information. This will identify the person's condition and help ensure appropriate medical treatment if he or she ever has a hypoglycemic reaction while in public.

A person also can become very ill if the blood glucose level rises too high, a condition known as hyperglycemia. This usually happens when the person has not taken enough insulin or oral medication or has not properly regulated his or her blood glucose level with diet. Symptoms are the same as those of type 1 diabetes. Hypoglycemia and hyperglycemia can occur in people with both types of diabetes, and both are potentially life-threatening emergencies.

Keeping the blood glucose level as close to normal as possible reduces the risk of developing serious complications. In a person who does not have diabetes, the normal level of glucose in the blood ranges from 60 to 110 mg/dL. The blood glucose level goes up after eating but returns to the normal range within 1 or 2 hours. Most people with diabetes should aim for a blood glucose range of about 90 to 120 mg/dL before a meal and less than 150 mg/dL about 2 hours after their latest meal.

The doctor will monitor how well you control your diabetes and check for any possible complications, such as nerve damage. Doctors who specialize in treating diabetes and other disorders of the endocrine system are called endo-crinologists. People with diabetes should also see an ophthalmologist (a doctor who specializes in treating diseases of the eyes) for eye examinations (see page 370) and a podiatrist (a doctor who specializes in care of the feet) for routine foot care (see page 371).

The biggest problem for people with diabetes is heart and blood vessel disease, which can lead to heart attacks, stroke, and high blood pressure. Diabetes

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Concerns also can cause poor circulation (blood flow) in the legs and feet. To check for heart and blood vessel disease, the doctor will order certain tests, including an electrocardiogram (which measures and records the flow of electricity through the heart) and a cholesterol test. The doctor will take your blood pressure at each visit and check the pulse in your feet and legs to make sure you have good circulation. He or she will recommend that you eat foods low in fat and salt, lose weight if you need to, and exercise regularly. Your doctor will also advise you not to smoke and to limit your intake of alcohol.

Having diabetes also is a risk factor for kidney disease. After several years, a high blood glucose level can cause your kidneys to stop functioning. This condition is called kidney (or renal) failure (see page 291). Diabetes is the primary preventable cause of kidney failure in the United States. The doctor will check your urine at least once a year for protein, a sign of kidney damage. A blood pressure medication called an angiotensin-converting enzyme (ACE)

Diabetic Eye Disease

People who have diabetes are at high risk for a number of eye problems that can cause severe vision loss or blindness. The most common diabetic eye disease is diabetic retinopathy, which is damage to the blood vessels in the retina, the lightsensitive membrane at the back of the eyeball. In some people with diabetic retinopathy, blood vessels in the retina may swell and leak fluid. In other people, abnormal new blood vessels grow on the surface of the retina. These changes can produce loss of vision or blindness.

In the early stages of the disease, no pain or other symptoms may be present. This is why, if you have diabetes, you should have your eyes examined at least once a year. During the examination, the doctor will use eyedrops to dilate (enlarge) your pupils so that he or she can see inside your eyes to check for signs of the disease. As diabetic retinopathy progresses, the person may experience blurred vision or vision loss.

Doctors treat diabetic retinopathy by using laser surgery to seal the leaking blood vessels or to shrink abnormal vessels. Diabetic retinopathy cannot be prevented, but you can reduce your risk of developing the disease and slow its onset and progression by keeping your blood glucose level within normal range.

A cataract (see page 390) is a cloudy covering that appears over the normally clear lens of the eye. People with diabetes are twice as likely to develop cataracts as are people without diabetes. Cataracts also develop at an earlier age in people with diabetes. Usually cataracts can be surgically removed.

If you have diabetes, you also have twice the normal risk of developing glaucoma (see page 388). This disease is caused by abnormally high pressure from excess fluid in the eyeball. The increased pressure damages the optic nerve and blood vessels in the eye, resulting in vision loss. Doctors treat glaucoma with medications or laser surgery.

Early detection and treatment, before vision loss occurs, are the best ways to control diabetic eye disease. If you have diabetes, make sure you have a thorough eye examination at least once a year. For more information on diabetic retinopathy, cataracts, and glaucoma, see chapter 20.

inhibitor can sometimes help prevent kidney damage, even if your blood pres- 371

sure is normal. It is very important to control your blood pressure to prevent kid- Endocrine ney damage. Be sure to take your blood pressure medication as prescribed. See system your doctor right away if you think you might have a bladder or kidney infection, indicated by cloudy or bloody urine, pain or burning during urination, and frequent urination or an urgent need to urinate. Back pain, chills, and fever also are possible symptoms of a kidney infection.

Over time, a high blood glucose level can damage the nerves in your body. Nerve damage due to diabetes can produce a loss of sensation or cause pain and

Foot Care Tips for People with Diabetes

People with diabetes are prone to developing severe infections that are slow to heal.

The feet are especially susceptible to infection, even from something as common as an ingrown toenail. Nerve damage produced by diabetes can cause numbness in the feet that reduces the person's ability to feel pain from an injury or infection. An infection can become so serious that it results in the need for amputation.

Controlling your blood glucose level with diet, exercise, and your daily insulin intake can go a long way toward preventing foot problems. The following tips also can help you take better care of your feet:

• Check your feet every day. Look for cuts, blisters, red spots, and swelling, and use a mirror to check the bottoms of your feet.

• Wash your feet every day. Bathe your feet in warm (not hot) soapy water every day and dry them well, especially between the toes.

• Keep your feet soft and smooth. Apply a moisturizing lotion over the tops and bottoms of your feet but not between your toes.

• Smooth corns and calluses gently. Use a pumice stone to gently rub rough spots away.

• Trim your toenails each week. Cut them straight across and file the edges gently with an emery board or nail file.

• Always wear shoes and socks. Never walk barefoot, because you could injure your feet. Wear shoes that are comfortable and fit well.

• Protect your feet from hot and cold. Wear shoes at the beach or on hot pavement. Wear socks if your feet get cold at night.

• Keep the blood circulating to your feet. Put your feet up when sitting. Wiggle your toes and move your feet up and down for a few minutes two or three times a day. Do not cross your legs for long periods. Do not smoke.

• Be more active. Ask your doctor to help you plan a regular exercise program.

• See your doctor regularly. The doctor will check your feet for any potential problems. Call your doctor right away if a cut, sore, blister, or bruise on your foot does not begin to heal after a day. Follow your doctor's advice about routine foot care.

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Concerns burning in your feet. Nerve damage happens slowly, and you may not realize that you have a problem. Your doctor will routinely check the sensation and the pulse in your feet to look for signs of nerve damage.

A high level of blood glucose also can damage the small blood vessels and nerves in and around the penis. Therefore diabetes can interfere with both the nerve impulses and the blood flow necessary to produce and maintain an erection. About 60 percent of men with diabetes experience erectile dysfunction (see page 146).

Diabetes can cause infection of the gums and the bones that hold your teeth in place. Like any infection, gum disease (see page 409) can cause your blood glucose level to rise, making the problem worse. Without treatment, your teeth can become loose and begin to fall out. To help prevent gum disease, see your dentist twice a year and tell him or her that you have diabetes. And be sure to brush and floss your teeth twice a day.

Cancer of the Pancreas

Pancreatic cancer is one of the leading cancers in men, with 26,000 new cases diagnosed each year. It is the fifth most common cause of cancer deaths in the United States and around the world. Most pancreatic cancer begins in the ducts that carry pancreatic juices into the first section of the small intestine. A rare type of pancreatic cancer begins in the cells inside the pancreas (known as the islets of Langerhans) that produce insulin. As the cancer grows, the tumor invades organs—such as the stomach and the small intestine—that surround the pancreas. Cancer cells also can break away from the main tumor and spread to other parts of the body—most commonly the lymph nodes or the liver—through the bloodstream.

Cancer of the pancreas has been called a "silent" disease because it usually does not cause symptoms in the early stages. The cancer may grow for some time before it causes symptoms. When symptoms occur, they may be so vague that they go unnoticed. For these reasons, cancer of the pancreas is often not detected until the later stages, when the cancer has already spread outside the pancreas.

Symptoms include pressure in the upper abdomen that sometimes spreads to the back. The pressure may worsen after the person eats or lies down. Other symptoms include nausea, loss of appetite, weight loss, and weakness. If the tumor blocks the duct through which bile (a fluid produced by the liver that helps digest fat) passes into the small intestine, the person develops jaundice (yellowing of the skin and the whites of the eyes), and his or her urine may become dark.

The cause of cancer of the pancreas is unknown, but certain factors can increase your risk of developing the disease. Age is a risk factor; the disease rarely occurs before age 40, and the average age at diagnosis is 70. Smoking and heavy drinking are also risk factors for cancer of the pancreas. Cigarette smok-

ers develop the disease two to three times more often than nonsmokers. Having 373

diabetes also increases your chances of developing cancer of the pancreas. Peo- Endocrine ple with diabetes develop the disease about twice as often as the general popula- system tion. The risk of developing pancreatic cancer is higher in people who consume a diet that is high in fat and low in fruits and vegetables.

To diagnose cancer of the pancreas, the doctor will perform a physical examination and ask about the person's health history (see page 82). He or she will order tests that will produce images of the pancreas. Such tests also will help the doctor determine how far the cancer has progressed. Computed tomography (CT) scanning (which uses a series of X rays and a computer to produce cross-sectional images), magnetic resonance imaging (MRI; which uses a powerful magnetic field and a computer to produce three-dimensional images), and ultrasound scanning (which uses high-frequency sound waves to produce images) are commonly used to diagnose cancer of the pancreas. To view the pancreatic ducts, the doctor probably will order a test called endoscopic retrograde cholangiopan-creatography (ERCP). In ERCP, an endoscope (a lighted, flexible viewing tube) is passed down the throat, through the stomach, and into the small intestine. After the endoscope is in place, contrast medium (a type of dye) is injected into the pancreatic ducts, and a series of X-ray images is produced.

Images of the pancreas and nearby organs may not provide adequate information for the doctor to make a firm diagnosis of pancreatic cancer. He or she also may have to perform a biopsy, in which a small sample of tissue is taken from the pancreas for analysis under a microscope. A biopsy can be performed in three ways. In a needle biopsy, the doctor inserts a long needle into the abdomen and then into the pancreas to obtain a tissue sample. A brush biopsy is performed at the same time as the ERCP. The doctor inserts a tiny brush into the endoscope and rubs off some cells for later analysis. Sometimes the doctor performs the biopsy during a surgical procedure known as a laparoscopy. During this procedure, the doctor inserts a laparoscope (a viewing tube equipped with a precision optical system that sends clear images to a video monitor) into the abdomen through a small incision and removes a small tissue sample. The doctor also can use the same tube to see inside the abdomen to determine the location and the extent of the cancer.

Cancer of the pancreas can be cured only in its early stages. However, because of the lack of early symptoms, the disease is not often detected until it is in its later stages, when treatment is difficult. Therefore, treatment often focuses on improving the person's quality of life by controlling the symptoms of the disease. Pain relievers are usually prescribed.

Depending on the type of pancreatic cancer, its location, and whether it has spread, the doctor may attempt to remove the tumor or stop its growth by using surgery, radiation therapy, or chemotherapy (treatment with powerful anticancer drugs). Surgery involves removing all or part of the pancreas and possibly

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Concerns some surrounding tissue. Doctors also use surgery to help relieve symptoms that occur if a duct is blocked. During radiation therapy, the doctor uses a radioactive substance or X rays to damage cancer cells and stop them from growing and spreading. The radiation affects cells only in the treated area. Chemotherapy uses drugs to kill cancer cells. It is given in cycles so the person can have a period of recovery between treatments. Sometimes doctors use surgery, radiation therapy, and chemotherapy in combination to treat cancer of the pancreas. All three forms of treatment have side effects that your doctor will describe for you.

Surgery to treat cancer of the pancreas is major surgery that requires a lengthy recovery period. Pain, fatigue, and weakness are common. Fatigue is also a side effect of radiation therapy, which also can cause hair loss, darkening of the skin, nausea, vomiting, and diarrhea. People undergoing chemotherapy may be more susceptible to infection; may bruise or bleed easily; may have nausea, vomiting, and diarrhea; and may develop sores in the mouth. The side effects vary from person to person.

People living with cancer of the pancreas (and their families) face many problems and an uncertain future. Coping with these problems may be easier when they can share their concerns in a support group and if they have help with home care. Your doctor or a social worker at your local hospital can refer you to appropriate sources of information and assistance.

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