Treatment Guide Pancreatic Disease CHOOSING YOUR CARE

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1 Treatment Guide Pancreatic Disease The pancreas is one of the body s great multi-taskers this dual-purpose organ is also a gland. Some people may not give much thought to the pancreas, especially those with normal pancreatic function. But for the 1.2 million Americans diagnosed with pancreatic disease each year, treatment decisions are crucial. CHOOSING YOUR CARE As the nation s rate of pancreatic disease continues to climb, Cleveland Clinic s Pancreas Clinic rises to the challenge of diagnosing and treating pancreasrelated diseases. The Pancreas Clinic, part of Cleveland Clinic s Digestive Disease Institute (DDI), specializes in multidisciplinary, patient-centered treatments and innovative research for all types of pancreatic diseases and disorders. Our clinic unites specialists from across Cleveland Clinic, including pancreatic surgeons, gastroenterologists, radiologists, anesthesiologists, psychologists and oncologists from Taussig Cancer Institute, when needed, who together work to customize the best possible treatment for patients and give them improved quality of life. This collaboration also means that patients get the care they need right away, rather than waiting for separate appointments with various specialists. U.S.News & World Report s America s Best Hospital s survey has ranked Cleveland Clinic #2 in the nation in gasteroenterology every year since Using this guide Please use this guide as a resource as you learn about pancreatic diseases, diagnoses and treatment options. As a patient, you have the right to ask questions and to seek a second option. pancreas clinic at the digestive disease institute

2 cleveland clinic pancreas disease treatment guide What is the pancreas? The pancreas is a dual-function, glandular organ located between the stomach and spine and next to the upper part of the small intestine (duodenum). Approximately six inches in length, this thin, pear-shaped organ is part of both the endocrine and digestive systems. The large end of the pancreas is called the head, the middle section the body, and the thin end the tail. The pancreas produces juices that contain enzymes and hormones. The main functions of the pancreas are to: Secrete enzymes into the small intestine to help digest carbohydrates, proteins, and fat Release the hormones insulin and glucagon into the bloodstream to help regulate blood sugar About the Digestive Disease Institute Of the top digestive centers in the United States, the Cleveland Clinic Digestive Disease Institute is the first of its kind to unite all specialists in gastroenterology and hepatology, colorectal surgery, general surgery (including hepato-pancreato-biliary and transplant surgery), and human nutrition within one unique, fully integrated model of care aimed at optimizing the patient experience. This exciting change also helps us offer the most advanced, safest and proven treatments performed in the most effective and patient-friendly way. This includes shorter waits for appointments and more seamless interactions with all of our specialists. In addition, our institute model enhances opportunities for cutting-edge research and physician education pancreas clinic at the digestive disease institute

3 pancreas disease treatment Guide cleveland clinic What are the different types of pancreatic diseases? The most common pancreatic diseases treated at Cleveland Clinic s Pancreas Clinic include acute pancreatitis, chronic pancreatitis and pancreatic cancer. Pancreatitis Pancreatitis is a painful inflammation of the pancreas. Pancreatic damage occurs when digestive enzymes attack the pancreas. In severe cases, pancreatitis can cause loss of blood flow to the gland, leading to serious tissue damage, infection and cyst formation. Severe pancreatitis can cause damage if enzymes and toxins are released into the bloodstream and harm other vital organs, such as the heart, lungs and kidneys. Typically, pancreatitis develops gradually and becomes progressively worse. There two forms of pancreatitis: acute and chronic. Acute pancreatitis is a sudden inflammation of the pancreas that occurs over a short period of time. More than 80 percent of acute pancreatitis cases are caused by heavy alcohol use or gallstones. In the latter case, gallstones passing from the gallbladder can become lodged at the ampulla (opening to the ducts that drain the gallbladder and pancreas). This blockage causes an obstruction of the pancreatic duct. Pancreatic juices can then back up into the pancreas and lead to acute pancreatitis. Symptoms of acute pancreatitis range from mild abdominal discomfort to a severe, life-threatening illness. Other less common causes of acute pancreatitis include: Altered pancreatic anatomy Medications Infections Trauma Metabolic disorders Autoimmune disease In approximately 10 percent of cases, the cause of acute pancreatitis is unknown. Chronic pancreatitis it is the result of ongoing inflammation of the pancreas and often occurs after multiple episodes of acute pancreatitis. In some cases, chronic pancreatitis is caused by prolonged, heavy alcohol use but it can also be caused by metabolic or genetic disorders. Though rare, chronic pancreatitis may run in families (hereditary pancreatitis). of note 122,000 Chronic pancreatitis results in more than 122,000 outpatient visits and 56,000 hospitalizations annually. What are the symptoms of pancreatitis? Most patients with acute pancreatitis experience upper abdominal pain that spreads to the back. Often described as a deep boring sensation, the pain is aggravated by eating and slowly worsens. Swollen and tender abdomen, nausea, sweating, vomiting, fever, and increased heart rate are other signs of acute pancreatitis. pancreas clinic at the digestive disease institute

4 cleveland clinic pancreas disease treatment guide Understanding Diagnostic Tests The Pancreas Clinic offers state-of-the-art diagnostic tests available, including: Abdominal ultrasound Detects gallstones and fluid from inflammation in the abdomen (ascites). Ultrasound can also show an enlarged common bile duct, an abscess, or a pseudocyst (a collection of tissue, fluid and pancreatic enzymes). Computed tomography (CT) Can help rule out other abdominal pain causes and determine if tissue is dying. CT can identify complications (fluid around the pancreas, abscess or pseudocyst.) Endoscopic retrograde cholangiopancreatography (ERCP) A tube is placed down the throat, into the stomach, then into the small intestine. Dye helps the doctor view the bile and pancreatic ducts on an X-ray. Endoscopic ultrasound - A scope is inserted down the throat into the stomach. Sound waves show abdominal organs and may reveal gallstones. Endoscopic ultrasound can help diagnose chronic pancreatitis when an invasive test might exacerbate the condition. Fecal elastase test Measures elastase (an enzyme found in the pancreas) in a stool sample to test how well the pancreas works. Magnetic resonance cholangiopancreatography A type of MRI used to view bile ducts and the pancreatic duct. Secretin pancreatic function test - Measures the ability of the pancreas to respond to the hormone secretin. How is pancreatitis diagnosed? In most cases, acute pancreatitis is suspected when a patient has the abovementioned symptoms coupled with risk factors, such as heavy alcohol use or gallstone disease. Measuring levels of amylase and lipase in the blood can confirm a pancreatitis diagnosis. High levels of these two enzymes strongly suggest acute pancreatitis. In general, chronic pancreatitis is suspected when a patient has abdominal pain compounded by risk factors such as: Heavy and prolonged alcohol use (can cause pancreas damage or scarring) Hereditary conditions Conditions such as high triglycerides or high calcium levels Tropical pancreatitis Pancreas divisum (two pancreas ducts rather than one, present at birth) Diagnosing chronic pancreatitis can be difficult because its symptoms are similar to those of other conditions, like ulcer, gallstones, irritable bowel syndrome and pancreatic cancer. Cleveland Clinic specialists rely on a number of new diagnostic techniques including pancreatic function tests and imaging of the pancreas gland with a CT scan or EUS for accurate, chronic pancreatitis diagnoses. The Pancreas Clinic at Cleveland Clinic is one of a few healthcare facilities in the United States using endoscopic pancreatic function testing for diagnosing earlystage pancreatitis. How is pancreatitis treated? Most people suffering from acute pancreatitis require hospitalization, intravenous fluids and pain medication. For the 20 percent of patients who experience severe symptoms, admittance to an intensive care unit (ICU) is necessary. Severe pancreatitis can lead to loss of blood flow, causing infection, fluid collections, and damage to the heart, lungs or kidneys. Some cases of severe pancreatitis cause death of pancreatic tissue (necrosis). In these cases, surgery may be necessary to remove the damaged pancreatic tissue. Despite the severity of the symptoms, 80 percent of patients diagnosed with acute pancreatitis recover completely. At the Cleveland Clinic s Pancreas Clinic, patients with acute pancreatitis benefit from the latest in endoscopic, minimally invasive and radiographic imaging for diagnosis and treatment of pancreatic inflammation. Just as chronic pancreatitis can be difficult to diagnose, it can be somewhat difficult to treat. Doctors will try to relieve the patient s pain and improve nutritional and metabolic problems that result from loss of pancreatic function. Patients with chronic pancreatitis may be prescribed: Pancreatic enzymes (taken at meals to help nutrient absorption) Pain medications Vitamin supplements Small, frequent meals pancreas clinic at the digestive disease institute

5 pancreas disease treatment Guide cleveland clinic In addition to the above medical intervention, endoscopy or surgery may be necessary to: Relieve abdominal pain Restore drainage of pancreatic secretions Treat chronic pancreatitis caused by blockage of the pancreatic duct Reduce the frequency of pancreatitis attacks Perform pain blocks Cleveland Clinic is one of a handful of centers performing total pancreatectomy and islet transplant for selected patients with chronic pancreatitis with no other surgical options. Pancreatic Cancer Pancreatic cancer is the tenth most common cancer in the United States. It is also the fourth deadliest. Approximately 37,000 people in the U.S. are diagnosed with pancreatic cancer annually. Pancreatic cancer is a malignant disease that starts in the ductal cells of the pancreas. The disease occurs when cells in the pancreas grow, divide, and spread uncontrollably, forming a malignant tumor. In addition to cancerous tumors, there also are a variety of benign (noncanceroous) tumors that can develop in the pancreas. Pancreatic cancer is known to spread silently, so in most cases, symptoms do not present themselves until the disease is in an advanced stage. Unfortunately, by this point, treatment options are limited. What are the symptoms of pancreatic cancer? Pancreatic cancer is known to spread silently, so in most cases, symptoms do not present themselves until the disease is in an advanced stage. Unfortunately, by this point, treatment options are limited. These symptoms often include: Jaundice (a yellowing of the skin and/or whites of the eyes) Upper abdominal pain that can radiate to the back Weight loss Nausea Vomiting Weakness and fatigue Some patients may experience additional, subtle symptoms including: Dark urine or light-colored stools Abdominal bloating Feelings of fullness with less-than-normal food intake Diarrhea pancreas clinic at the digestive disease institute

6 cleveland clinic pancreas disease treatment guide Who is at risk for pancreatic cancer? Though the exact cause of pancreatic cancer is unknown, several factors increase an individual s changes of developing the disease: Smoking (smokers are three to four times more likely to develop pancreatic cancer) Chronic pancreatitis Age (80 percent of pancreatic cancer occurs in people over age 50) Gender (more common in males) Family history (rare) Pancreatic cancer cannot be prevented, but the odds of developing the disease are reduced significantly by not smoking, maintaining a healthy weight and eating a plant-based diet. of note Clinical Trials Cleveland Clinic patients have access to clinical trials, should they qualify. This provides them treatments otherwise unavailable. To learn more, visit clevelandclinic.org/ddiresearch How is pancreatic cancer diagnosed? Once a patient history and physical exam are complete, imaging tests may be performed to help diagnose pancreatic cancer. Tumors may be visible on radiographic imaging, such as a CT (computed tomography) scan or MRI (magnetic resonance imaging). If scans do not reveal a tumor, but one is suspected, more invasive imaging, such as endoscopic ultrasound, may be used. For a definitive diagnosis of pancreatic cancer, a biopsy may be performed at the time of EUS. Types of pancreatic cancer Pancreatic cancer is classified by the specific part of the pancreas that is affected: the part that makes digestive secretions (exocrine) or the part that makes insulin and other hormones (endocrine). Exocrine pancreatic cancer - Cancer that forms in the pancreas ducts, called adenocarcinoma. Because the exocrine pancreas makes up 95 percent of the pancreas, the majority of pancreatic cancers (95 percent) are adenocarcinomas. Sometimes these cancers are called exocrine tumors. Other, less common, exocrine pancreatic cancers include adenosquamous, squamous cell, giant cell and acinar cell carcinomas. Endocrine pancreatic cancer - A rare cancer that forms in the hormone-producing cells of the pancreas (also called islet cells or islets of Langerhans). Cancer arising from one of these cells is called neuroendocrine pancreatic cancer or islet cell cancer. Some of these tumors are called nonfunctional because they are not hormonally active. Others secrete hormones and are named based on the hormones they produce (such as gastrinoma, insulinoma, etc.) pancreas clinic at the digestive disease institute

7 pancreas disease treatment Guide cleveland clinic What are the treatment options for pancreatic cancer? Treatment is based on how far the cancer has spread and generally includes the following options: Surgical treatment Surgery is still considered the gold standard treatment for cancer that has not spread outside the pancreas. Removing the tumor and surrounding tissue gives the best chance for cure for patients whose disease is localized. Your surgeon will determine whether a tumor is resectable (removable). Experience is critical to properly planning surgery and making sure that an appropriate treatment strategy and operation is chosen. Depending on the patient and their tumor, minimally invasive surgery (including laparoscopic and robotic surgery) is offered at Cleveland Clinic. How much tissue will be removed and what type of surgical approach will be used depends on where the tumor is located, its size, patient s body type/weight and any previous surgeries. Surgical resection of pancreatic cancer is generally performed as: Pancreaticoduodenectomy A pancreaticoduodenectomy (or Whipple procedure) is the most common surgical treatment for cancerous or benign tumors of the head of the pancreas. The procedure involves removal of the gallbladder, bile duct, part of the stomach and duodenum, and the head of the pancreas. Distal pancreatectomy This surgical option is used for cancers in the pancreatic tail and body. The procedure removes the tail of the pancreas, sometimes along with a small portion of the pancreatic body. Be Aware of all Your Options When combating a stealth disease like pancreatic cancer, our physicians and surgeons are armed with the latest medical technology and treatments. For example, we are one of the few U.S. medical facilities using robotic surgery for certain pancreatic cancers. This technology gives surgeons improved 3-D visualization and enhances their motion control. Also, patients who undergo robotic surgery recover in an average of four days instead of nine days after open surgery. of note Robotic surgery is a new technology that advances patient care. For example, patients recover in four days, on average, compared to nine days after open surgery. pancreas clinic at the digestive disease institute

8 cleveland clinic pancreas disease treatment guide Medical Treatment Medical treatment, including chemotherapy and radiation therapy, is often used to complement surgical treatment. It may be used before or following surgery, or when the tumor is advanced to extend life, if possible, or improve symptoms. Cleveland Clinic Taussig Cancer Institute doctors and nurses who specialize in cancer treatment can suggest ways to make side effects more manageable and to help relieve symptoms that may occur during and after procedures. Chemotherapy is the use of drugs that are designed to kill rapidly growing cells such as cancer cells. Chemotherapy may be injected directly into a vein (by IV, or intravenously) or given through a catheter, which is a thin tube placed into a large vein and kept there until it is no longer needed. Some chemotherapy drugs are taken by pill. This treatment affects both normal cells and cancer cells. Your doctors will try to prevent side effects as much as possible while treating the cancer appropriately. Side effects depend largely on the specific type of drug and the amount given. They can be different for each person and may only be temporary. Common side effects of chemotherapy include nausea and vomiting, hair loss, mouth sores and fatigue. Radiation therapy is a form of high energy X-ray that kills cancer cells. It is often used in conjunction with chemotherapy before or after surgery, and in cases where the cancer is limited to the pancreas. Treatment with radiation and chemotherapy is aimed at sterilizing cancer cells before an anticipated surgical resection, called neoadjuvant therapy. Treatment with chemoradiation to reduce the size of the tumor is rarely successful. Radiation therapy is a focused treatment, meaning it is designed to maximize its effect on the cancer cells while minimizing any injury to normal cells. Radiation to treat pancreatic cancer most often comes from a machine (external radiation). Patients may notice some skin changes in the area exposed to radiation. The skin may become red, warm and sensitive as if with a sunburn. It may also become darker and appear tanned. It may peel or become moist and tender. Depending on the dose of radiation given receive, there may be a loss of hair or decreased perspiration within the treated area. These skin reactions are common and temporary they will subside gradually within two to four weeks of completing treatment. What are the treatment options for islet cell tumors? Different types of treatments are available for patients with islet cell tumors, or cancer that forms in the hormone-producing cells (islet cells) of the pancreas. Some treatments are standard and some are being tested in clinical trials. Generally, five types of standard treatments are used: Surgery Types include enucleation, Whipple procedure, distal pancreatectomy, total gastrectomy, liver resection, radiofrequency ablation, or cryosurgical ablation Chemotherapy Drugs that kill cancer cells pancreas clinic at the digestive disease institute

9 pancreas disease treatment Guide cleveland clinic Hormone therapy Injections of hormones can help relieve symptoms Hepatic arterial occlusion or chemoembolization This treatment is not targeted at the primary tumor, but for cases when the cancer has spread to the liver. It employs drugs or other agents to block or reduce blood flow to liver through hepatic artery to kill the cancer cells growing in liver. Chemotherapy delivered during this procedure is called chemoembolization. Clinical trials For some patients, participating in a clinical trial may be the best treatment choice. Clinical trials are done to find out if new cancer treatments are safe and effective, or to see if they are better than the standard treatment. Many of today s standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment. Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move medical knowledge forward. Find out more about participating in any available pancreatic clinical trials by visiting clevelandclinic.org/ddiresearch. of note Our Pancreas Clinic focuses on delivering multidisciplinary and comprehensive treatments for our patients no matter what type of pancreatic health challenge they face, and with the goal of improving their quality of life. R. Matthew Walsh, MD, Chairman of General Surgery Innovations in treating pancreatic disease at DDI The Cleveland Clinic s Digestive Disease Institute (DDI) is a leader in advanced treatment options and medical research, research that may lead to new therapies for those living with pancreatic disease: Pancreaticoduodenectomy In 2009, DDI surgeons performed Cleveland Clinic s first robotic pancreaticoduodenectomy. Also known as the Whipple procedure, it is the most common and complex operation used to combat pancreatic cancer. It involves removing the pancreas head, the upper part of the small intestine (duodenum), and sometimes nearby lymph nodes. The success this robotic surgery catapults the Cleveland Clinic into a new era in the minimally invasive treatment of complex pancreatic disorders. Pancreatic cyst research Another groundbreaking development at the DDI is an experimental animal model to determine if pancreatic cysts can be removed without surgery. Though many pancreatic cysts are benign and symptom-free, some may become cancerous. DDI surgeons are investigating a non-surgical method of removing fluid from pre-cancerous cysts and injecting liquid to kill the cyst surface, eliminating the risk of cancer growth. Early cancer detection Perhaps the most promising Cleveland Clinic DDI research centers on a study to develop a new test for the early detection of pancreatic cancer. With a five-year survival rate of just one percent, pancreatic cancer patients face difficult odds. However, if caught in its early stages, the five-year survival rate can jump to 80 percent. Despite the prognosis of pancreatic cancer, the Cleveland Clinic s Digestive Disease Institute (DDI) is a beacon of hope for those living with the disease. State-of-the-art diagnostics and innovative treatments can help pancreatic cancer patients live longer and enjoy improved quality of life. pancreas clinic at the digestive disease institute

10 cleveland clinic pancreas disease treatment guide Why Choose Cleveland Clinic? Cleveland Clinic s Pancreas Clinic is one of the few centers in the nation that specializes in patient-centered treatments and frontline research for every type of pancreatic disorder. The Pancreas Clinic treats disorders such as complicated acute pancreatitis, chronic pancreatitis, and pancreatic cancer. Each year, more than 1,500 patients trust the Pancreas Clinic with their healthcare needs. In 2010, the Cleveland Clinic treated more than 350 patients chronic pancreatitis and nearly 500 patients with pancreatic cancer. The Digestive Disease Institute has been ranked No. 2 in the nation by U.S.News and World Report s since 2003 by its America s Best Hospitals survey. of note 1,500 With nearly 1,500 pancreatic patients seen annually, our physicians have vast experience with every type of pancreatic disorder. The Pancreas Clinic offers a single location for patients to receive the best therapies and treatment options for pancreatic disorders. Patients travel from around the country to receive our innovative treatments and services, including: Endoscopic, minimally invasive and radiographic diagnostic imaging Islet auto transplantation Robotic surgery for pancreatic cancer Robotic pancreaticoduodenectomy Chronic pain management using pancreatic enzymes, subcutaneous injections of octreotide, and other alternative treatments. Current Pancreas Clinic research may lead to the development of a new test for the early detection of pancreatic cancer. Working Together The Cleveland Clinic Pancreas Clinic, in collaboration with the Cleveland Clinic s Pain Management Department, offers various approaches to help patients with chronic pancreatitis who struggle with very painful and debilitating pain, which comes and goes for years and significantly impacts their quality of life and even their ability to work pancreas clinic at the digestive disease institute

11 pancreas disease treatment Guide cleveland clinic Our Staff Pancreatic surgeons, specialists and subspecialists work closely with DDI s gastroenterologists, surgeons, radiologists, anesthesiologists and psychologists and oncologists from Taussig Cancer Institute to deliver optimal treatments and follow-up care for every patient. Making an Appointment Call to make an appointment with any of our experts at Cleveland Clinic s Pancreas Clinic. Making Your Care Easier Patient Resource Center If your care brings you to Cleveland Clinic Taussig Cancer Institute, please visit the Patient Resource Center in the northeast corner of the building. It is a place for patients, their friends and families to come for cancer information.the Patient Resource Center is open from 8 a.m. to 5 p.m., Monday Friday. Medical Concierge If you are traveling from out of state and need any assistance, call the complimentary Medical Concierge at , ext , or MyChart This secure online tool connects patients to their own health information from the privacy of their home any time, day or night. Some features include renewing prescriptions, reviewing test results and viewing medications, all online. For the convenience of physicians and patients across the country, MyChart now offers a secure connection to Google Health. Google Health users can securely share personal health information with Cleveland Clinic, and record and share the details of their Cleveland Clinic treatment with the physicians and healthcare providers of their choice. To establish a MyChart account, visit clevelandclinic.org/mychart. Need a Second Opinion But Cannot Travel to Cleveland? Our MyConsult service offers secure online second opinions for patients who cannot travel to Cleveland. Through this service, patients enter detailed health information and mail pertinent test results to us. Then, Cleveland Clinic experts render an opinion that includes treatment options or alternative recommendations regarding future therapeutic considerations. To learn more about MyConsult, please visit clevelandclinic.org/myconsult. pancreas clinic at the digestive disease institute

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