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Pancreas – Hermit of the Abdomen

Pancreas – Hermit of the Abdomen

Ashley Davidoff MD

O’ Dear pancreas

You have been called the hermit of the abdomen
By whom I do not know
But in your dark and hidden way, you have
spoken without a word
from the gurgling depths of the abdomen
Yes – you have earned this lonely title
and a coin should be tossed
to the person who coined the phrase


 

But it took a long time to understand who this hermit was – and what he was doing in the darkness of the abdomen

From the day of antiquity
You have been looked upon by many
Herophilus, the father of anatomy had the first incisive insights into you
As he was one of very few who had the guts to explore the guts in open fashion

Aristotle at the same time seemed to have known something about you
But then you lay unharmed and unexplored for almost 500 years
Until Rufus mistook you for a piece of meat –
You must have laughed at the “pan kreas” thing
How wrong he was – you evasive little trickster

And then the Talmud – always seeming to be right
Thought you were the finger of the liver –
Little did they know how independant you were

While Vesalius was up to your “hide and seek” game
The magical eyes of da Vinci missed you completely
Even though he saw the serpiginous splenic artery snake right above you

Your ducts seemed to have intrigued the next generation, Wharton, Wirsung, and de Graaf
As you sustained the pain of the quill penetrating your inner gut
(I forget you were already dead but it must of hurt just watching!)

A little later it was that man called Vater and the little Italian Santorini found your minor duct and your nipple
And so by this time we had a good understanding of you in your nakedness
But of course, as said – you were dead

And so young Bernard explored your factories, and got a sense of your canine workings,
But you were able to hold on to your sweet secret for just a little longer
Until the Langerhans found the family jewels in the famous 2% of your population-
The islets – those beautiful eyelits – governess of all things sweet in the body

Eberle Bernard Danilevsky, and Kuhne joined up across the world to expose your antacid and enigmatic enzymatic brew
And once again your wonderful workings for a better world were exposed –
And we knew then, that you were the quiet and effective type –
A hermit who did good
But did not want the limelight

To see you as you lived and breathed in the flesh
was the mission of Wilhelm the X-Ray man
who crusaded the path to visualise 40,000 Angstroms under the skin

 

abdomen, pancreas, liver, gallbladder, kidneys, CT scan, Art in Anatomy, Ashley Davidoff MD

 

And then there was a slew of heroes who learned to slew your sickened parts – including the famous Whipple who was able to Whipple you in an inimitable way

And then a bone guy – for God’s sakes – a bone guy! – called Banting and his student Best
Exposed the insular chemistry of you insulin that had given you the power over the sweet
Never mind – in the end it was for the good of all –
And a new era was borne

And so we try to understand your form as our scans explore you as you live and breathe
And we stare in awe at your odd shape – why oh why did you choose that shape?
What are you supposed to look like? – we have no clue
And we are happy – so happy for you that you are well nourished by a double blood supply
And we wonder why you have no skin – we thought all the organs had a skin
Except for your tail – almost a foreskin

And you are off axis on two planes – what is that all about? – kinda crooked

And your twin origins and the intimacy with the duodenum, of the ventral twin
And the strange fusion of the Wirsung guy excluding the little Italian Santorini
It seems to me that your matrimonial fusion with Wirsung and the bile duct has led to more problems than the merger was worth
It does not seem in the long run, to have been a marriage made in heaven
What was that all about? Is there a grand plan to come?

 

And so we try to understand your diseases
And in some way we understand that the guy glugging down the bottle
Could be punished by your reaction
But why Oh why are you so nasty to those whose misfortune it is to have stones roll down and get no satisfaction.. down the green vile bile route
Have you not learned to live with the green secretion by now
And did you not know that by reacting the way you do, that you are cutting off your nose to spite you head?

While type 2 seems remote from you
We don’t know about this Type 1 business
Why are you made to suffer so much at the hands of your own body on your own body?
We feel sorry for you – to have your own buddies reject you – must be awful
And then to see so many young ones suffer because you don’t work
And we once again see and understand what power you control from that deep dark hermit home of yours

And the cancer thing … so silently it creeps on you causing your collagen to counter
And only making things worse as it strangles nerve, blood vessel, and your spouse duct – the green one, – without regard

And then I think of you in your prime and in your happiness
When you are with you two buddies – the splenic vein and the renal vein
And you all look so much alike, and happy swimming in that deep ocean where you hide
And I wish this was forever

 

 

Copyright 2017 Revised from previous publication in The Common Vein

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Anatomy of the Liver, Alcohol, and Addiction

The Liver – Just Another Normal Miracle of the Body

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24/7 Clockwork Purple 

The liver is the largest gland in the body and is central to many metabolic functions. It is known as the body’s “metabolic warehouse.”

The liver serves several important functions. It is integral to the digestive system, producing both internal and external secretions. The external secretion, bile, aids in the digestive process, while internal secretions are responsible for the metabolism of both nitrogenous and carbohydrate materials absorbed from the intestine.

Some of the liver’s functions take milliseconds and others take days and sometimes weeks. It secretes bile in order to  alter toxic substances chemically (e.g. converts ammonia to urea), converts glucose to glycogen, and can produce glucose from breaking down certain proteins. The liver also synthesizes triglycerides and cholesterol, breaks down fatty acids and produces plasma proteins necessary for the clotting of blood such as clotting factors I, III, V, VII, IX and XI. Nearly 30% of the blood pumped by the heart passes through the liver each minute.

One of the unique structural features of the liver is its dual blood supply. It is supplied both by an artery (hepatic artery) and a vein (yes a vein!) – the portal vein. The portal vein  drains the gastrointestinal tract of digested metabolic products and transports the nutrients to the liver for processing.

Four to five thousand  years ago, the sheep’s liver held godly powers in the Babylonian culture. The Babylonians, and many cultures thereafter, believed that since the liver was the largest organ, it certainly must be the organ of most importance.

The Cells

Hepatocytes are the major cellular component of the liver, comprising approximately 70% by volume. Structurally they are characterised by their large size and the absence of a basement membrane.  Functionally they are characterised by their remarkable metabolic and regenerative capability.  Kupffer cells are found within the space of Disse and they act as macrophages of the liver, identifying and removing substances and organisms toxic to the body.

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The Cells

The AiA rendering of cells in the round provide an image that is reminiscent of craters on the moon surface.  The thought process behind the image is the formation of tissues from cells.  The building of the whole from the parts starts with the cell and progresses to the tissue and finally the organ.  In this instance, groups of liver cells are artistically combined to form a tissue and an imaginary spherical organ.

Cellular Organization

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Organization of the Liver Cells in Cords Along the Rivers of Blood Flow

The liver  is a compound tubular serous gland. The cells are arranged in plates or cords alongside rivulets of a capillary network called  sinusoids.  The  spaces of Disse are spaces below the lining of the Kupffer cells. The plates and cords are lined by the sinusoids which are the channels which carry blood to the liver.  Just below the sinusoids, between the wall of the sinusoid and the capsule of the liver there is a space called the space of Disse which carries the lymphatic fluid of the liver.

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Organization of the Liver Cells in Cords in the Liver Lobule

The cells of the liver are organized in cords and plates and are organized like spokes of a wheel  around the central vein.  The periphery of the lobule contains  groups of portal triads consisting of portal vein (dark blue), hepatic artery (red) and bile duct (green).

The structural liver unit is called a lobule.  Cellular plates branch and anastomose alongside and in parallel with the sinusoids.  Each lobule measures 1-2mm and is shaped like a hexagon. A central venule lies at the center of the lobule and is the destination of the sinusoids, which carry both hepatic arteriole as well as portal venous blood.  At the periphery of the lobules are sets of portal triads consisting of portal vein, bile duct and hepatic artery.  The biliary system collects bile from the liver and evolves into an independent network terminating in the common bile duct which empties bile, into the duodenum.  The hepatic artery and portal vein supply the liver with metabolic substrates via the sinusoids, and also collect metabolic  products produced by the liver to transport to the rest of the body.

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Anatomy of the Liver in a Nutshell– 

From its Embryonic Beginnings to Full Member of the Society of the Body 

Pleasure

Alcohol – Drink of the Gods in Moderation and Poison of the Devil in Excess

Anatomy of the  Initial Positive Effects of Alcohol

“Drink because you are happy, but never because you are miserable.”
G.K. Chesterton, 

genitourinary tract, genitourinary system, uterus, woman, Art in Anatomy, Ashley Davidoff MD

Social Drinking: The Prostate Having a Drink with the Uterus

The uterus and prostate are out on a date and sharing a cocktail   The uterus approximates a rectangular shape as does the prostate, accounting for their fascination with each other and their similarity with the shape of the wine glass.  The uterus is accompanied by the ovaries and the vagina which forms the stem of the wine glass.  The prostate is accompanied by the Seminal vesicles and Cowper’s glands and the urethra which acts as the stem of the wine glass. The male secretion seen in the urethra consists of a mixture of sperm, prostatic secretions, and seminal vesicle secretions.

Social drinking to celebrate an event is a wonderful means to enable people to open up to each other  

As G.K. Chesterton wrote – “Drink because you are happy, but never because you are miserable.”  

William Shakespeare, in Othello, on the other hand wrote – “I would not put a thief in my mouth to steal my brains.”

Most cultures favor the use of alcohol in celebration of events, and the positive effects of alcohol when used judiciously is to promote a pleasurable feeling via the nucleus accumbens, and to reduce stressful feelings (often social interactions) by reducing inhibitions by acting on the amygdala

Anatomy of the Feeling of Pleasure and the Nucleus Accumbens

The nucleus accumbens is one of the most primitive part of the brain.  It is part of the  basal part of the forebrain.  It is a paired structure. Alcohol promotes pleasure by stimulating the nucleus accumbens.

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The Nucleus Accumbens

The coronal section of the brain shows the nucleus accumbens (ringed red) opposite its partner at the base of the brain.  It lies just inferior to the internal capsule and frontal horns, near the hypoyhalamus

Courtesy Department of Anatomy and Neurobiology at Boston University School of Medicine Dr. Jennifer Luebke , and Dr. Douglas Rosene

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Artistic Rendition of the Nucleus Accumbens on a sagittal T1 Weighted MRI

The nucleus accumbens, which is the site enabling the sensation of pleasure is shown as a red dot at the base of brain near the hypothalamus.

Stress

Anatomy of Stress and the Amygdala

The amygdalae are paired structures that are part of the limbic system that play an important part in emotional reactions including the reactions to stress.  Alcohol reduces the uncomfortable emotion of stress and distress.  Stress, in general is healthy, while distress on the other hand is not.  The distinction between the two is not always obvious.  Social situations are often stressful since in general people are “forced”into a position with “new” people they do not know too well.  Using alcohol in such a social situation disinhibits the individuals, reduces the feeling of stress and promotes a sense of social confidence.. The origin of the physiology is in the amygdala.

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Amygdala of the Forebrain in Sagittal Projection

The amygdala (red arrow)is a nucleus that is part of the limbic system.  It is a paired structure.  They are located deep in the temporal lobes and participate in emotional reactions, memory, and decision making.

 

Peer Pressure 

Stressful social situations are particularly prominent in adolescence when peer pressure is pervasive.  The college experience with new adventures of socialization,  combined with freedom from the constraints of paternal disciplines are ripe for the use of substance abuse.

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Peer Pressure

The scene: Party night – adolescent on the right, different innocent, alone and anxious. The in- crowd on the left are homogenous, powerful in number and stature, and encourage the newcomer to join in and be “one of us” – perhaps drink or smoke – and this is how it starts.
Educate, support, and love your children – Promote confidence in themselves so when they are confronted they can just say “no!”

Loneliness

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Loneliness

Alone and bored, some turn to alcohol to provide relief.  It is a short term, and short sighted relief to the problem

Early Addiction

Every form of addiction is bad, no matter whether the narcotic be alcohol or morphine or idealism.

Carl Jung

The signs of early addiction

There are a few early warning signs that are forebears of early addiction as they start to surface.

They include; drinking alone, hiding and lying about the habit, blacking out, neglecting responsibility, deteriorating relationships, drinking in dangerous circumstances (eg before driving) and inability to quit.

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Too Much of a Good Thing- can make your life tipsy turvy and turn you upside down –

shows bottles of alcohol in different positions and personify the state of inebriation.  Alcoholic intoxication is a form of poisoning, and can make your life tipsy turvy and turn you upside down. The art piece expresses the uncontrolled situation of inebriation.  When the liver cannot metabolize the alcohol due to excess in the blood stream drunkenness ensues. At lower blood levels there is a sensation of elation and lack of social reserve.  With higher levels of alcohol in the blood, cerebral and cerebellar dysfunction ensues with ataxia, imbalance and muscle incoordination.  Forebrain impairment includes disability to make appropriate decisions.  Coma and death can ensue when blood levels are extremely high.

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Drunk Man in the Town Square

A drunk man in the town plaza is toying with the idea of another swig.  His indifference to his environment, and lack of judgement suggests he is inebriated.  However his body language with an outstretched arm holding the bottle and the other hand pointed in another direction may suggest, at least idealistically, symbolically and hopefully subconsciously, that he realises he could go one of two ways “Decision time” he says to himself – “on the one hand I could take a swig .. Yet on the other I may take a different and more healthful course” Which way do you think he would go? (Photograph modified to enable anonymity) 

Cirrhosis

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Normal Liver and Cirrhosis

The left sided image shows the CT scan of a normal liver.  The liver is the biggest structure that you can appreciate on the CT scan and is triangular in shape. The scan on the right shows a liver with cirrhosis.  Alcohol pickles and scars the liver making it look like a knobby shrunken prune. The first image reflects healthy and romantic enjoyment of two people enjoying a beer at sunset. The colorful sunset transposes int a black and white background providing the mood of a lonely alcoholic. The alcoholic drinks in loneliness and in excess, until finally the person and the the bottle do not remain upright symbolically reflecting physical and psychosocial failure.

The Failing Liver

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Normal Liver and Cirrhosis and Ascites

The AiA rendering shows a normal liver on the left, and a person with cirrhosis on the right evidenced by a shrunken, knobbly and pickled liver, jaundice of the skin and a distended abdomen caused by the accumulation of litres of fluid (ascites). In the long run, the addiction results in much suffering, a miserable existence, and immediately life threatening hemorrhagic episodes.

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Alcoholism and Ascites

(Photograph modified to enable anonymity) 

Liver Cancer

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Liver Cancer 

Liver cancer, frequently arises as a complication of cirrhosis and most particularly from alcoholic cirrhosis. The  AiA rendering of the liver shows the inner workings of the organ, now inhibited by the large yellow cancer preventing the clockwork function of the liver. The liver starts to fail as a result of the cirrhosis so that the synthesis of biochemical products that  keep the body going are no longer produced to the degree which they are needed.

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Wasting of Body and Life 

The collage shows normal healthy liver cells (top left) with a healthy appearing torso (CT scan  reconstruction bottom left).  The top right image reflect cancerous hepatic cells where the nuclear to cytoplasmic ratio is too large meaning that the the nuclei are too big and the cytoplasm too scanty.  This finding is one of the typical findings in cancer.  An emaciated torso (bottom right) is seen in contrast to the healthy counterpart.

Artistically the stark reality of health and disease is exposed.  This terrible disease stares at us in stark graphic reality.

Philosophically – the cancer cell is like a rebel in the community, who only has selfish interests and contributes nothing to the welfare of the community.  As a result the whole community of the body  eventually fails, and hence the emaciation of the body.

Lessons?  Kick the Habit Early  or Kick the Bucket

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Art of Anatomy of the Pancreas

Art of Anatomy of the Pancreas

Introduction

Ashley Davidoff MD Copyright 2015

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Pancreas in the Sky

is a photograph that shows a cloud formation embodying the shape of a pancreas

The anatomy of the pancreas is unusual and the physiology is multifaceted.  It is  a gland and is part of both the digestive and hormonal systems of the body.  Structurally it is characterised by its unusual shape and position and the absence of a capsule.  Functionally it is involved in the digestion of food as well as in the metabolism of glucose.  The most common diseases include pancreatitis, pancreatic carcinoma and diabetes. Serum tests, ultrasound, CT scan, MRI and endoscopy are most commonly used in diagnosis of pancreatic disease.  Treatment options include medical treatment (eg insulin in type 1 diabetes) minimally invasive procedures, and surgery.

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“Pancreas in Pink” 

is artwork derived from a CT scan and shows the upper abdominal cavity with the pancreas in bright pink surrounded by the liver, gallbladder, and kidneys. The aorta and inferior vena cava are the major transport vessels and serve to connect the organs.

Structure

Unusual Shape

“…and we stare in awe at your odd shape – why oh why did you choose that shape?
What are you supposed to look like? – we have no clue”  

from  “Hermit of the Abdomen” 

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Shapes of the Pancreas

The pancreas has been compared to many objects including an elongated comma on its side, an elongated number 9 on its side, a prism, a banana, an inverted and curved upside down tobacco pipe, and even an old fashioned revolver. Placing a seahorse or a woodpecker with head down and tail up probably brings us closest to the complex shape of the pancreas. The objects used for description are so varied and disparate, that one wonders if we truly have a grasp of the shape of this organ. A more practical way to look at the shape of the organ is to define the shape of its component parts.

Structure – Position

Deep in the Abdomen in the Retroperitoneum

The pancreas lies in the anterior pararenal space of the retroperitoneum surrounded by a vertebral body and kidneys posteriorly, the liver and gall bladder to its right, the spleen to its left, and the stomach and left lobe of the liver in front.  This AiA rendering shows the pancreas cycling through the seasons.  In the  spring it is in shades of  pink, the summer in blue, the fall in  red, and in the winter in ice blue and white. 

Function

The pancreas has dual functions in the the metabolism of the body.  It acts as an as both an exocrine gland (secretes into ducts) and an endocrine gland (secretes into the circulation).

As an exocrine gland it secretes enzymes into ducts that lead to the duodenum.  These enzymes aid in the digestion of fat, proteins, and carbohydrates. As an endocrine gland it is a key player in the control of glucose metabolism which it accomplishes by secreting insulin into the circulation.

The acini are the microscopic glands making up 98% of the parenchyma and they function as the exocrine component.

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“Blueberries of the Glands of the Pancreas”

is a rendering of the histological appearance of the pancreatic acinar glands. The artpiece  illustrates the ductules that subtends the acini  which are the exocrine glandular cells. The shape of the acinar cells and ductules are reminiscent of grapes or berries on a stalk.

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“Histology of the Glands of the Pancreas”  

The exocrine hormones of the pancreas that aid in the digestion of fats, proteins and carbohydrates are produced in the acinar cells in the glandular unit called the acinus.  The art piece shows the acinus with acinar cells and the duct that transports the secretions to the pancreatic duct and eventually to the duodenum where they aid in the digestion of proteins fats and carbohydrates.

The islets of Langerhans secrete insulin into the blood stream, very soon after ingestion of a meal in order to control blood sugar and intracellular glucose concentrations. The endocrine cells called the islets of Langerhans represent only 1-2% of the tissue volume of the pancreas, but play a vital role in body function and well being. They are most numerous in the tail of the pancreas.

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Islets of Langerhans

Immunohistochemistry on mouse pancreas for insulin shows the brown stained Islets of Langerhans that secrete insulin among the acinar cells.  They represent only 2% of the population of pancreatic cells. 

(Modified  Image –  Courtesy  Billyboy Wikipedia Public Domain)

Diseases

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Acute Necrotic Pancreatitis

This is a CT of an elderly man who had severe pancreatitis.  Within the retroperitoneum there is necrotic pancreas (asterisk).  It is enlarged and consists mostly of air (arrow), fluid, and high density hemorrhagic components.  The findings are consistent with a gangrenous pancreatic abscess.  The surgeon noted that the pancreas looked and smelled like a “dead fish…. that had been dead for quite a long time.”  Other structures including the gallbladder(gb), liver, kidneys, spleen and stomach surround the pancreas

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Pancreatic Cancer with Spread to the Liver

The CT scan shows a primary pancreatic cancer (red asterisk) with metastases to the liver.  Four of many metastases are identified with white asterisks

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Normal Pancreatic Cells and Pancreatic Cancer Cells

In the upper image the cellular makeup of the acinar cells of the pancreas manifest with a normal nuclear to cytoplasmic ratio reflecting the relative size of the nucleus to the cytoplasm.   The 2nd image show cancerous cells of the exocrine pancreas.  The blue nuclii are far too large for the amount of the cytoplasm of the cell (abnormal nuclear to cytoplasm ratio).  The malignant cells are also too dark (hyperchromatic) and lack uniformity and organization.  These are all features of malignant cells .  Cancerous cells do not obey the rules of the body and  have no regard for the body at large. Malignant cells are equivalent to rebels in the community. They destroy and do not contribute to the wellbeing of the society.  They also invade the territory of neighboring structures.

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Ravages of Diabetes 

The foot of a person with diabetes following amputation of the 2nd, 3rd, and 4th digits as a result of poor circulation of the tissues.  The magnified view shows the calcification and hardening of the arteries. 

Diagnosis

“Doppler Ultrasound of the Pancreas-Hermit of the Abdomen”

shows the pancreas in black in front of the splenic vein

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“ERCP – Ductal Skeleton of the Pancreas”

is from an ERCP with an injection into normal the dorsal pancreatic duct of Wirsung with contrast also noted in the distal common bile duct

“Arteries of the Pancreas”

is from an angiogram of the celiac axis and shows the multiple arteries that supply the pancreas.  The head of the pancreas is supplied by the  superior pancreatico-duodenal vessels which arises from the gastroduodenal artery,  and inferior pancreatico-duodenal artery which arises from the SMA.  The body is supplied by the splenic artery and the superior mesenteric artery.

Treatment

Treatment options include medical treatment (eg insulin in type 1 diabetes) minimally invasive procedures for drainage and relief of obstruction, and surgery.

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3D Nuclear Magnetic Resonance Structure  of Insulin Dimer

(Modified from public domain image from Wikipedia and Courtesy Jawahar Swaminathan Jawahar Swaminathan and MSD staff at the European Bioinformatics Institute) 

“And then a bone guy – for God’s sakes – a bone guy! – called Banting and his student Best
exposed the insular chemistry of your insulin that had given you the power over the sweet
Never mind – in the end it was for the good of all –
And a new era was born 

from “Hermit of the Abdomen” Davidoff

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Pancreas and Buddies

This aquatic scene shows the relationship of the pancreas to its neighbours particularly the splenic vein and left renal vein which run a parallel course, almost like a bunch of buddies romping in the water.  The arching bodies with heads all in the same direction is quite beautiful

And then I think of you in your prime and in your happiness
When you are with your two buddies – the splenic vein and the renal vein
And you all look so much alike, and happy swimming in that deep ocean where you hide
And I wish this was forever”

from “Hermit of the Abdomen” Davidoff

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