1. Diseases of the Pancreas
Victor Politi, M.D., Medical Director
SVCMC, School of Allied Health Professions, Physician Assistant Program

2. Pancreas anatomy
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).

4. Pancreas anatomy The pancreas is made up of two types of tissue:
exocrine tissue
The exocrine tissue secretes digestive enzymes. These 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.

6. Pancreas anatomy The pancreas has digestive and hormonal functions:
The enzymes secreted by the exocrine tissue in the pancreas help break down carbohydrates, fats, and proteins 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 bicarbonate to neutralize stomach acid in the duodenum.

7. Pancreas anatomy
The hormones secreted by the endocrine tissue in the pancreas are insulin, glucagon (which regulate the level of glucose in the blood), somatostatin (which prevents the release of the other two hormones), and many others.

8. What is Pancreatitis?
Pancreatitis is an inflammatory process in which pancreatic enzymes autodigest the gland

9. Normally, digestive enzymes do not become active until they reach the small intestine, where they begin digesting food.
But if these enzymes become active inside the pancreas, they start "digesting" the pancreas itself

11. The gland can sometimes heal without any impairment of function or any morphologic changes.
This process is known as acute pancreatitis.
It can recur intermittently, contributing to the functional and morphologic loss of the gland.
Recurrent attacks are referred to as chronic pancreatitis.

12. Acute pancreatitis occurs suddenly and lasts for a short period of time and usually resolves.
Chronic pancreatitis does not resolve itself and results in a slow destruction of the pancreas.

13. Either form can cause serious complications.
In severe cases, bleeding, tissue damage, and infection may occur.
Pseudocysts, accumulations of fluid and tissue debris, may also develop.
Enzymes and toxins may enter the bloodstream, injuring the heart, lungs, and kidneys, or other organs.

14. Acute edematous pancreatitis
Since the pancreas is located in the retroperitoneal space with no capsule -inflammation can spread easily.
In acute pancreatitis, parenchymal edema and peripancreatic fat necrosis occur first.
This process is known as acute edematous pancreatitis

15. Necrotizing pancreatitis
When necrosis involves the parenchyma, accompanied by hemorrhage and dysfunction of the gland, the inflammation evolves into hemorrhagic or necrotizing pancreatitis

17. Necrotizing pancreatitis
Pseudocysts and pancreatic abscesses can result from necrotizing pancreatitis because of enzymes being walled off by granulation tissue (ie, pseudocyst formation) or bacterial seeding of pancreatic or peripancreatic tissue (ie, pancreatic abscess formation).
An ultrasound or, preferably, a CT scan can be used detect both.

19. The inflammatory process can cause systemic effects because of the presence of cytokines, such as bradykinins and phospholipase A.
These cytokines may cause vasodilation, increase in vascular permeability, pain, and leukocyte accumulation in the vessel walls.
Fat necrosis may cause hypocalcemia.
Pancreatic B cell injury may lead to hyperglycemia.

20. Mortality/Morbidity
Although acute pancreatitis should be noted, chronic pancreatitis has a more severe presentation as episodes recur.
Acute respiratory distress syndrome (ARDS), acute renal failure, cardiac depression, hemorrhage, and hypotensive shock all may be systemic manifestations of acute pancreatitis in its most severe form.

21. Acute Pancreatitis
Some people have more than one attack and recover completely after each, but acute pancreatitis can be a severe, life-threatening illness with many complications.

22. Acute Pancreatitis
About 80,000 cases occur in the United States each year; some 20 percent of them are severe.
Acute pancreatitis occurs more often in men than women.

23. The risk for African American persons aged 35-64 years is 10 times higher than for any other group.
African American persons are at higher risk than white persons in that same age group

24. History
The main presentation of acute pancreatitis is epigastric pain or right upper quadrant pain radiating to the back
The pain may be severe and may become constant--just in the abdomen-or it may reach to the back and other areas.
It may be sudden and intense or begin as a mild pain that gets worse when food is eaten.

25. History Nausea and/or vomiting Fever
Query the patient about recent surgeries and invasive procedures (ie, endoscopic retrograde cholangiopancreatography) or family history of hypertriglyceridemia.
Patients frequently have a history of previous biliary colic and binge alcohol consumption, the major causes of acute pancreatitis.

26. Physical Tachycardia Tachypnea Hypotension Fever
Abdominal tenderness, distension, guarding, and rigidity

27. Physical Mild jaundice Diminished or absent bowel sounds
Because of contiguous spread of inflammation (effusion) from the pancreas, lung auscultation may reveal basilar rales, especially in the left lung.
Occasionally, in the extremities, muscular spasm may be noted secondary to hypocalcemia.

28. Physical
Severe cases may have a Grey Turner sign (ie, bluish discoloration of the flanks) and Cullen sign (ie, bluish discoloration of the periumbilical area) caused by the retroperitoneal leak of blood from the pancreas in hemorrhagic pancreatitis.

29. This is Grey-Turner's sign with haemorrhage appearing in both flanks
This is Grey-Turner's sign with haemorrhage appearing in both flanks. It is due to extensive retro-peritoneal bleeding and typically occurs in haemorrhagic pancreatitis

30. Causes
The major causes are long-standing alcohol consumption and biliary stone disease.

31. Causes
In developed countries, the most common cause of acute pancreatitis is alcohol abuse
On the cellular level, ethanol leads to intracellular accumulation of digestive enzymes and their premature activation and release.
On the ductal level, ethanol increases the permeability of ductules, which allow enzymes to reach the parenchyma, resulting in pancreatic damage

32. Causes
Ethanol increases the protein content of the pancreatic juice and decreases bicarbonate levels and trypsin inhibitor concentrations. This leads to the formation of protein plugs that block the pancreatic outflow and obstruction

33. Causes
Another major cause of acute pancreatitis is biliary stone disease (eg, cholelithiasis, choledocholithiasis).
A biliary stone may lodge in the pancreatic duct or ampulla of Vater and obstruct the pancreatic duct, leading to extravasation of enzymes into the parenchyma.

34. Minor causes of acute pancreatitis
Medications,
including azathioprine, corticosteroids, sulfonamides, thiazides, furosemides, NSAIDs, mercaptopurine, methyldopa, and tetracyclines
Endoscopic retrograde cholangiopancreatography (ERCP)
Hypertriglyceridemia
(When the triglyceride (TG) level exceeds 1000 mg/U, an episode of pancreatitis is more likely.)
Peptic ulcer disease

35. Minor causes of acute pancreatitis
Abdominal or cardiopulmonary bypass surgery
may insult the gland by ischemia
Trauma to the abdomen or back
resulting in sudden compression of the gland against the spine posteriorly
Carcinoma of the pancreas
which may lead to pancreatic outflow obstruction
Viral infections, including mumps, Coxsackievirus, cytomegalovirus (CMV), hepatitis virus, Epstein-Barr virus (EBV), and rubella
Bacterial infections
such as mycoplasma

36. Minor causes of acute pancreatitis
Intestinal parasites, such as ascaris, which can block the pancreatic outflow
Pancreas divisum
Scorpion and snake bites
Vascular factors, such as ischemia or vasculitis

37. Acute Pancreatitis - Diagnosis
History
Physical exam
Lab Studies
During acute attacks, the blood contains at least three times more amylase and lipase than usual. Amylase and lipase are digestive enzymes formed in the pancreas.
Changes may also occur in blood levels of glucose, calcium, magnesium, sodium, potassium, and bicarbonate.
After the pancreas improves, these levels usually return to normal.

38. Acute Pancreatitis - Diagnosis
Imaging Studies
X-ray
ultrasound CT

39. Lab Studies
A complete blood count (CBC) demonstrates leukocytosis (WBC >12000) with the differential being shifted towards the segmented polymorphs.
If blood transfusion is necessary, as in cases of hemorrhagic pancreatitis, obtain type and crossmatch.
Measure blood glucose level because it may be elevated from B cell injury in the pancreas.
Obtain measurements for BUN, creatine (Cr), and electrolytes (Na, K, Cl, CO2, P, Mg); a great disturbance in the electrolyte balance is usually found, secondary to third spacing of fluids

40. Lab Studies
Measure amylase levels, preferably the Amylase P, which is more specific to pancreatic pathology. Levels more than 3 times higher than normal strongly suggest the diagnosis of acute pancreatitis
Lipase levels also are elevated and remain high for 12 days. In patients with chronic pancreatitis (usually caused by alcohol abuse), lipase may be elevated in the presence of a normal serum amylase level

41. Lab Studies
Perform liver function tests (eg, alkaline phosphatase, serum glutamic-pyruvic transaminase [SGPT], serum glutamic-oxaloacetic transaminase [SGOT], G-GT) and bilirubin, particularly with biliary origin pancreatitis.
In chronic pancreatitis the enzymes may be normal or low due to pancreas burn out

42. Imaging Studies
Perform a plain KUB (Kidneys, ureters, bladder) with the patient in the upright position to exclude viscus perforation (ie, air under the diaphragm).
In cases with a recurrent episode of chronic pancreatitis, peripancreatic calcifications may be noted.

43. Imaging Studies Ultrasound can be used as a screening test.
If overlying gas shadows secondary to bowel distention are present, it may not be specific.

44. Imaging Studies
CT scan is the most reliable imaging modality in the diagnosis of acute pancreatitis.

45. Pancreatitis, Acute - CT Scan

46. Pancreatitis, Chronic - CT Scan

47. Treatment Treatment depends on the severity of the attack.
If no kidney or lung complications occur, acute pancreatitis usually improves on its own.
Treatment, in general, is designed to support vital bodily functions and prevent complications.

48. Treatment
Most of the cases presenting to the ED are treated conservatively, and approximately 80% respond to such treatment

49. Treatment Fluid resuscitation
Monitor accurate intake/output and electrolyte balance of the patient.
Crystalloids are used, but other infusions, such as packed red blood cells (PRBCs), are occasionally administered, particularly in the case of hemorrhagic pancreatitis.
Central lines and Swan-Ganz catheters are used in patients with severe fluid loss and very low blood pressure.

50. Treatment
Patients should have nothing by mouth, and a nasogastric tube should be inserted to assure an empty stomach and to keep the GI system at rest.
Begin parenteral nutrition if the prognosis is poor and if the patient is going to be kept in the hospital for more than 4 days.

51. Treatment
Analgesics are used to relieve pain. Meperidine is preferred over morphine because of the greater spastic effect of the latter on the sphincter of Oddi.
Antibiotics are used in severe cases associated with septic shock or when the CT scan indicates that a phlegmon of the pancreas has evolved.

52. Treatment
Other conditions, such as biliary pancreatitis associated with cholangitis, also need antibiotic coverage.
The preferred antibiotics are the ones secreted by the biliary system, such as ampicillin and third generation cephalosporins.

53. Treatment
Continuous oxygen saturation should be monitored by pulse oxymetry and acidosis should be corrected. When tachypnea and pending respiratory failure develops, intubation should be performed.
Perform CT-guided aspiration of necrotic areas, if necessary.
An ERCP may be indicated for common duct stone removal

54. Treatment Surgical Consult For phlegmon of the pancreas
Hemorrhagic pancreatitis
Patients who fail to improve despite optimal medical treatment
Patients who push the Ranson score even further
Biliary pancreatitis

55. Medications Antibiotics
Used to cover the microorganisms that may grow in biliary pancreatitis and acute necrotizing pancreatitis.
The empiric antibiotic regimen usually is based on the premise that enteric anaerobic and aerobic gram-bacilli microorganisms are often the cause of pancreatic infections.
Once culture sensitivities are made, adjustments in the antibiotic regimen can be done.

56. Antibiotics Analgesics Ceftriaxone (Rocephin), Unasyn, Mefoxitin
Ampicillin (Marcillin, Omnipen),Gent, Flagyl
Analgesics
Meperidine (Demerol)

57. Ranson Scale
Ranson developed a series of different criteria for the severity of acute pancreatitis
For the following catagories-
answer each question regarding the patient then add up total score for prognosis
If answer is no (o point)
If answer is yes (1 point)

58. Ranson Scale Present on admission Older than 55 years
WBC higher than 16,000 per mcL
Blood glucose higher than 200 mg/dL
Serum lactate dehydrogenase (LDH) more than 350 IU/L
SGOT (ie, aspartate aminotransferase [AST]) greater than 250 IU/L

59. Ranson Scale Developing during the first 48 hours
Hematocrit fall more than 10%
BUN increase more than 8 mg/dL
Serum calcium less than 8 mg/dL
Arterial oxygen saturation less than 60 mm Hg
Base deficit higher than 4 mEq/L
Estimated fluid sequestration higher than 600 mL

60. Ranson Score A Ranson score of 0-2 has a minimal mortality rate.
A Ranson score of 3-5 has a 10%-20% mortality rate.
A Ranson score higher than 5 has a mortality rate of more than 50% and is associated with more systemic complications

61. Other Disorders of the Pancreas

62. Pancreatic Cancer
Pancreatic cancer is the fourth most common cancer in men and women in the US, according to the American Cancer Society.
The majority of pancreatic cancer occurs in people 50 years of age or older

63. In the United States, approximately 30,000 people die of pancreatic cancer each year.
Among cancers of the gastrointestinal tract, it is the third most common malignancy and the fifth leading cause of cancer-related mortality.

64. About 95% of cancerous tumors of the pancreas are adenocarcinomas.
Adenocarcinomas usually originate in the glandular cells lining the pancreatic duct.
Most adenocarcinomas occur in the head of the pancreas, the part nearest the first segment of the small intestine (duodenum).

65. Adenocarcinoma usually does not develop before age 50; the average age at diagnosis is 55.
These tumors are nearly twice as common in men as in women and are slightly more common in blacks than in whites.
Adenocarcinoma of the pancreas is 2 to 3 times more common in heavy smokers than in nonsmokers.
People with chronic pancreatitis are at greater risk as well

66. The disease is difficult to diagnose in its early stages, and most patients have incurable disease by the time they present with symptoms.
The overall 5-year survival rate for this disease is less than 5%.

67. Pancreatic cancers can arise from both the exocrine and endocrine portions of the pancreas.
Of pancreatic tumors, 95% develop from the exocrine portion of the pancreas, including the ductal epithelium, acinar cells, connective tissue, and lymphatic tissue.
Approximately 75% of all pancreatic carcinomas occur within the head or neck of the pancreas

68. Typically, pancreatic cancer first metastasizes to regional lymph nodes, then to the liver, and less commonly, to the lungs. It can also directly invade surrounding visceral organs such as the duodenum, stomach, and colon.

69. As in other organs, chronic inflammation is a predisposing factor in the development of pancreatic cancer.
Patients with chronic pancreatitis from alcohol, especially those with familial forms, have much higher incidence and an earlier age of onset of pancreatic carcinoma.

70. Cystadenocarcinoma
Cystadenocarcinoma of the pancreas is a rare type of pancreatic cancer that develops from a fluid-filled noncancerous tumor called a cystadenoma.
It often causes upper abdominal pain and may grow large enough for a doctor to feel it through the abdominal wall.

72. Mortality/Morbidity
Pancreatic carcinoma is unfortunately usually a fatal disease.
Most patients eventually succumb to the consequences of local invasion and metastatic cancer, and true long-term cures are rare.
Endocrine and cystic neoplasms of the pancreas have much better survival rates than pancreatic adenocarcinoma.

73. History
Unfortunately, the initial symptoms are often quite nonspecific and subtle in onset.
Patients typically report the gradual onset of nonspecific symptoms such as anorexia, malaise, nausea, fatigue, and midepigastric or back pain.
Significant weight loss is a characteristic feature of pancreatic cancer.

74. History
Pain is the most common presenting symptom in patients with pancreatic cancer.
Typically, it is midepigastric in location, with radiation of the pain sometimes occurring to the mid- or lower-back region.

75. History
The most characteristic sign of pancreatic carcinoma of the head of the pancreas is painless obstructive jaundice.
Patients with this sign may come to medical attention before their tumor grows large enough to cause abdominal pain.
Pruritus may accompany obstructive jaundice.

76. History
Migratory thrombophlebitis (ie, Trousseau sign) and venous thrombosis also occur with higher frequency in patients with pancreatic cancer.
Depression is reported to be more common in patients with pancreatic cancer than in patients with other abdominal tumors.
In some patients, depression may be the most prominent presenting symptom.

78. Physical
The physical examination findings in a patient with pancreatic cancer are usually limited to evidence of significant weight loss and some mild-to-moderate midepigastric tenderness.
Patients with jaundice may have a palpable gallbladder (ie, Courvoisier sign) and may have evidence of skin excoriations from pruritus.

79. Physical
Patients presenting with end-stage disease may have ascites, a palpable abdominal mass, hepatomegaly from liver metastases, or splenomegaly from portal vein obstruction.

80. Labs
The laboratory findings in patients with pancreatic cancer are usually nonspecific.
As with many chronic diseases, a mild normochromic anemia may be present.
Thrombocytosis is also sometimes observed in patients with cancer.
The major useful tumor marker for pancreatic carcinoma is carbohydrate antigen 19-9 (CA 19-9).

81. Gross section of an adenocarcinoma of the pancreas measuring 5 X 6 cm resected from the pancreatic body and tail. Although the tumor was considered to have been fully resected and had not spread to any nodes, the patient died of recurrent cancer within 1 year

82. CTshowing a pancreatic adenocarcinoma of the pancreatic head
CTshowing a pancreatic adenocarcinoma of the pancreatic head. The gallbladder (gb) is distended because of biliary obstruction. The superior mesenteric artery (sma) is surrounded by tumor, making this an unresectable T4 lesion.

83. Treatment
The only therapy that has definitively been shown to increase the survival of patients with pancreatic cancer is surgical resection.
For patients with disease not amenable to curative resection, little has been shown to significantly impact survival.
The mean survival for patients with unresectable disease remains 4-6 months.

84. Treatment
Other therapies for pancreatic cancer should include palliation of the major symptoms of disease.
Chemotherapy
Radiation therapy

85. Pancreaticoduodenectomy (Whipple operation)
The standard operation for carcinoma of the head of the pancreas is a pancreaticoduodenectomy (Whipple procedure).
This operation involves resection of the pancreatic head; the first, second, and third portions of the duodenum; the distal antrum; and the distal common bile duct

86. Deterrence/Prevention
Smoking is the most significant reversible risk factor for pancreatic cancer. Estimates indicate that smoking accounts for up to 30% of cases of pancreatic cancer.
A diet high in energy intake and low in fresh fruits and vegetables increases the risk of pancreatic cancer.
Alcohol consumption does not increase the risk of pancreatic cancer unless it leads to chronic pancreatitis. A multicenter study of more than 2000 patients with chronic pancreatitis showed a 26-fold increase in the risk of developing pancreatic cancer.

87. Prognosis
The mean survival for patients with unresectable disease remains 4-6 months, with a 5-year survival rate of less than 3%.
The median survival for patients who undergo successful resection (only 20% of patients) is approximately months, with a 5-year survival rate of 15-20%.
Although discouraging, these results are still markedly better than those for patients with unresectable pancreatic carcinoma.

88. Management
The management of pancreatic carcinoma is a multidisciplinary process.
Most patients initially present to their primary care practitioner with general symptoms such as abdominal pain, weight loss, or fatigue.
Patients may also be seen initially by a gastroenterologist if they present with obstructive jaundice.
Typically, the management of pancreatic cancer would entail consultations with a gastroenterologist, medical oncologist, general surgeon or surgical oncologist, and possibly a radiation oncologist.

89. Benign Tumors of the Pancreas
Insulinoma –
rare pancreatic tumor
secretes insulin
10% cancerous
Gastrinoma –
secretes above average levels of gastrin
can cause peptic ulcers
50% cancerous
Glucagonoma –
secretes glucagon
Causes rash
80% cancerous

90. Insulinoma
An insulinoma is a rare type of pancreatic tumor that secretes insulin, a hormone that lowers the levels of sugar (glucose) in the blood.
Only 10% of insulinomas are cancerous.

91. Insulinoma Symptoms result from low levels of sugar in the blood.
The symptoms include faintness, weakness, trembling, awareness of the heartbeat (palpitations), sweating, nervousness, and profound hunger.
Other symptoms include headache, confusion, vision abnormalities, unsteadiness, and marked changes in personality.
The low levels of sugar in the blood may even lead to a loss of consciousness, seizures, and coma.

92. Insulinoma
Very low levels of sugar and high levels of insulin in the blood can indicate the presence of an insulinoma.
The location must be pinpointed. Imaging tests—such as CT, ultrasound, and arteriography of the intestinal arteries—can be used to locate the tumor, but sometimes exploratory surgery is needed

93. Insulinoma
The primary treatment for an insulinoma is surgical removal - cure rate of about 90%.
When the insulinoma cannot be completely removed and symptoms continue, several drugs (for example, streptozocin (Zanosar) and octreotide (Sandostatin)can be helpful

95. GASTRINOMA
A gastrinoma is a tumor usually in the pancreas or duodenum (the first segment of the small intestine) that produces excessive levels of the hormone gastrin, which stimulates the stomach to secrete acid and enzymes, causing peptic ulcers.

96. GASTRINOMA
Most people with gastrinomas have several tumors clustered in or near the pancreas.
About half of the tumors are cancerous.
Sometimes a gastrinoma occurs as part of multiple endocrine neoplasia, a hereditary disorder in which tumors arise from the cells of various endocrine glands, such as the insulin producing cells of the pancreas.

97. GASTRINOMA
The excess gastrin secreted by the gastrinoma causes Zollinger-Ellison syndrome (ZES)
a rare disorder that causes tumors in the pancreas and duodenum and aggressive peptic ulcers in the stomach and duodenum

98. Synonyms of Zollinger Ellison Syndrome
Gastrinoma
Pancreatic Ulcerogenic Tumor Syndrome
Z-E Syndrome
ZES

99. GASTRINOMA
However, as many as 25% of people with (ZES) Zollinger-Ellison syndrome may not have an ulcer when the diagnosis is made.
Rupture, bleeding, and obstruction of the intestine can occur and are life threatening.

100. GASTRINOMA
For more than half of the people with a gastrinoma, symptoms are no worse than those experienced by people with ordinary peptic ulcer disease.
In 25 to 40% of people, diarrhea is the first symptom.

101. GASTRINOMA
a gastrinoma is suspected when a person has frequent peptic ulcers or several peptic ulcers that do not respond to the usual ulcer treatments.
Blood tests to detect abnormally high levels of gastrin are the most reliable diagnostic tests.

102. GASTRINOMA
High doses of proton pump inhibitors may be effective for reducing acid levels and relieving symptoms temporarily.
About 20% of people who do not have multiple endocrine neoplasia can be cured with surgical removal of the gastrinoma.
If these treatments fail, a total gastrectomy may be necessary.

103. GASTRINOMA
This operation does not remove the tumor, but the gastrin can no longer create ulcers after the acid-producing stomach is removed.
If the stomach is removed, daily oral iron and calcium supplements and monthly injections of vitamin B12 are needed, because absorption of these nutrients is impaired when stomach juices that prepare these nutrients for absorption are no longer available.

104. Gastrinoma

105. GASTRINOMA
If cancerous tumors have spread to other parts of the body, chemotherapy may help reduce the number of tumor cells and the levels of gastrin in the blood.
However, such therapy does not cure the cancer, which is ultimately fatal.

106. Glucagonoma
A glucagonoma is a tumor of the pancreas that produces the hormone glucagon, which raises the level of sugar (glucose) in the blood and produces a distinctive rash.

107. Glucagonoma About 80% of glucagonomas are cancerous.
However, they grow slowly, and many people survive for 15 years or more after the diagnosis.
The average age at which symptoms begin is 50.
About 80% of people with glucagonomas are women.

108. Glucagonoma
High levels of glucagon in the blood cause the symptoms of diabetes mellitus.
Often, the person loses weight.
In 90% of people, the most distinctive features are a chronic reddish brown skin rash (necrolytic migratory erythema) and a smooth, shiny, bright red-orange tongue.

109. Glucagonoma The mouth also may have cracks at the corners.
The rash, which causes scaling, starts in the groin and moves to the buttocks, forearms, and legs.

110. Glucagonoma syndrome -- necrolytic migratory erythema

111. Glucagonoma
The diagnosis is made by identifying high levels of glucagon in the blood and then locating the tumor by arteriography

112. Glucagonoma
Ideally, the tumor is surgically removed, which eliminates all symptoms.
However, if removal is not possible or if the tumor has spread, chemotherapy may reduce the levels of glucagon and lessen the symptoms.
However, chemotherapy does not improve survival.

113. Glucagonoma
The drug octreotide also reduces glucagon levels, may clear up the rash, and may restore appetite, facilitating weight gain.
Octreotide may elevate the levels of sugar in the blood even more.

114. Glucagonoma Zinc ointment may be used to treat the skin rash.
Sometimes the rash is treated with intravenous amino acids or fatty acids.