Most healthcare providers, when asked would equate the role of the pancreas with blood sugar regulation. While true, this fact was unknown until the late 19th century. The pancreas’ role in blood sugar regulation was initially discovered by Dr. Oscar Minkowski and Dr Joseph VonMering much by accident. These two researchers were studying the role of the pancreas in breaking down fatty acids by taking dogs and removing their pancreas. What they expected to occur was that the dogs would cease to be able to break down and process fatty acids, but what also happened was these same dogs exhibited the common symptoms of hyperglycemia (polyphagia, polydipsia and polyuria). In essence, they inadvertently gave the dogs diabetes by removing their pancreas. This discovery led to the idea of the role of the pancreas in blood sugar regulation and the eventual development of insulin.
The pancreas is both an exocrine organ that assists the body in breaking down ingested fatty acids and an endocrine gland that uses hormones to assist in blood sugar regulation. Only approximately 1% of the total pancreatic mass is made up of Islets cells (formerly known as the Islets of Langerhans). Islets cells secrete 3 main hormones. Alpha cells secrete Glucagon to elevate the circulating blood sugar levels when necessary. Beta cells secrete the hormone Insulin to decrease circulating blood sugar levels and Delta cells secrete Somatostatin, which regulates and balances the secretion of Insulin and Glucagon as well as some other functions.
When everything is working as it should, a patient’s blood sugar level is kept within a very narrow homeostatic range. It’s when the body’s own immune system mistakenly attacks the Beta cells is when the patient begins to suffer the effects of diabetes. Once 90% or greater of the Beta cells are damaged is usually when the individual becomes symptomatic and Beta cells do not have the ability to regenerate. This exaggerated autoimmune response is the most common cause of Type 1 or Insulin Dependent Diabetes. Type 2 Diabetes is largely thought to be an Insulin resistance of the cellular membrane to allow Insulin and Dextrose molecules to pass into the cell. Lifestyle changes often can be undertaken to minimize or cure Type 2 Diabetes.
The typical hypoglycemic patient presents with altered mental status and a more rapid development of symptoms along with pale, moist skin and a shallow or slow respiratory pattern. Hyperglycemic patients often have a slower development of symptoms with non specific flu-type complaints followed by polyuria, polydipsia and polyphagia. Hyperglycemia can be further divided into Diabetic Ketoacidosis (DKA) and Hyperglycemic Hyperosmolar Non- Ketotic State (HHNK). DKA is seen most often in Type 1 diabetics and is accompanied by a blood sugar between 250-600 mg/dl while HHNK is more often associated with Type 2 diabetics and has a higher blood sugar level (often well above 600 mg/dl). DKA results in more severe acidosis, usually with a pH of less than 7.30 while HHNK has a milder acidosis on an Arterial Blood Gas. Ketosis and the resulting fruity or acetone breath is more often associated with DKA than it is with HHNK. HHNK patients tend to be more dehydrated than their DKA counterparts and the development of symptoms and signs often is more gradual with HHNK.
Regardless of cause, hypoglycemia is often rapidly corrected by either an oral, intraosseous or intravenous infusion of a dextrose containing solution or intramuscular injection of Glucagon. . Hyperglycemia should be corrected more gradually with a focus initially on correcting the dehydration followed by a controlled decrease in serum blood glucose levels. It is widely accepted that bringing down the blood glucose level faster than 100 mg/dl/hr puts the patient at risk for cellular swelling and potentially an increase in intracranial pressure that can lead to long standing neurological impairment. The provider should also keep an eye on the serum Potassium levels as there is inverse correlation between blood pH and Potassium levels. Often Insulin boluses and infusions are utilized for the adult population while pediatric patients often receive an infusion without a bolus
So as you can see, the pancreas is an amazing cluster of cells that performs both exocrine and endocrine functions. While Islets cells account for a very small proportion of the total mass of the pancreas, they play a major role in keeping our blood sugar within a very
narrow and consistent range. It’s work behind the scenes allows us to function at an optimal level by avoiding large swings in circulating blood sugar levels while the remainder of the pancreas aids in digestion by breaking down fatty acids. It is just one more miracle in a large number of miracles that collectively make up the human body.
