11. Exocrine Pancreas, Gallbladder, Liver Patholog Flashcards
What is an annular pancreas?
developmental malformation in which the pancreas forms a ring around the duodenum
what is the problem with an annular pancreas?
there is a risk of duodenal obstruction since it is encircled
what is acute pancreatitis?
inflammation, hemorrhage of the pancreas
what happens to the pancreas in acute pancreatitis?
autodigestion of the pancreatic parenchyma, by pancreatic enzymes
in acute pancreatitis, why is the panc parenchyma digested by enzymes?
normally the enzymes are secreted in inactive form; with pancreatitis, they are prematurely activated within the pancreas and begin digestion
what is the first enzyme activated in acute pancreatitis?
trypsin
what does the autodigestion of pancreatic parenchyma lead to?
liquefactive hemorrhagic necrosis (hemorrhagic due to high vascularity) and fat necrosis of the peripancreatic fat
what are the most common 2 causes of acute pancreatitis? what are other causes?
most common: alcohol, gallstones
other causes: trauma, hypercalcemia, hyperlipidemia, drugs, scorpion stings, mumps, rupture of a posterior duodenal ulcer
how does alcohol cause acute pancreatitis?
creates contraction of sphincter of Oddi (where panc enters duodenum), increases risk of activation of enzymes while still in the pancreas
how do gallstones cause acute pancreatitis?
same mech as alcohol: contraction of sphincter of Oddi (where panc enters duodenum), increases risk of activation of enzymes while still in the pancreas
how can trauma lead to acute pancreatitis?
happens esp in kids with seatbelt across abdomen: pancreas is compressed
how does hypercalcemia lead to acute pancreatitis?
remember that Ca is an enzyme activator; leads to premature enzyme activation
what are some clinical features of acute pancreatitis?
epigastric abd pain, radiates to back
nausea, vomiting
periumbilical and flank hemorrhage
why does acute pancreatitis present with periumbilical and flank hemorrhage?
necrosis spreads into the periumbilical soft tissue and retroperitoneum
what labs will be elevated with acute pancreatitis?
serum lipase, serum amylase
why will serum lipase and serum amylase be elevated with acute pancreatitis? which is more specific for pancreatic damage?
both produced by pancreas. lipase is more specific; amylase also from salivary glands
why can acute pancreatitis present with hypocalcemia?
calcium is consumed during fat necrosis and saponification
Hypocalcemia indicates what kind of prognosis with acute pancreatitis?
poor prognosis; indicates that there is widespread necrosis of peripancreatic fat
what are some complications of acute pancreatitis?
- shock
- pancreatic pseudocyst
- pancreatic abscess
- DIC
- ARDS
how can acute pancreatitis result in shock?
due to peripancreatic hemorrhage (highly vascularized) and fluid sequestration due to tissue damage
how can acute pancreatitis result in a pancreatic pseudocyst?
fibrous tissue surrounds the liquefactive necrosis and pancreatic enzymes; not a true cyst because only fibrous tissue rather than real cyst lining (?)
how will a pancreatic pseudocyst present? what can happen?
presents as abdominal mass with persistently elevated serum amylase.
can result in rupture and release of enzymes into abdominal cavity. also, can hemorrhage
why is serum amylase persistently elevated with a pancreatic pseudocyst?
normally serum amylase will return to normal with resolution of the acute pancreatitis. in this case, it stays elevated. Sattar did not clarify
what can cause a pancreatic abscess? how does it present?
E Coli; presents as abd pain, high fever, persistently elevated serum amylase (in face of recent acute pancreatitis)
how can acute pancreatitis cause DIC?
enzymes from the panc are released into the blood, cause activation of coag factors
how can acute pancreatitis result in ARDS?
from widespread damage to the alveolar-capillary interface due to panc enzymes in bloodstream
what is chronic pancreatitis?
recurrent bouts of acute pancreatitis result in fibrosis of the panc.
what are the most common causes of chronic pancreatitis?
alcohol (adults), cystic fibrosis (kids)
often idiopathic
how does cystic fibrosis result in chronic pancreatitis?
increases secretions from the panc, leading to decr ability for them to drain
what are clinical features of chronic pancreatitis?
- epigastric abd pain radiating to back
- pancreatic insufficiency
- pancreatic calcification visible on imaging
- secondary T1DM
what results from pancreatic insufficiency?
malabsorption with steatorrhea, deficiencies in ADEK
why are serum amylase and lipase decreased with pancreatic insufficiency?
panc is not producing these; has been largely destroyed by fibrosis
what does chronic pancreatitis reveal on imaging?
dystrophic calcification of parenchyma. contrast studies reveal a ‘chain of lakes’ pattern due to dilatation of panc ducts
why can chronic pancreatitis lead to secondary T1DM?
late complication, due to destruction of islets
chronic pancreatitis is a risk factor for what type of cancer?
pancreatic carcinoma
pancreatic carcinoma arises from what structure? what is the most common population affected?
arises from pancreatic ducts
elderly: age age is 70
what is a classic appearance of pancreatic carcinoma?
thin elderly person with onset of T1DM late in life (70s).
what are the major risk factors for pancreatic carcinoma?
smoking, chronic pancreatitis
clinical features of pancreatic carcinoma?
epigastric abd pain, wt loss
obstructive jaundice, pale stools, palpable gallbladder
secondary T1DM
migratory thrombophlebitis
what is the serological marker for pancreatic carcinoma?
CA 19-9
what is obstructive jaundice? why pale stools, palpable gallbladder?
blocked the flow of bile; bili leaks into blood. no bili in stool –> pale stool.
palpable gallbladder due to backup pressure and expansion
secondary T1DM is associated with tumors that occur where in the pancreas?
where the islet cells reside: body/tail
what is migratory thrombophlebitis?
Trousseau sign, occurs in 10% of panc carcinoma pts
presents as swelling, erythema, tenderness in extremities
what is the surgical treatment of pancreatic carcinoma?
en bloc removal of head/neck of pancreas, prox duodenum, gallbladder. Whipple procedure
pancreatic carcinoma: prognosis?
1 year survival is < 10%
