159b/160b - Pathology and Clinical Features of Pancreatic Disorders

Question 1

What inflammatory cells will dominante in acute pancreatitis?

Answer 1

Neutrophils

Question 2

What is the “typical” presentation of chronic pancreatitis?

Answer 2

There isn’t really one

May have:

• Fat malabsorption (Exocrine insufficiency)
• Diabetes mellitus (Endocrine insufficienty)
• Abdominal pain
• Neuropathic pain
• Also may be asymptomatic

Question 3

Is tobacco use a risk factor for chronic pancreatitis?

Answer 3

Yes

(Previously unrecognized, but highlighted as important in the lecture)

Note: also increses risk of acute pancreatitis

Question 4

What causes acute pancreatitis?

Answer 4

Autodigestion of the pancreas; premature activation of trypsin

Caused by:

• Duct obstruction (Gallstone)
• Acinar cell injury
  
  • Alcohol, drugs, ischemia
• Defective intracellular transport

Question 5

Which pancreatic cystic neoplasms are benign?

When would they need to be removed?

Answer 5

• Retention cyst
• Pseudocyst
• Serous cystadenoma

None have malignant potential :)

Remove if symptomatic, rapidly growing, or unsure if it might be MCN

Question 6

How is acute pancreatitis diagnosed?

Answer 6

Must have 2/3 of:

• Abdominal pain radiating to back
• Elevated pancreatic enzymes (amylase or lipase x3 ULN)
• Confirmed radiographic findings
  
  • Not needed if top 2 criteria are met

Question 7

Compare the histology of acute and chronic pancreatitis

Answer 7

• Acute
  
  • Inflammation (neutrophils)
  • Fat necrosis
• Chronic
  
  • Chronic inflammation (lymphocytes)
  • Fibrotic stroma

Question 8

What is the most common cause of chronic pancreatitis?

Answer 8

Long term alcohol use

Question 9

What are the most commonly mutated genes in pancreatic ductal adenocarcinoma? (4)

(In the tumor; not necessarily hereditary)

Answer 9

• KRAS (oncogene)
• P16 aka CDKN2a (Tumor suppressor - cell cycle regulator)
• P53 (Tumor suppressor - responds to DNA damage)
• SMAD4 (involved in TGF-beta pathway

Question 10

What are the two most common causes of acute pancreatitis?

Answer 10

Gallstone (more common in women w/pancreatitis)

Alcohol use (more common in men w/pancreatitis)

Question 11

Which pancreatic cystic neoplasms have malignant potential and should be resected? (2)

Answer 11

• Mucinous cystic neoplasm
  
  • Ovarian-like stroma
• Intraductal papillary mucinous neoplasm

Question 12

What are the 2 types of acute pancreatitis?

Answer 12

Interstitial edamatous pancreatitis

Necrotizing pancreatitis

Only difference = necrosis in necrotizing

Question 13

List 3 symptoms of acute pancreatitis

Answer 13

• Acute epigastric pain - may radieate to the back
• Nausea
• Vomiting

Question 14

How is acute pancreatitis managed?

Answer 14

Goal = improve blood flow and reduce inflammation

• Supportive treatment
  
  • Early hydration
  • Avoid parenteral nutrition if possible
  • Analgesia
• Prevent infection

If autoimmune-mediated, give steroids

Question 15

What is the most common pancreatic tumor?

Answer 15

Pancreatic ductal adenocarcinoma

Question 16

What procedure increses one’s risk of acute pancreatitis?

How can this risk be reduced?

Answer 16

ERCP

(Use MRCP to evaluate patinet if pancreatitis is suspected)

To reduce risk:

• Aggressive IV hydration to improve bloodflow
• Stent in pancreas during procedure to allow drainage
  OR
• Rectal indomethacin

Question 17

What genetic mutations predispose an individual to pancreatitis?

Which one is considered “hereditary pancreatits”?

Answer 17

• PRSS1
  
  • Hereditary pancreatitis
• STK11
  
  • Peutz-Jegher’s
• CDKN2A
  
  • Familial atypical multiple melanoma

Note: Chronic pancreatitis increases risk of pancreatic cancer

=> All of these may be considered risk factors for pancreatic cancer

Question 18

What is the treatment for chronic pancreatitis?

Answer 18

Pancreatic enzyme replacement therapy

(This thing is def not meeting your enzymatic needs - fibrotic changes are irreversible!)

Question 19

What is the characteristic histologic finding of mucinous cystic neoplasms in the pancreas?

How would you manage this neoplasm?

Answer 19

Ovarian-like stroma

Remove! Has malignant potential (considered a precursor for pancreatic ductal adenocarcinoma)

Question 20

What hereditary genetic mutations predispose an individual to pancreatic adenocarcinoma?

Answer 20

• STK11*
  
  • Peutz-Jegher’s
• CDKN2A*
  
  • Familial atypical multiple melanoma
• BRCA1, BRCA2
• Lynch Syndrome

*Increased risk of pancreatitis - but it seems like increased cancer risk independent of pancreatitis risk?

Question 21

What are the precursor legions of pancreatic ductal adenocarcinoma? (3)

Answer 21

• PanIN tumor
• Intraductal papillary mucinous neoplasm (IPMN)
• Mucinous cyst neoplasm (MCN)

Question 22

A patient is having an abdominal for some random reason and she is found to have a mass in her pancreas.

Biopsy reveasl “ovarian-like stroma”

How would you manage this patient?

Answer 22

Ovarian-like stroma = mucinous cystic neoplasm

• Occurs almost exclusively in women, usually > 40 y/o
• Remove immediately!
  
  • ​MCNs are precursor lesions for pancreatic ductal adenocarcinoma