159b/160b - Pathology and Clinical Features of Pancreatic Disorders Flashcards
What inflammatory cells will dominante in acute pancreatitis?
Neutrophils
What is the “typical” presentation of chronic pancreatitis?
There isn’t really one
May have:
- Fat malabsorption (Exocrine insufficiency)
- Diabetes mellitus (Endocrine insufficienty)
- Abdominal pain
- Neuropathic pain
- Also may be asymptomatic
Is tobacco use a risk factor for chronic pancreatitis?
Yes
(Previously unrecognized, but highlighted as important in the lecture)
Note: also increses risk of acute pancreatitis
What causes acute pancreatitis?
Autodigestion of the pancreas; premature activation of trypsin
Caused by:
- Duct obstruction (Gallstone)
- Acinar cell injury
- Alcohol, drugs, ischemia
- Defective intracellular transport
Which pancreatic cystic neoplasms are benign?
When would they need to be removed?
- Retention cyst
- Pseudocyst
- Serous cystadenoma
None have malignant potential :)
Remove if symptomatic, rapidly growing, or unsure if it might be MCN
How is acute pancreatitis diagnosed?
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
Compare the histology of acute and chronic pancreatitis
- Acute
- Inflammation (neutrophils)
- Fat necrosis
- Chronic
- Chronic inflammation (lymphocytes)
- Fibrotic stroma
What is the most common cause of chronic pancreatitis?
Long term alcohol use
What are the most commonly mutated genes in pancreatic ductal adenocarcinoma? (4)
(In the tumor; not necessarily hereditary)
- KRAS (oncogene)
- P16 aka CDKN2a (Tumor suppressor - cell cycle regulator)
- P53 (Tumor suppressor - responds to DNA damage)
- SMAD4 (involved in TGF-beta pathway
What are the two most common causes of acute pancreatitis?
Gallstone (more common in women w/pancreatitis)
Alcohol use (more common in men w/pancreatitis)
Which pancreatic cystic neoplasms have malignant potential and should be resected? (2)
- Mucinous cystic neoplasm
- Ovarian-like stroma
- Intraductal papillary mucinous neoplasm
What are the 2 types of acute pancreatitis?
Interstitial edamatous pancreatitis
Necrotizing pancreatitis
Only difference = necrosis in necrotizing
List 3 symptoms of acute pancreatitis
- Acute epigastric pain - may radieate to the back
- Nausea
- Vomiting
How is acute pancreatitis managed?
Goal = improve blood flow and reduce inflammation
- Supportive treatment
- Early hydration
- Avoid parenteral nutrition if possible
- Analgesia
- Prevent infection
If autoimmune-mediated, give steroids
What is the most common pancreatic tumor?
Pancreatic ductal adenocarcinoma
What procedure increses one’s risk of acute pancreatitis?
How can this risk be reduced?
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
What genetic mutations predispose an individual to pancreatitis?
Which one is considered “hereditary pancreatits”?
-
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
What is the treatment for chronic pancreatitis?
Pancreatic enzyme replacement therapy
(This thing is def not meeting your enzymatic needs - fibrotic changes are irreversible!)
What is the characteristic histologic finding of mucinous cystic neoplasms in the pancreas?
How would you manage this neoplasm?
Ovarian-like stroma
Remove! Has malignant potential (considered a precursor for pancreatic ductal adenocarcinoma)
What hereditary genetic mutations predispose an individual to pancreatic adenocarcinoma?
- 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?
What are the precursor legions of pancreatic ductal adenocarcinoma? (3)
- PanIN tumor
- Intraductal papillary mucinous neoplasm (IPMN)
- Mucinous cyst neoplasm (MCN)
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?
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
