Exocrine Pancreas Path

Question 1

Acute pancreatitis

Answer 1

Inflammation & hemorrhage of the pancreas that results from aberrant release of pancreatic enzymes, autodigestion of pancreatic parenchyma by pancreatic enzymes

Premature activation of trypsin –> activation of other pancreatic enzyme

Question 2

Acute pancreatitis

Patho

Answer 2

Results in liquefactive hemorrhagic necrosis of pancreas

Fat necrosis of peripancreatic fat

Question 3

Acute pancreatitis

Etiology – 1/2

Answer 3

Mechanical: gallstones, biliary sludge, neoplasms, duodenal stricture, obstruction

Gallstones&raquo_space;» (most common cause)

Toxic: ethanol, methanol, organophosphate poisoning

Alcohol&raquo_space; (2nd most common cause)

Trauma: blunt or penetrating abdominal injury, iatrogenic injury during a procedure

Question 4

Acute pancreatitis

Etiology – 2/2

Answer 4

Metabolic: hyperlipidemia (type V)–> elevations of chylomicrons/VLDL

Vascular: ischemia, hemorrhagic shock, vasculitis

Genetic

Drug-induced

Infectious agents: consider in immunocompromised patients
-Acute infection of pancreas usually a secondary event
-Usually 2/2 gram-aerobic bacteria

Question 5

Mild Acute pancreatitis

Micro

Answer 5

1. Spotty peripancreatic or perilobular fat necrosis
2. Interstitial acute inflammation
3. clinical dx»> morphologic

Question 6

Severe Acute pancreatitis

Micro

Answer 6

1. Large areas of fat necrosis & variable pancreatic parenchymal necrosis (saponification)
   a) Necrotic areas: abundant neutrophils, can involve duct lumina
   b) Hemorrhage & venous thrombosis
   c) Fat necrosis: may extend to omentum, retroperitoneum, bone marrow, subcutaneous tissue

Question 7

Mild acute pancreatitis

Gross

Answer 7

Enlarged & swollen w/ foci of fat necrosis (yellow-white, waxy, chalky)

Usually recover w/in 5-7 days

Question 8

Severe acute pancreatitis

Answer 8

Larger confluent areas of fat necrosis & parenchymal necrosis, hemorrhage can encase the pancreas & stimulate hematoma

Sequelae: pancreatic abscesses & pseudocyst

Question 9

Acute pancreatitis
Sx & complications

Answer 9

i. Epigastric abdominal pain → radiates to back
ii. Nausea, vomiting
iii. Periumbilical & flank hemorrhage signs
1) Necrosis spreads into periumbilical soft tissue / retroperitoneum

iv. Shock d/t peripancreatic hemorrhage & fluid sequestration

DIC, ARDS, AKI

Question 10

Acute pancreatitis labs

Answer 10

Elevated lipase, amylase, hypocalcemia

Question 11

Chronic pancreatitis

Answer 11

Progressive inflammatory disorder of the pancreas, resulting in scarring, gland destruction, functional impairment

Question 12

Chronic pancreatitis

Epidemiology

Answer 12

1. alcohol-related: >40 yo males >
2. Hereditary/tropical forms: childhood
   -presents w/ recurring attacks of acute pancreatitis
   - complications like alcohol-related, only at a young age

Question 13

Chronic pancreatitis

Etiology

Answer 13

1. Alcohol
2. Duct obstruction: stones, tumors
3. Metabolic: hypercalcemia, hyperlipidemia
4. Genetics

Question 14

Chronic pancreatitis

Etiology – Genetics

Answer 14

Trypsinogen gene (PRSS1) –> 60-80% of hereditary CP

Cystic fibrosis (CFTR)

Serine protease inhibitor kazal type 1 (SPINK1)

Chymotrypsin C (CTRC)

Question 15

Chronic pancreatitis

Symptoms

Answer 15

Abdominal pain, WT loss, N/V, jaundice

Steatorrhea (malabsorption 2/2 impaired pancreatic enzyme secretion)

Diabetes, pancreatic CA, portal vein thrombosis, ascites, pancreatic pseudocyst

Question 16

Chronic pancreatitis

Labs
Micro

Answer 16

Elevated CA19-9 > 1000 (highly specific) –> pancreatic CA

M: Fibrosis & chronic inflammation – retention of normal lobular pancreatic architecture

Islets of langerhans preserves, my show pseudo hyperplasia

Question 17

Mucinous cystic neoplasms

Answer 17

Neoplasm of mucin-producing epithelial cells, assoc w/ ovarian-type stroma (precursors to invasive carcinomas)

Question 18

Mucinous cystic neoplasms

Gross

Answer 18

40-50 yo
Female»»

Body or tail of pancreas

Solitary & large

Multiloculated w/ thick walls filled w/ thick, tenacious mucoid material

Question 19

Mucinous cystic neoplasms

Micro

Answer 19

Tall, columnar, mucin- producing epithelium w/ varying degrees of cellular atypia

Ovarian-type stroma REQUIRED for dx (mimics a spindle cell stroma)

Question 20

Mucinous cystic neoplasms

Symptoms

Answer 20

Vague
Abdominal symptoms (pain, fullness)
Compression of adjacent organs/tissue

Question 21

Intraductal papillary mucinous neoplasm (IPMN)

Answer 21

Grossly visible mucin-producing epithelial neoplasm present w/in main pancreatic duct and/or branches

Question 22

Intraductal papillary mucinous neoplasm (IPMN) v. Mucinous cystic neoplasms

Answer 22

1. Absence of dense ovarian stroma
2. Involvement of pancreatic duct

Question 23

Intraductal papillary mucinous neoplasm (IPMN)

Epidemiology
Risk Fx
Symptoms

Answer 23

Mid-60s
Fam hx of diabetes or pancreatic ductal adenocarcinoma

Asymptomatic, nonspecific
-Abdominal, back pain, anorexia, wt loss
-Symptoms often present for month-years before dx

Question 24

Intraductal papillary mucinous neoplasm (IPMN)

Gross
Endoscopy
Micro

Answer 24

Pancreatic HEAD
Markedly dilated pancreatic duct w/ abundant mucin

Mucin extravasation from patulous ampulla of Vater

M: flat or papillary mucinous epithelium

Question 25

Serous cystic neoplasm (serous cystadenoma)

Answer 25

Benign, cystic epithelial neoplasm Anywhere in pancreas, mainly the tail

Question 26

Serous cystic neoplasm (serous cystadenoma) Sx

Answer 26

Abdominal mass/pain (larger -- more likely to have sx) No comunication of cyst to pancreatic ductals sys Sponge-like or honeycomb appearance Numerous, tightly packed cysts

Question 27

Pancreatic intraepithelial neoplasia (PanIN)

Answer 27

Noninvasive pancreatic intraductal epithelial proliferation, precursor of pancreatic ductal adenocarcinoma

Question 28

Pancreatic intraepithelial neoplasia (PanIN) Micro

Answer 28

Enlarged hyperchromatic nuclei & slight loss of nuclear polarity Prominent cytologic atypia, variably prominent nuclei, loss of polarity

Question 29

Pancreatic exocrine neoplasia (pancreatic adenocarcinoma, duct cell adenocarcinoma)

Answer 29

Malignant epithelial neoplasm arising in pancreatic ductal system w/ glandular differentiation 85-90% of all pancreatic adenocarcinomas 60-80 yo male >> AA

Question 30

Pancreatic exocrine neoplasia (pancreatic adenocarcinoma, duct cell adenocarcinoma) Patho

Answer 30

Multifactorial Precursor lesions: pancreatic intraepithelial neoplasia, intraductal papillary mucinous neoplasm, mucinous cystic neoplasm Familial pancreatic CA (increased risk w/ inherited syndromes w/ known germline mutations)

Question 31

Pancreatic exocrine neoplasia (pancreatic adenocarcinoma, duct cell adenocarcinoma) Gross

Answer 31

Can arise anywhere in pancreas (HEAD>>>) Solid & firm mass w/ ill-defined borders Bile & pancreatic ducts dilated Adjacent areas of fibrosis, secondary to chronic pancreatitis Common bile duct & duodenum invasions common

Question 32

Pancreatic exocrine neoplasia (pancreatic adenocarcinoma, duct cell adenocarcinoma) Micro

Answer 32

Loss of lobular configuration Sharp angulated edges of malignant glands Neoplastic glands in close proximity to a thick-walled vessel

Question 33

Pancreatic exocrine neoplasia (pancreatic adenocarcinoma, duct cell adenocarcinoma) Sx

Answer 33

Painless jaundice and pruritus if common bile duct obstructed WT loss, epigastric pain -- radiates to back, anorexia, depression CA19-9 elevated, lewis blood group antigen increased Migratory thrombophlebitis (Trousseau syndrome)