Exocrine Pancreas Pathology

Question 1

What do the small ductules secrete?

Answer 1

Bicarbonate

Question 2

What do the large ductules secrete?

Answer 2

Mucin

Question 3

What do the Islets of Langerhans secrete?

Answer 3

Insulin, glucagon, somatostatin

Question 4

What are some of the ways that the pancreas prevents autodigestion?

Answer 4

• Inactive proenzymes are synthesized
• Enzymes are in membrane bound zymogen granules
• Activation of proenzymes requires activation of trypsinogen to trypsin
• Resistance of acinar cells

Question 5

What is acute pancreatitis?

Answer 5

It is an acute inflammatory process of the pancreas that is associated with acinar cell injury. With respect to severity it can range from mild self-limited disease to a life threatening acute inflammatory process.

Question 6

What are the 2 most common causes of acute pancreatitis?

Answer 6

Alcohol and gallstones (biliary obstruction)

Question 7

What is the pathogenesis of acute pancreatitis?

Answer 7

There is inappropriate activation of trypsinogen to trypsin and a lack of prompt elimination of active trypsin inside the pancreas. Activation of digestive enzymes causes pancreatic injury and results in an inflammatory response that is out of proportion to the response of other organs with a similar insult.

Question 8

How does alcohol cause acute pancreatitis?

Answer 8

Alcohol may act as a toxin that directly injures acinar cells releasing activated enzymes which autodigest the pancreas.

Question 9

How do gallstones cause acute pancreatitis?

Answer 9

Biliary obstruction, such as by gallstones, can lead to reflux of bile into the pancreatic ducts. This increased back-pressure leads to acinar cell injury.

Question 10

What is the cause of acute pancreatitis seen most often in males? Females?

Answer 10

Males - alchohol

Females - gallstones

Question 11

What are some drugs that can cause acute pancreatitis?

Answer 11

Azathioprine and estrogens

Question 12

What is hemorrhagic pancreatitis?

Answer 12

This is the most severe form of acute pancreatitis – extensive parenchymal necrosis is accompanied by diffuse hemorrhage within the gland.

Question 13

What are the typical clinical manifestations of acute pancreatitis?

Answer 13

Sudden onset of severe abdominal pain which may radiate to the back and non-specific symptoms:

Nausea and vomiting, fever, sweating, tachypnea, and tachycardia.

Question 14

Which enzymes appear in high concentration in the blood during acute pancreatitis?

Answer 14

Amylase and lipase

Question 15

Why can hypocalcemia develop during acute pancreatitis?

Answer 15

Fat necrosis leads to local formation of calcium soaps, called suponificiation and this process consumes calcium from the blood, typically leading to hypocalcemia 2 to 4 days after the onset of acute pancreatitis.

Question 16

What is the approach to treatment of acute pancreatits?

Answer 16

Supportive treatment and address the underlying cause

Question 17

What is chronic pancreatitis?

Answer 17

A progressive fibroinlammatory process of the pancreas that results in permanent structural damage and loss of exocrine followed by endocrine function.

Question 18

What is the most common cause of chronic pancreatitis?

Answer 18

Chronic alcohol abuse

Question 19

What are the other causes of chronic pancreatitis?

Answer 19

Chronic biliary obstruction
Hereditary
Tropical Pancreatitis

Question 20

What are the proposed pathogenetic mechanisms of chronic pancreatitis?

Answer 20

Hypersecretion of protein with insufficient ductal bicarbonate leading to proteinacious plug formation within ducts. This obstruct ducts and serves as a nidus for calcification and stone formation. Duct injury leads to scar formation and further obstruction.

Question 21

What are the morphologic changes seen in chronic pancreatitis?

Answer 21

Fibrosis
Reduced number and size of acini
Obstruction and dilatation of pancreatic ducts
Pseudocyst formation

Question 22

What are the clinical manifestations of chronic pancreatitis?

Answer 22

• Persistent upper abdominal pain radiating to the back, often precipitated by alcohol
• Malabsorption due to pancreatic insufficiency—steatorrhea and vitamins A, D, E, and K deficiency

Question 23

What is a pancreatic pseudocyst?

Answer 23

A localized collection of pancreatic secretions in pancreatic interstitium as a result of damaged ducts.

Importantly – a pseudocyst LACKS a true epithelial lining.

Question 24

A 42‐year old obese woman presents with a 1 day history of severe abdominal pain which radiates to her back. She has no known medical problems. She does not smoke cigarettes. She drinks one glass of wine ~twice per month. There is no history of drug abuse. She takes ranitidine as needed for heartburn. Her BP is 90/45, respirations 32/min, pulse 104/min. Physical exam shows marked epigastric tenderness to palpation. Laboratory studies reveal elevated serum amylase (850 U/L) and lipase (675 U/L) and hypocalcemia. Which of the following is most likely associated with the pathogenesis of this patient’s condition?

A. Alcohol abuse
B. Carcinoid tumor
C. Cholelithiasis
D. Hypoparathyroidism
E. Hypercholesterolemia

Answer 24

C. Cholelithiasis

Question 25

What are causes of pancreatic pseudocyst?

Answer 25

Acute pancreatitis, chronic pancreatitis, trauma.

Question 26

What are some risk factors for pancreatic cancer?

Answer 26

Smoking
Long standing diabetes mellitus
Chronic pancreatitis

Question 27

What is the precursor lesion and associated molecular pathogenesis of pancreatic adenocarcinoma?

Answer 27

The precursor lesion is pancreatic intraepithelial neoplasia (PanIN). There is a stepwise progression of pancreatic intraepithelial neoplasia from low grade to high grade. These are associated with accumulating genetic alterations.

Question 28

What is a common mutation seen in pancreatic adenocarcinoma?

Answer 28

There is a very high rate of KRAS mutations in pancreatic adenocarcinoma and a majority are ductal in origin.

Question 29

What is the main location of the pancreas where adenocarcinoma arises in?

Answer 29

The head

Question 30

What are the clinical manifestations of pancreatic cancer?

Answer 30

• Most cancers remain clinically silent until the tumor impinges on other structures
• Pain is usually first symptom
• Obstructive jaundice with tumors arising in the head of the pancreas

Question 31

What is a sign with pancreatic carcinoma of the head?

Answer 31

Obstructive jaundice
• Tumor obstructs ampullary region/common bile duct
• Obstruction prevents conjugated bile from entering
duodenum, bile pressure increases in the biliary tract and it enters the vascular space

Question 32

What is “Trousseau’s Sign”?

Answer 32

Mucin is a pro-coagulation factor that is overproduced in pancreatic adenocarcinoma as some of it will leak into the blood leading to migratory thrombophlebitis of spontaneously appearing and disappearing venous thromboses.

Question 33

What is a “Whipple Procedure”?

Answer 33

A type of surgical resection for tumors in the head and neck of the pancreas - a pancreaticoduodenectomy

Question 34

What are some of the features of serous cystoadenoma?

Answer 34

• Benign
• Cuboidal cells
• Elderly females
• Cysts with clear fluid

Question 35

What are some of the features of mucinous cystic neoplasms?

Answer 35

• Can be benign or malignant
• Columnar epithelium
• Almost exclusively in female
• Cysts with mucin

Question 36

What are some of the features of intraductal papillary mucinous neoplasms?

Answer 36

• Can be benign or malignant
• Columnar epithelium
• More in men
• Head of pancreas

Question 37

What is pancreatic agenesis?

Answer 37

Absence of the pancreas; usually associated with multiple other congenital organ anomalies.

Question 38

What is an Annular pancreas?

Answer 38

The head of the pancreas encircles the duodenum. This may narrow the duodenum and interfere with passage of food.

Question 39

Where can “ectopic” pancreatic tissue be found?

Answer 39

Ectopic pancreatic tissue refers to displaced pancreatic tissue.

Glands (ducts and acinar tissue) and Islets of Langerhans and be found in the Stomach and duodenum, jejunum, Meckel diverticulum, ileum. There are usually in the submucosa.

Question 40

Describe pancreas divisum.

Answer 40

It is a congenital anomaly of the anatomy of the ducts of the pancreas in which a single pancreatic duct is not formed, but rather remains as two distinct dorsal and ventral ducts.

Normally, in embryogenesis, the two ducts will fuse together to form one main pancreatic duct. In pancreas divisum the major drainage of the pancreas is done by the dorsal duct which opens up into the minor papilla.

Question 41

What are the complications of pancreas divisium?

Answer 41

The majority of patients with pancreas divisum have no symptoms. A small subgroup of patients may develop chronic pancreatitis.

Question 42

A 51‐year‐old man has a history of chronic alcohol abuse. He has had multiple bouts of epigastric abdominal pain in the past year. For the past month, he has had more frequent and worsening abdominal pain. Physical examination reveals right upper and left upper quadrant pain. An abdominal plain film radiograph reveals no free air, but there is extensive peritoneal fluid collection along with dilated loops of small bowel. An abdominal CT scan reveals a an 8 cm cystic mass in the tail of the pancreas. Which of the following is the most likely diagnosis?

A. Pancreatic adenocarcinoma
B. Pancreatic pseudocyst
C. Acute pancreatitis
D. Pancreatic mucinous cystadenoma


Answer 42

B. Pancreatic pseudocyst