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Histopathology > Histopathology 7 - Diseases of the pancreas and gall bladder > Flashcards

Histopathology 7 - Diseases of the pancreas and gall bladder Flashcards

1
Q

Recall the mnemonic for the causes of acute pancreatitis

A

I GET SMASHED

Idiopathic (15%)

Gallstones (50%)
Ethanol (33%)
Trauma

Steroids
Mumps
Autoimmune
Scorpion sting
Hyperlipidaemia/hypercalcaemia/hyperparathyroidism
ERCP
Drugs

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2
Q

Recall two causes of pancreatitis via duct obstruction

A 
Gallstones 
Alcohol (via spasm/ oedema of Sphinter of Oddi)
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3
Q

Recall the pathophysiology of injury seen in acute pancreatitis

A
  1. Enzymes activated
  2. Acinar necrosis
  3. Enzyme release

Can cause anything from stromal oedema to haemorrhagic necrosis (**coagulative necrosis)

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4
Q

What are the 3 patterns of injury that may be seen in acute pancreatitis?

A

Periductal (necrosis of acinar cells near ducts) - caused by obstruction

Perilobular (necrosis at the edges of lobules) - caused by poor blood supply

Panlobular (develops from either of the above)

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5
Q

Why are yellow/white foci seen in acute pancreatitis?

A

Lipases cause fat necrosis
Calcium ions bind to free fatty acids forming soaps (which are white yellow)

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6
Q

What is a pseudocyst?

A

Dilated space with no epithelial lining

A psuedocyst can increase the chances of having an abscess

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7
Q

What is a cyst?

A

Dilated space lined by epithelium

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8
Q

Recall 2 pancreatic and 3 systemic complications of acute pancreatitis

A

Pancreatic: pseudocyst + abscess
Systemic: shock, hypoglycaemia, hypocalcaemia

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9
Q

Recall 4 complications of chronic pancreatitis

A

Malabsorption
Diabetes mellitus
Pseudocysts
Carcinoma of the pancreas

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10
Q

What is contained within a pancreatic pseudocyst?

A

Pancreatic enzymes and necrotic material (which is why it’s so bad when they perforate - it causes peritonitis)

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11
Q

Causes of chronic pancreatitis- what is the most common?

A
  1. Metabolic/ Toxic (2):
    a) ALCOHOL (80%)
    b) Haemochromatosis- iron overload (bronzed diabetes)
  2. Duct Obstruction (3):
    a) Gallstones
    b) Abnormal pancreatic duct anatomy
    c) Cystic fibrosis (mucoviscoidosis)
  3. Tumours
  4. Idiopathic
  5. Autoimmune
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12
Q

DIfference in pathology between acute and chronic pancreatitis

A

Pattern of Injury- distinguishes chronic pancreatitis from acute pancreatitis:

Chronic inflammation with:

parenchymal (functional tissue) fibrosis

→ loss of parenchyma

Duct strictures with:calcified stones

→ secondary dilatations

Histology of chronic pancreatitis:

  • no acini
  • fibrous tissue
  • remaining ducts and islets of langerhans are prominent
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13
Q

Complications of chronic pancreatitis

A

Malabsorption (exocrine dysfunction)

Diabetes mellitus- fibrosis can overwhelm the islets of langerhans → DM

Pseudocysts, abscess

Pancreatic calcifications

Carcinoma of the pancreas

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14
Q

Which immunoglobin is implicated in autoimmune acute pancreatitis?

A

IgG4

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15
Q

What type of cancer makes up 85% of pancreatic neoplasms?

A

Ductal carcinoma

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16
Q

What are the different types of pancreatic tumour?

A

Carcinomas:

  1. Ductal
  2. Acinar

Cystic neoplasms:

  1. Serous cystadenomas
  2. Mucinous cystic neoplasms

Pancreatic neuroendocrine tumours (Islet cell tumours)

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17
Q

What mutation is very common in ductal carcinoma?

A

K-Ras

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18
Q

Tumour marker of pancreatic cancer

A

CA-19-9

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19
Q

Risk factors for pancreatic ductal carcinoma

A

smoking

BMI and dietary risk factors

Chronic pancreatitis

Diabetes

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20
Q

What are the 2 types of precancerous dysplastic ductal lesions in the pancreas?

A
  1. PanIn (pancreatic intraductal neoplasm)
  2. Intraductal mucinous papillary neoplasm

**remember PanIn

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21
Q

Which type of tumour has a “gritty and grey” macroscopic appearance?

A

Ductal adenocarcinoma

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22
Q

What is the typical microscopic appearance of ductal carcinoma of the pancreas?

A

Mucin-secreting glands set in desmoplastic stroma

stroma that arises in response to cancer - makes it hard and gritty

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23
Q

Define adenocarcinoma

A

Mucin-secreting glands set in desmoplastic stroma (means: strong stromal reaction)

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24
Q

Recall 3 complications of ductal carcinoma

A
  1. Liver metastasis
  2. Chronic pancreatitis
  3. Venous thrombosis (“migratory thrombophlebitis”/ Trousseau syndrome) = mucin activating coagulation in circulatory system causing thrombosis
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25
Q

Which type of pancreatic tumours are usually benign?

A

Cystic tumours

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26
Q

WHich part of the pancreas are serous cystadenomas found in?

A

The head

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27
Q

Which type of pancreatic tumour is likely to contain neuroendocrine markers?

Are these tumours secretory or non-secretory?

A

Pancreatic endocrine neoplasms

**most are non-secretory

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28
Q

Recall a neuroendocrine marker in pancreatic endocrine neoplasms

A

Chromogranin

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29
Q

Which type of pancreatic tumour is associated with MEN1?

A

Pancreatic endocrine neoplasms

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30
Q

What is the most common type of secretory pancreatic tumour?

A

Insulinomas

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31
Q

In which portion of the pancreas are neuroendocrine tumours most common?

A

Tail

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32
Q

What are the 2 types of gallstone?

A

Cholesterol- mostly single, mostly radiolucent
Pigment-mostly multiple, mostly radio-opaque

*can also get mixed stones - these are the most common

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33
Q

What do pigment gallstones contain?

A

Calcium salts of unconjugated bilirubin

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34
Q

Risk factors for gallstones

A

1) Acquired disorders (e.g. rapid weight loss- body tries to remove all the cholestrol that it has been storing)
2) Ethnic factors can contribute (e.g. Native Americans have a very high incidence of gallstones)
3) Hereditary factors (e.g. disorders of bile metabolism)
4) Drugs (e.g. oral contraceptive)\
5) age and gender: increasing age, F>M

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35
Q

Which type of gallstones are radiolucent/radio opaque

A

Cholesterol: radiolucent (i.e. appear white on x-ray)
Pigment: radio-opaque (i.e. appear black on x-ray)

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36
Q

Recall 4 potential complications of gallstones

A

Pancreatitis- acute or chornic (mostly acute)
Bile duct obstruction
Cholecystitis
Gall bladder cancer

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37
Q

What is the most common cause of acute cholecystitis?

A

Gallstones (accounts for 90%)

38
Q

What is a key histopathological finding in chronic cholecystitis?

A

Diverticula Rokitansky-Aschoff sinuses

39
Q

What is the most common cause of gallbladder cancer?

A

Gallstones

**rmb gallbladder cancer is very rare

40
Q

What is IgG4 related disease?

A

A type of autoimmune disease that may affect the pancreas, surrounding structure or pretty much anywhere else in the body

41
Q

What type of cancer can lead to cholangiocarcinoma?

A

Gallbladder cancer

42
Q

Where does pancreatic duct join?

A

Joins the common bile duct which drains into the duodenum

43
Q

Endocrine and exocrine components of the pancreas

A

Endocrine: islets of langherhans

Exocrine: acini and ducts

44
Q

What has better prognsois: cholangiocarcinoma or pancreatic cancer?

A

Cholangiocarcinoma

45
Q

Defnition of acute pancreatitis

A
  • acute inflammation of the pancreas caused by aberrant release of pancreatic enzymes
  • so essentially the pancreas damages itself with the pancreatic enzymes
  • Relatively common, incidence is increasing
46
Q

What is the most common cause of pancreatitis?

A

Gallstones

47
Q

Pathogenesis of acute pancreatitis?

A

obstruction

  • gallstone gets stuck distal to where the pancreatic duct joins the common bile duct –> bile refluxes back into the pnacreatic duct –> damage to acini–> release of proenzymes–> autodigestion
  • alcohol can also cause obstructive damage - leads to spasm of sphincter of oddi and formation of protein rich substance which can cause obstruction
    • but main mechanism of alcohol causing pancreatitis is via direct chemical injury

direct acinar injury

everything else

48
Q
A
49
Q
A
50
Q

Which complication of pancreatitis renders the worst prognosis?

A

Haemorrhagic necrotic pancreatitis

mortality is 50% due to risk of shock

51
Q
A
52
Q

Two types of chronic pancreatitis

A

Relapsing or persistent

53
Q

What is the precursor of chronic pancreatitis?

A

Acute pancreatitis - chornic pancreatitis is assoictaed with thsi in about 50% of cases.

Mild acute pancretaitis tends to resolve quickly but severe acute pancreatitis risks progressing to chornic pancreatitis

54
Q

Causes of chronic pancreatitis

A
  1. Alcohol - most common cause (as opposed to acute pancreatitis where alcohol causes 1/3 of cases)
  2. Haemochromatosis - bronzed diabetes (damage to pancreas causes diabetes)
  3. duct obstruction
  4. cystic fibrosis (mucoviscoidosis)
  5. tumours - cause obstruction
  6. idiopathic
  7. autoimmune
55
Q

Pattern of injury in chronic pancreatitis

A

Chronic inflammation with panrechymal fibrosis and loss of parenchyma

Duct strictures with calcified stones with secondary dilatations

**damage to acini as well as the ducts

56
Q

Complications of chronic pancreatitis

A
  • malabsorption
  • diabetes - presents later as exocrine damage is before endocrine damage
  • pseudocyst
  • pancreatic cancer
57
Q

x ray appearance of chronic pancreatitis

A

calcified stones in pancreas

58
Q

What lines pseudocysts?

A

fibrous tissue

not lined by epithelium like pancreatic cysts

59
Q

What do pancreatic pseudocysts contain?

A

Fluid rich in pancreatic enzymes or necrotic material

60
Q

What do panreatic pseudocysts connect to?

A

Pancreatic ducts

61
Q

When do you usually get pancreatic pseudocysts?

A

Post-surgical

62
Q

Progression of pseudocysts including complications

A
  • May resolve
  • May compress adjacent structures
  • May become infected → abscess
  • May become infected → perforate:
    • necrotic material rich in activated enzymes leaks into peritoneal cavity
    • acute peritonitis
63
Q

Which parts of the body does IgG4 disease affect?

A

Pancreas, bile ducts and almost any other part of the body

64
Q

Histology of IgG4 disease

A

duct is surrounded by loads of IgG4 expressing plasma cells

65
Q

Treatment of IgG4 disease

A

Respond well to steroids

66
Q
A
67
Q
A
68
Q

Precursor lesions of pancreatic ductal carcinoma

A
  1. PANIN - pancreatic intraductal neoplasia
  2. intraductal mucinous papillary neoplasm
69
Q

Which type of pancreatic tumour (location) presents earlier and therefore has better prognosis?

A

Tumour of the head of the pancreas

70
Q

Most common site of pancreatic cancer

A

Head

71
Q

How does ductal carcinoma of the pancreas spread?

A

DIRECT: bile ducts, duodenum

LYMPHATIC: lymph nodes (celiac lymph nodes)

BLOOD: liver

SEROSA/ CAVITIES: peritoneum

NERVES: celiac plexus

72
Q

Complications of ductal adenocarcinoma

A
  • Pancreatic cancers cause obstruction → Chronic pancreatitis
  • Complications due to spread
  • Venous thrombosis (migratory thrombophlebitis):
    • This is because circulating pancreatic cancer cells release mucous into bloodstream
    • → activates clotting cascade
73
Q
A
74
Q

Where are neuroendocrine tumours of the pancreas commonly found?

A

Tail (unlike adenocarcinoma)

75
Q

Are neuroendocrine tumours secretory or non-secretory?

What is the most common secretory tumour?

A

Mostly non-secretory

Insulinomas are the most common secretory tumour

76
Q

Presentation of neuroendocrine tumours

A
  • Diabetes
  • Epigastric mass
  • Hepatosplenomegaly
    • NOT jaundice
    • because tail of the pancreas not the head
77
Q

Presentation of inulinomas

A

hypoglycaemia

78
Q
A
79
Q

What is the most common cause of chronic cholecystitis?

A

Gallstones

80
Q

Role of secretin and CCK

A

Secretin: produced by s-cells of the duodenum, controls gastric acid secretion and buffering with HCO3-

CCK: responsible for stimulating digestion of fat and protein. Made by I-cells in the duodenum. Causes release of digestive enzymes.

**these stimulate pancreas to produce enzymic fluid

81
Q

What scoring system is used for acute pancreatitis?

A

Glasgow score

>3= severe pancreatitis

82
Q

Most sensitive marker for acute pancreatitis

A

Amylase- transient increase

Serum lipase is the most sensitive!!

83
Q
A
84
Q

Acinar cell carcinoma

A
85
Q

What is trousseau syndrome?

A

Recurrent superficial thrombophlebitis

86
Q

What is a gastrinoma?

A

Causes zollinger-ellison syndrome –> high acid output –> reucurrent ulceration

**tumour of the G cells in pancreas or duodenum**

87
Q

Men1

A

pituitary- adenoma

parathyroid- adenoma

pancreas - endocrine tumour

88
Q

MEN2A

A

parathyroid

thyroid (medullary thyroid carcinoma)

phaeo

89
Q

MEN2B

A

medullary thyroid

phaeo

neuroma

marafnoid (men2B- b for big)

90
Q
A
91
Q

How many g. of glucose given for OGTT?

A

75g

Histopathology (18 decks)

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