Histopathology 9: Pancreatic pathology

Question 1

Which 2 mediators control enzyme and alkali release from the pancreas ?

Answer 1

Secretin - released by S cells in the duodenum causes pancreatic HCO3- secretion

CCK- released by I cells in the duodenum causes pancreatic release of digestive enzymes

Question 2

Which cells release glucagon ?

Answer 2

Alpha cells

Question 3

Which cells release somatostatin ?

Answer 3

Delta cells

Question 4

What type of hypersensitivity reaction is T1DM ?

Answer 4

Type 4 delayed T cell mediated

Question 5

List the causes of Acute pancreatitis ?

Answer 5

I GET SMASHED

Idiopathic 
Gall stones
Ethanol
Trauma 
Steroids
Mumps 
Auto-immune 
Scorpion venom
Hyperlipidaemia 
ERCP
Drugs- Thiazide diuretics

Question 6

Which blood test is most sensitive for Acute pancreatitis ?

Answer 6

Serum Lipase

Question 7

List 4 causes of chronic pancreatitis ?

Answer 7

Cystic fibrosis
Alcoholism
Pancreatic duct obstruction - stones /cancer
Auto-immune

Question 8

Describe the histology of chronic pancreatitis ?

Answer 8

• Dilated ducts
• Fibrosis
• calcification
• loss of exocrine tissue

Question 9

A patient presents with significant weight loss, abdominal pain, multifocal fat necrosis and polyarthralgia. Histopathology: Eosinophilic granular cytoplasm, immune reactivity for lipase

Most likely diagnosis ?

Answer 9

Acinar cell carcinoma

neoplasm that releases lots of lipase

Question 10

A patient presents with epigastric pain that radiates to the back, he’s jaundiced and appears cachectic. An abdominal mass is felt on examination.

Most likely diagnosis ?

Answer 10

Ductal adenocarcinoma of the pancreas

Question 11

Where in the pancreas do Ductal adenocarcinomas tend to occur ?

Answer 11

Head of the pancreas

Question 12

what is courvoisiers law?

Answer 12

Presence of a palpable enlarged gallbladder, with painless jaundice means gallstones are unlikely.

Question 13

What is the tumour marker for pancreatic cancer ?

Answer 13

CA19.9

Question 14

Histopathology: Cells arranged in nests or trabecular with granular cytoplasm.

Hypoglycaemic attacks.

Most likely diagnosis ?

Answer 14

Islet cell tumour- Insulinoma

Question 15

List 3 types of neuroendocrine islet cell tumours ?

Answer 15

• Insulinoma
• Gastrinoma
• VIPoma

Question 16

Which syndrome is associated with gastrinomas

Answer 16

Zollinger ellison syndrome

Question 17

What are Rokitansky-Aschoff sinuses ?

Answer 17

Cholecystitis causes fibrosis which means the gallbladder is contracting against an obstruction. This pressure causes diverticula to form which are known as Rokitansky-Aschoff sinuses.

Question 18

what are the 2 components of the exocrine parts of the pancreas

Answer 18

ductal

acinar - where enzymes are made

Question 19

define acute pancreatitis

Answer 19

acute inflammation of the pancreas caused by the aberrant release of pancreatic enzymes

Question 20

describe how duct obstruction causes acute pancreatitis

Answer 20

gallstone distal to where CBD and pancreatic ducts join leads to reflux of bile up the pancreatic duct followed by damage to acini and release of proenzymes which become activated

Question 21

describe different patterns of injury in acute pancreatitis

Answer 21

periductal - necrosis of acinar cells near the ducts (usually secondary to obstruction)
perilobular - necrosis at the edges of the lobules (usually due to poor blood supply)
panlobular - develops from worsening of periductal or perilobular inflammation

Question 22

pathway of inflammation in acute pancreatitis

Answer 22

activated enzymes - acinar necrosis - enzyme release

lipase release - fat necrosis
calcium binds - saponification

Question 23

what are complications of acute pancreatitis

Answer 23

pancreatic pseudocysts formation
abscess
systemic - shock, hypoglycaemia, hypocalcemia

Question 24

features of chronic pancreatitis

Answer 24

caused by: alcohol, haemochromatosis, gallstones, abnormal pancreatic duct anatomy, CF, tumours, idiopathic

chronic inflammation with parenchymal fibrosis and loss of parenchyma
duct strictures with calcified stones with secondary dilations

Question 25

list complications of chronic pancreatitis

Answer 25

malabsorption
DM
pseudocysts (lined by fibrous tissue, contains fluid risk in pancreatic enzymes or necrotic material)
carcinoma of the pancreas

Question 26

describe features of AI pancreatitis

Answer 26

IgG4 related disease
large numbers of IgG4 positive plasma cells
responds well to steroids

Question 27

features of pancreatic tumours

Answer 27

ductal (85% of all neoplasms)
M>F 
5% 5yr survival 
most arise from acini 
acinar-ductal metaplasia

Question 28

RF for pancreatic cancer

Answer 28

smoking
BMI and diet
chronic pancreatitis
DM

Question 29

describe ductal carcinoma of the pancreas

Answer 29

arises from 2 types of dysplastic ductal lesions:

• pancreatic intraductal neoplasia (PanIN)
• intraductal mucinous papillary neoplasm (IMP)

K-Ras mutations in 95%

gritty and grey
invades adjacent structures
tumours at the head present earlier

Question 30

describe metastasis of ductal carcinoma

Answer 30

direct - bile ducts, duodenum
lymphatic - LN
blood - liver
serosa - peritoneum

Question 31

describe pancreatic endocrine neoplasms

Answer 31

usually non-secretory
contain neuroendocrine markers - eg chromogranin
can be associated with MEN1
insulinomas - hypoglycaemia

Question 32

2 types of gallstone

Answer 32

cholesterol - may be single
usually radiolucent

pigment - contain calcium salts of unconjugated bilirubin
often multiple
radiopaque

Question 33

complications of gallstones

Answer 33

bile duct obstruction
acute and chronic cholecystitis
gallbladder cancer
pancreatitis

Question 34

features of gallbladder cancer

Answer 34

adenocarcinoma
90% associated with gallstones
uncommon