L16- GIT Pathology VIII (pancreas) Flashcards
Pancreatic Insufficiency:
- describe as (1) syndrome
- (2) are the most common causes
- (3) indicates clinical significance
1- malabsorption syndrome
2- pancreatitis, CF
3- >90% functions is lost
Pancreatic Insufficiency, describe exocrine dysfunction
fat malabsorption = steatorrhea:
- lipolytic activity dec faster than proteolysis
- loose, greasy, foul-smelling stool
- vitADEK malabsorption (fat soluble)
Pancreatic Insufficiency, describe endocrine dysfunction
glucose intolerance / DM (not as common as exocrine)
CF, Cl ion transport (CFTR) is defective in (efflux/influx), and leads to (2) and (3)
1- influx
2- high sweat salt concentration
3- thick luminal secretions from GIT, respiratory system, salivary glands, reproductive system
CF:
- (often/occasionally) affects pancreas
- (2) changes are most serious
- (3) is very common complication / occurrence
1- often, 85-90% cases [via obstruction of biliary tree + pancreatic / secretion insufficiency]
2- pulmonary changes
3- superimposed infections
Acute Pancreatitis:
- (1) is the main presenting symptoms
- mostly caused by (2) or (3)- include brief mechanisms
1- abdominal pain (due to enzymatic necrosis + inflammation of pancreas)
2- gallstones: obstruction causes interstitial edema –> BV compression –> ischemia
3- alcohol: direct acinar cell injury
list the ‘other’ causes of acute pancreatitis
- Infections: mumps, coxsackie, myoplasma
- Acute Ischemia: shock, trauma, vascular thrombosis, embolism, vasculitis
- Hyperlipoproteinemias
- Drugs: diuretics, azathioprine, estrogens, sulfonamides
- Hypothermia
Compare presentations of acute and chronic pancreatitis
Acute:
- acute inflammation
- abdominal pain
- elevated pancreatic enzymes in serum
- self-limiting (possibly fatal)
Chronic:
- chronic inflammation and abdominal pain
- progressive loss of endocrine / exocrine function
Acute Pancreatitis:
- (1) is the main presenting symptom with (2) as associated symptoms
- (3) is the cause of the episode progression
1- mild to severe epigastric pain referring to upper back
2- n/v
3- release of enzymes, toxins, CKs —> systemic inflammatory response
list some other not as evident or common acute pancreatic symptoms / clinical features
- leukocytosis
- DIC
- peripheral vascular collapse
- shock (DIC)
- tetany (hypocalcemia)
list lab findings for acute pancreatitis
- raised amylase in first 24hrs
- raised lipase in 48-72hrs
- hypocalcemia
list complications of acute pancreatitis
- ARDS
- ATN
- pancreatic abscess (up to wks after episodes)
Note- recurrent bouts may lead to chronic pancreatitis
Acute Pancreatitis Morphology:
- (1) are the important changes noted
- in severe cases (2) is involved and (3) is usually evident
1- focal fat necrosis (pancreas, peri-pancreas, abdominal cavity) w/ Ca deposition (saponification)
2- necrosis of all pancreatic tissue (acini, ducts, islets)
3- hemorrhage = hemorrhagic pancreatitis
Chronic Pancreatitis:
- caused by (1), common in (2) patients
- (3) list the other causes
1- repeated bouts of mild/moderate pancreatic inflammation (loss of pancreatic parenchyma + replacement with fibrotic tissue)
2- alcoholism (alcohol use)
3- pancreatic divisum (12%)
Rarely: tropical pancreatitis, hereditary pancreatitis, CFTR mutation associated
Note- 40% of the time there is no obvious cause
Chronic pancreatitis:
- possible progression to (1) and (2)
- the malabsorption may be corrected by (3)
- (4) are radiography features
- inc risk of (5)
- 10% of patients have (6)
1- pancreatic insufficiency
2- DM
3- pancreatic enzyme supplements
4- calcifications (X-ray, CT)
5- carcinoma (especially alcohol cases)
6- pseudocysts (10%)
Pancreatic Adenocarcinoma:
- (1) is most common association / possible cause and (2) factors
- strong association with (3), although very rare
- (4) describe location distribution
1- smoking
2- alcohol, fatty rich diet (inconsistent findings)
3- familial relapsing pancreatitis
4- head 60-70%, tail 10-15%, body 5-10%
Pancreatic Adenocarcinoma:
- (1) is main initial symptom, but (2) is considered the first symptom
- (3) is the common marker used (explain any possible drawbacks)
- generally (good/poor) prognosis
1- silent / asymptomatic
2- pain (due to invasion into posterior abdominal wall / nerves)
3- CA19.9: nonspecific, also raised in ovarian cancer
4- poor prognosis
Pancreatic Adenocarcinoma:
- tumor releases (1)
- (2) are complications from tumor of head of pancreas
- (3) complication may be present
1- platelet activating factors + procoagulants
2- obstructive jaundice
3- Trosseau’s syndrome = migratory thrombophlebitis
list the progression of pancreatic adenocarcinoma (include related mutations)
(PanIN = pancreatic intraepithelial neoplasm)
-PanIN-1A / PanIN-1B: telomere shortening, K-RAS mutation (activating)
- PanIN-2: inactivation of CDKN2A
- PanIN-3: inactivation of p53, SMAD4, BRCA2
- invasive adenocarcinoma
Pancreatic NET = (1):
- tumor of (2) cells in pancreas
- either in (3) or (4) form
1- neuroendocrine tumor (Steve Jobs tumor)
2- islet cell tumors
3- functional: insulinoma, gastrinoma, glucagonoma
4- non-functional
Insulinoma:
- cancer of (1) cells
- usually (solitary/multiple) and (benign/malignant)
- (3) is the main symptom that changes with (4- explain)
1- β-cells
2- solitary, benign
3- hypoglycemia
4- accentuated by fasting, relieved by food
Insulinoma Whipple Triad
- low blood glucose
- presence of hypoglycemic Sxs
- resolution when blood glucose is normalized
Note- elevated insulin recognized by high C-peptide
Gastrinomas:
- found in (1) locations
- (2) is main finding leading to (3)
- (4) is usually present at diagnosis
- (5) and (6) is a common associated syndrome
1- pancreas, duodenum, peripancreatic tissue
2- hypergastrinemia
3- multiple ulcers (esophagus, stomach, duodenum, jejunum)
4- local invasion / metastasis
5- Zollinger-Ellison Syndome
6- MEN-1 (multiple endocrine neoplasia)
list main features of Zollinger-Ellison syndrome
- multiple duodenal peptic ulcers
- prominent gastric rugal folds due to inc oxyntic gland mass
- steatorrhea
