Lecture 15: Pathology of Pancreas and Gallbladder

Question 1

Congenital pancreatic abnormalities

Answer 1

Pancreas agenesis/hypoplasia (rare, associated with other malformations), pancreas divisum, annular pancreas, heterotopic/ectopic pancreas

Question 2

Pancreas divisum: main following

Answer 2

Main pancreatic duct drains through smaller minor papilla

Question 3

Annular pancreas: define, disease, association

Answer 3

Band-like ring of pancreatic tissue around duodenum; can lead to obstruction; trisomy 21

Question 4

Heterotopic/ectopic pancreas: define, common/rare? Disease?

Answer 4

Pancreatic tissue in an abnormal location (stomach, duodenum); very common; can lead to pain and bleeding if the enzymes accumulate

Question 5

Pathophysiology of pancreatitis and 3 main ways

Answer 5

Digestion of pancreatic tissue due to inappropriate release of pancreatic enzymes; 1. Obstruction of duct; 2. Acinar cell injury; 3. Defective intraceullar transport

Question 6

Alcohol can lead to which of the three pancreatitis pathways?

Answer 6

ALL THREE

Question 7

Classification of pancreatitis (note: one pancreas can have all three patterns)

Answer 7

Interstitial edema, acute necrotizing pancreatitis, acute hemorrhagic pancreatitis

Question 8

True/False: Acute pancreatitis is reversible

Answer 8

True

Question 9

How is chronic pancreatitis different from acute?

Answer 9

Ongoing inflammation due to rounds of acute –> release of cytokines like TGFbeta and PDGF (fibrogetic) –> fibrosis and loss of acinar cells

Question 10

Chronic pancreatitis: three patterns

Answer 10

1. Duct dilation with abnormal shapes and calcification; 2. Fibrosis; 3. Atrophy of ACINAR CELLS FIRST (and eventually islet cells)

Question 11

How to detect chronic pancreatitis on CT scan

Answer 11

Calcification

Question 12

Chronic pancreatitis: sx, prognosis, complications

Answer 12

Silent until insufficiency occurs: malabsorption and diabetes; 25 year mortality = 50%; pseudocyst and adenocarcinoma

Question 13

Describe pancreatic pseudocyst. IF a pancreatic cyst has an epithelium, what do you think about?

Answer 13

Most common pancreatic cyst, can be quite large, often peripancreatic (in ST around pancreas), hemorrhagic debris lined by capsule (NOT epithelium); cancer

Question 14

T/F: Pancreatic ductal adenocarcinoma is preceded by dysplasia

Answer 14

True: there is a series of early lesions called “PanINs”

Question 15

Almost all pancreatic ductal adenocarcinoma have these two lesions; half have these two

Answer 15

KRAS and p16/CDKN2A; TP53 and SMAD4/DPC4

Question 16

Pancreatic cancer and genes (top three genetic associations)

Answer 16

1. Peutz-Jeghers = 130x; 2. Hereditary pancreatitis = 75x; 3. Family history (>3 relatives) = 20x

Question 17

Pancreatic cancer: gross

Answer 17

Firm, stellate, poorly defined, head of pancreas

Question 18

Pancreatic cancer: histological

Answer 18

Irregular, infiltrating, gland-like

Question 19

Pancreatic cancer: histological findings unique to pancreas (3)

Answer 19

1. STRONG desmoplastic reaction; 2. Tends to spread outside pancreas EARLY; 3. Perineural invasion (explains pain presentation and spread)

Question 20

Trousseau sign

Answer 20

Migratory thrombophlebitis: painful nodules that appear and disappear, usually on legs due to tumor-produced prothrombotic factors

Question 21

What kind of jaundice and what sign might you get with pancreatic cancer?

Answer 21

Onset of acute, PAINLESS jaundice with dilated gallbaldder (Courvoisier sign)

Question 22

Virchow’s node

Answer 22

Nontender, firm, fixed left supraclavicular lymph node

Question 23

Pancreatic cancer: risk factors

Answer 23

Old age, smoking, chronic pancreatitis, hereditary factors

Question 24

5-year survival for pancreatic cancer. Why so low?

Answer 24

5-10%; typically non-resectable due to growth into SMA

Question 25

List pancreatic neuroendocrine tumors and the clinical syndrome they cause

Answer 25

Insulinoma, gastrinoma (ZE syndrome), glucagonoma, somatostatinoma, VIPoma (Verner-Morison/WDHA syndrome with watery diarrhea, hypokalemia, achlorhydria)

Question 26

Pancreatic neuroendocrine tumors tend to be…

Answer 26

Soft, well-differentiated, with SALT AND PEPPER CHROMATIN

Question 27

How to figure out what kind of neuroendocrine tumor you’re dealing with…However, most of these tumors are…?

Answer 27

Stain for antigen; non-functional

Question 28

Calculous cholecystitis means…

Answer 28

Accumulation of stones INSIDE gallbladder

Question 29

Histology of gallbladder disease. This can lead to? If the gallbladder wall is transmurally involved and you get exudate on serosal surface, you get…

Answer 29

Fibrin, blood, neutrophils –> bag of pus = EMPYEMA of gallbladder; gangrenous cholecystitis (if gas-producing = emphysematous)

Question 30

Chronic cholecystitis means you don’t have _________, but you still have stones

Answer 30

Obstruction (in fact, due to stones)

Question 31

Histological finding of chronic cholecystitis

Answer 31

Rokitansky-Anschoff sinuses (out pouching of epithelium to wall of gall bladder, like a diverticulum)

Question 32

Gross findings of chronic cholecystitis (3)

Answer 32

Fibrosis, porcelain gallbladder (calcification) or atrophy

Question 33

Long-term structural complications of chronic cholecystitis

Answer 33

Fistula (dx with barium enema); e.g. cholecysto-colonic

Question 34

What do you get if you have a gallbladder fistula into small bowel?

Answer 34

Gallstone ileus (irritation of small bowel due to stones)

Question 35

Adenocarcinoma of gallbladder characteristic

Answer 35

1. Firm growth along wall (like linitus in stomach) or 2. Fungating growth in lumen of gall bladder

Question 36

Adenocarcinoma of gallbladder: who gets it, risk, prognosis

Answer 36

Females, associated with gall stones and also with fungal infections in some parts of the world; poor prognosis (5 year = 5% due to difficult resection and silent growth)