Lecture 15: Pathology of Pancreas and Gallbladder Flashcards
Congenital pancreatic abnormalities
Pancreas agenesis/hypoplasia (rare, associated with other malformations), pancreas divisum, annular pancreas, heterotopic/ectopic pancreas
Pancreas divisum: main following
Main pancreatic duct drains through smaller minor papilla
Annular pancreas: define, disease, association
Band-like ring of pancreatic tissue around duodenum; can lead to obstruction; trisomy 21
Heterotopic/ectopic pancreas: define, common/rare? Disease?
Pancreatic tissue in an abnormal location (stomach, duodenum); very common; can lead to pain and bleeding if the enzymes accumulate
Pathophysiology of pancreatitis and 3 main ways
Digestion of pancreatic tissue due to inappropriate release of pancreatic enzymes; 1. Obstruction of duct; 2. Acinar cell injury; 3. Defective intraceullar transport
Alcohol can lead to which of the three pancreatitis pathways?
ALL THREE
Classification of pancreatitis (note: one pancreas can have all three patterns)
Interstitial edema, acute necrotizing pancreatitis, acute hemorrhagic pancreatitis
True/False: Acute pancreatitis is reversible
True
How is chronic pancreatitis different from acute?
Ongoing inflammation due to rounds of acute –> release of cytokines like TGFbeta and PDGF (fibrogetic) –> fibrosis and loss of acinar cells
Chronic pancreatitis: three patterns
- Duct dilation with abnormal shapes and calcification; 2. Fibrosis; 3. Atrophy of ACINAR CELLS FIRST (and eventually islet cells)
How to detect chronic pancreatitis on CT scan
Calcification
Chronic pancreatitis: sx, prognosis, complications
Silent until insufficiency occurs: malabsorption and diabetes; 25 year mortality = 50%; pseudocyst and adenocarcinoma
Describe pancreatic pseudocyst. IF a pancreatic cyst has an epithelium, what do you think about?
Most common pancreatic cyst, can be quite large, often peripancreatic (in ST around pancreas), hemorrhagic debris lined by capsule (NOT epithelium); cancer
T/F: Pancreatic ductal adenocarcinoma is preceded by dysplasia
True: there is a series of early lesions called “PanINs”
Almost all pancreatic ductal adenocarcinoma have these two lesions; half have these two
KRAS and p16/CDKN2A; TP53 and SMAD4/DPC4
Pancreatic cancer and genes (top three genetic associations)
- Peutz-Jeghers = 130x; 2. Hereditary pancreatitis = 75x; 3. Family history (>3 relatives) = 20x
Pancreatic cancer: gross
Firm, stellate, poorly defined, head of pancreas
Pancreatic cancer: histological
Irregular, infiltrating, gland-like
Pancreatic cancer: histological findings unique to pancreas (3)
- STRONG desmoplastic reaction; 2. Tends to spread outside pancreas EARLY; 3. Perineural invasion (explains pain presentation and spread)
Trousseau sign
Migratory thrombophlebitis: painful nodules that appear and disappear, usually on legs due to tumor-produced prothrombotic factors
What kind of jaundice and what sign might you get with pancreatic cancer?
Onset of acute, PAINLESS jaundice with dilated gallbaldder (Courvoisier sign)
Virchow’s node
Nontender, firm, fixed left supraclavicular lymph node
Pancreatic cancer: risk factors
Old age, smoking, chronic pancreatitis, hereditary factors
5-year survival for pancreatic cancer. Why so low?
5-10%; typically non-resectable due to growth into SMA
List pancreatic neuroendocrine tumors and the clinical syndrome they cause
Insulinoma, gastrinoma (ZE syndrome), glucagonoma, somatostatinoma, VIPoma (Verner-Morison/WDHA syndrome with watery diarrhea, hypokalemia, achlorhydria)
Pancreatic neuroendocrine tumors tend to be…
Soft, well-differentiated, with SALT AND PEPPER CHROMATIN
How to figure out what kind of neuroendocrine tumor you’re dealing with…However, most of these tumors are…?
Stain for antigen; non-functional
Calculous cholecystitis means…
Accumulation of stones INSIDE gallbladder
Histology of gallbladder disease. This can lead to? If the gallbladder wall is transmurally involved and you get exudate on serosal surface, you get…
Fibrin, blood, neutrophils –> bag of pus = EMPYEMA of gallbladder; gangrenous cholecystitis (if gas-producing = emphysematous)
Chronic cholecystitis means you don’t have _________, but you still have stones
Obstruction (in fact, due to stones)
Histological finding of chronic cholecystitis
Rokitansky-Anschoff sinuses (out pouching of epithelium to wall of gall bladder, like a diverticulum)
Gross findings of chronic cholecystitis (3)
Fibrosis, porcelain gallbladder (calcification) or atrophy
Long-term structural complications of chronic cholecystitis
Fistula (dx with barium enema); e.g. cholecysto-colonic
What do you get if you have a gallbladder fistula into small bowel?
Gallstone ileus (irritation of small bowel due to stones)
Adenocarcinoma of gallbladder characteristic
- Firm growth along wall (like linitus in stomach) or 2. Fungating growth in lumen of gall bladder
Adenocarcinoma of gallbladder: who gets it, risk, prognosis
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)
