Pancreas and Gallbladder Pathology Flashcards by Georgia Leggett

What is this?

Exocrine component of pancreas
Acini + canaliculi

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What is this?

Endocrine component of pancreas
Islets of Langerhans

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What is acute pancreatitis?

Acute inflammation of pancreas caused by aberrant release of pancreatic enzymes

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What are 6 general categories of causes of acute pancreatitis?

Duct obstruction

Metabolic/ toxic

Poor blood supply

Infection/ Inflammation

Autoimmune

Idiopathic (15%)

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What are 3 examples of duct obstruction which may lead to acute pancreatitis?

GALLSTONES (50% of all causes)

Trauma

Tumours

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What are 4 examples of metabolic/toxic which may cause acute pancreatitis?

Alcohol (33%) - 5% of alcoholics develop acute pancreatitis

Drugs (e.g. thiazides)

Hypercalcaemia

Hyperlipidaemia

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What are 2 examples of poor blood supply which may cause acute pancreatitis?

Shock

Hypothermia

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What is an example of infection/ inflammation that may cause acute pancreatitis?

Viruses (e.g. mumps)

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Describe the broad pathogenesis of acute and chronic pancreatitis

Duct obstruction
Direct acinar injury

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How can duct obstruction lead to acute pancreatitis?

Gallstone stuck distal to where the common bile duct + pancreatic ducts join leads to: reflux of bile up the pancreatic duct followed by damage to acini + release of proenzymes which then become activated.

Alcohol leads to spasm/ oedema of Sphincter of Oddi + formation of a protein rich pancreatic fluid which obstructs pancreatic ducts.

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What are patterns of injury for acute pancreatitis?

Periductal: Necrosis of acinar cells near ducts (usually secondary to obstruction).

Perilobular: Necrosis at the edges of the lobules (usually due to poor blood supply).

Panlobular: Develops from periductal + perilobular.

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What is the pathophysiology of acute pancreatitis?

Activated enzymes
Acinar necrosis
Further Enzyme release etc.

Ranges from stromal oedema, to haemorrhagic necrosis.

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Give an example of an enzyme released in acute pancreatitis and describe how it causes damage

Lipases lead to fat necrosis:
Lipases hydrolyse TGs to fatty acids
Ca ions bind to free fatty acids forming soaps which precipitate as yellow-white foci

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What are 2 pancreatitic complications of acute pancreatitis?

Pseudocyst: not lined by epithelium.

Abscess: stasis of necrotic material- infected

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What are 3 systemic complications of acute pancreatitis?

Shock

Hypoglycaemia: insulin released by damaged organ + part due to shock

Hypocalcaemia: Ca + FFA precipitate forming fat necrosis

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How could calcium levels fluctuate in acute pancreatitis?

If Hypercalcaemia is cause
could become normocalcaemic as Ca precipitates out with FFAs as fat necrosis

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What is the prognosis of acute pancreatitis?

Overall mortality up to 50% for haemorrhagic pancreatitis

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What is this? Describe the feature seen

Acute pancreatitis
Fat necrosis: yellow/ white nodules

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What is this? Describe the feature seen

Acute pancreatitis
Blue areas: fat necrosis

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What is chronic pancreatitis?

Relapsing or persistent, a/w acute pancreatitis in half of cases.

Relatively uncommon.

Mortality 3% per year.

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What are causes of chronic pancreatitis?

Metabolic/toxic:
* ALCOHOL (80%)
* Haemochromatosis

Duct obstruction:
* Gallstones
* Abnormal pancreatic duct anatomy
* CF (“mucoviscoidosis”)

Tumours

Idiopathic: Autoimmune

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Which immune cells dominate in acute and chronic pancreatitis?

Acute: Neutrophils
Chronic: Lymphocytes

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What is the pattern of injury of chronic pancreatitis?

Chronic inflammation with parenchymal fibrosis + loss of parenchyma.

Duct strictures with calcified stones with secondary dilatations.

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How is the endocrine function affected in chronic pancreatitis?

Islets relatively preserved + doesn’t matter ducts are obstructed
Ultimately islets squeezed out by fibrosis, leads to DM

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Why is haemochromatosis also known as bronzed diabetes?

Bronze: pigmentation in skin Diabetes: chronic pancreatitis from iron deposits initially affecting acini, going on to affect islets

What are 4 complications associated with chronic pancreatitis?

Malabsorption Diabetes mellitus Pseudocyts Carcinoma of the pancreas

What is this? Describe what can be seen

Chronic pancreatitis Pancreatic calcifications

What is this? What can be seen?

Chronic pancreatitis Scarring- pale tissue Cysts forming

What is this? What can be seen?

Chronic pancreatitis Islets surrounded by fibrosis, acini have atrophied

What is a pancreatic pseudocyst?

Lined by fibrous tissue (NOT epithelial lining) Contain fluid rich in pancreatic enzymes +/- necrotic material. A/w acute + chronic pancreatitis. Connect with pancreatic ducts. May resolve, compress adjacent structures, become infected or perforate.

What is this?

Pancreatic pseudocyst

What is this? Describe the histology

Pancreatic pseudocyst Lumen on LHS Fibrous tissue on RHS NO epithelial lining

What is autoimmune pancreatitis also known as?

IgG4 related disease

What is the pathophysiology of autoimmune pancreatitis?

Characterised by large no. of IgG4 +ve plasma cells. May involve pancreas, bile ducts + almost any other part of the body.

What is this?

AI pancreatitis Blue: Pancreatic duct White: Sheath of inflammation

What is this? Describe what can be seen

AI pancreatitis Pancreatic duct surrounded by dense plasma cell infiltrate Background parenchyma replaced by fibrosis Absence of acini

What types of tumours can occur in the pancreas?

**Carcinomas:** * Ductal (85% of all neoplasms) * Acinar **Cystic neoplasms:** * Serous cystadenoma * Mucinous cystic neoplasm **Pancreatic neuroendocrine tumours (Islet cell tumours)**

What is the most common neoplasm of the pancreas? What principle is this consistent with?

Ductal carcinomas (85% of all neoplasms) Same case in any other organ in body with ductal + acinar/ lobular components e.g. Breast

What is the epidemiology and prognosis of ductal carcinoma of the pancreas?

5% of cancer deaths Increasingly common with age, 2M: 1F 5y survival: 5%

What are 4 risk factors for pancreatic carcinomas?

SMOKING BMI + dietary factors Chronic pancreatitis Diabetes

What do ductal carcinomas of the pancreas commonly arise from?

Arise from dysplastic ductal lesions: * Pancreatic Intraductal Neoplasia (PanIN) * Intraducal Mucinous Papillary Neoplasm

What is the most common mutation associated with ductal carcinoma?

K-Ras mutations in 95%

What is the macroscopic appearance of ductal carcinoma?

Gritty + grey Invades adjacent structures Tumours in the head present earlier

What is the microscopic appearance of ductal carcinomas?

**Adenocarcinomas:** Mucin secreting glands set in desmoplastic stroma.

What is this?

Ductal carcinoma

What is this? What can be seen?

Ductal carcinoma Perineural invasion (characteristic of Pancreatic Ca) Glands containing mucin

What are common sites of ductal carcinomas?

Head (60%) Body Tail Diffuse

Where do ductal carcinomas commonly spread?

**Direct:** Bile ducts, duodenum **Lymphatic:** LNs **Blood:** Liver **Serosa:** Peritoneum

What are complications associated with ductal carcinoma?

Due to spread Chronic pancreatitis Venous thrombosis (“migratory thrombophlebitis”)- mucin acts like TF, activates coagulation

What are cystic tumours?

Contain serous or mucin secreting epithelium (cf. ovarian tumours) Usually benign

What is this?

Cystic tumour

What are typical behaviours of pancreatic endocrine neoplasms?

Usually non-secretory Contain neuroendocrine markers e.g. chromogranin Behaviour difficult to predict

What can pancreatic endocrine neoplasms be associated with?

Multiple Endocrine Neoplasia (MEN) 1 syndrome

What is the commonest type of secretory neuroendocrine tumour in the pancreas?

Insulinoma (derived from beta cells)

What is this?

Insulinoma

What is this?

Insulinoma

What are 3 common pathologies associated with the gall bladder?

Gall stones Inflammation Cancer

What are 5 risk factors for gall stones (cholelithiasis)?

**Age + sex:** Increasing age, F\>M **Ethnic + geographic:** e.g. Native Americans **Hereditary:** e.g. disorders of bile metabolism **Drugs:** e.g. oral contraceptive **Acquired disorders:** e.g. rapid weight loss (secrete fats via biliary system)

What are the two types of gall stones?

**Cholesterol (> 50% cholesterol):** May be single, mostly radiolucent. **Pigment (contain calcium salts of unconjugated BR):** Multiple, mostly radio-opaque.

What are 4 complciations associated with gall stones?

Bile duct obstruction Acute + chronic cholecystitis Gall bladder cancer Pancreatitis

What is acute cholecystitis?

Acute inflammation of gall bladder 90% a/w gall stones Acalculus cholecystitis rare

What is chronic cholecystitis?

Chronic inflammation (lymphocytes seen) Fibrosis Diverticula: Rokitansky-Aschoff sinuses 90% contain gall stones

What is this?

Rokitansky-Aschoff sinsus Blue: Lumen Orange: Epithelium lining lumen Green: Outpocketing

What is gall bladder cancer?

Adenocarcinomas 90% a/w gall stones

What is the commonest type of pancreatic neoplasm? A. Neuroendocrine B. Ductal adenocarcinoma C. Serous cyst adenoma

B. Ductal adenocarcinoma

The following are all complications of gall stones except... A. Acute cholecystitis B. Gall bladder cancer C. Haemolytic anaemia D. Obstructive jaundice

C. Haemolytic anaemia

What is this?

Gallbladder with chronic cholecystitis Thickness of wall of gallbladder due to fibrosis Diverticuli: mucosa pushed out into the wall due to raised intraluminal pressure (Rokitansky Ashcoff sinuses)