Pancreas/Biliary tree pathology

Question 1

Review the normal anatomy of the pancreas

Answer 1

Remember that the pancreas is retroperitoneal, lies next to 2nd part of duodenum

Question 2

Review the histology of the pancreas below

Answer 2

Exocrine: acinar cells (digestive enzymes)

Endocrine: Langerhans cells (insulin, glucagon)

Question 3

Review the embryology of the pancreas below

Answer 3

Dorsal and ventral buds fuse (the mature pancreases itself mostly from dorsal)

Question 4

The most common congenital pancreatic anomaly is ___, resulting from failure of fusion of dorsal and ventral buds @ 8 wks

Answer 4

The most common congenital pancreatic anomaly is pancreas divisum resulting from failure of fusion of dorsal and ventral buds @ 8 wks

Pancreas drains thru minor papilla; some pts predisposed to pancreatitis due to stasis of fluid into the duodenum

Question 5

___ results from abnormal rotation of the ventral pancreatic bud, creating a band around the 2nd part of the duodenum

Answer 5

Annular pancreas results from abnormal rotation of the ventral pancreatic bud, creating a band around the 2nd part of the duodenum

**

In the process of rotating, part of the pancreas encircles the duodenum >> band-like ring around duodenum

May cause duodenal narrowing, nausea, vomiting

Question 6

___ is pancreatic tissue in areas other than the pancreas

Answer 6

Pancreatic tissue in areas other than the pancreas - ectopic pancreas

Question 7

What are the mechanisms of acute pancreatitis? (3)

Answer 7

Duct obstruction, acinar cell injury, defective intracellular transport

**remember that acute pancreatitis >> autodigestion of pancreas by inappropriately activated enzymes**

Question 8

One main difference between acute and chronic pancreatitis is that ___ is inflammation of pancreas that may be reversible if underlying cause removed, whereas ___ is irreversible inflammation of the pancreas w/ fibrosis

Answer 8

One main difference between acute and chronic pancreatitis is that acute pancreatitis is inflammation of pancreas that may be reversible if underlying cause removed, whereas chronic pancreatitis is irreversible inflammation of the pancreas w/ fibrosis

Question 9

What is the pathology below?

Answer 9

Acute pancreatitis

Question 10

What is the pathology below?

Answer 10

Chronic pancreatitis

Question 11

___ is pancreatitis that is a manifestation of IgG4 related systemic disease

T/F: This disorder is a precursor for pancreatic cancer

Answer 11

Type I Autoimmune pancreatitis is pancreatitis that is a manifestation of IgG4 related systemic disease

Falsehood: This disorder mimics pancreatic cancer but responds to steroids

*Storiform fibrosis – fibrosis in all sorts of different directions*

Question 12

What is the pathology below?

Answer 12

Type I autoimmune pancreatitis

**note the lymphocytic infiltrate**

Question 13

___ is autoimmune pancreatitis that is confined to the pancreas and is characterized by neutrophilic microabscesses

Answer 13

Type 2 autoimmune pancreatitis is autoimmune pancreatitis that is confined to the pancreas and is characterized by neutrophilic microabscesses

Question 14

2 categories of non-neoplastic cysts that occur in the pancreas are ___, which may occur in polycystic disease + are unilocular and thin walled, and ___, which isthe most common cause of cysts in the pancreas

Answer 14

2 categories of non-neoplastic cysts that occur in the pancreas are congenital cysts, which may occur in polycystic disease + are unilocular and thin walled, and pseudocyst, which is the most common cause of cysts in the pancreas

*see slide for more info*

Question 15

Pancreatic neoplasms can be divided into cystic and solid.

Name the cystic neoplasms (4)

Name the solid neoplasms (3)

Answer 15

Cystic neoplasms:

Serous cystadenoma

Mucinous cystic neoplasm

IPMN

Solid-Pseudopapillary neoplasm

Solid neoplasms:

Ductal adenocarcinoma

Neuroendocrine tumor

Acinar cell carcinoma

Question 16

What is the pathology below?

Answer 16

Serous cystadenoma

Question 17

What is the pathology below?

Answer 17

Mucinous cystic neoplasm

Question 18

What is the pathology below?

Answer 18

Intraductal papillary mucinous neoplasm

Question 19

___ is a low-grade malignancy that occurs typically in young women and is characterized by pseudopapillae

Answer 19

Soild pseudopapillary neoplasm is a low-grade malignancy that occurs typically in young women and is characterized by pseudopapillae

(see slide)

Large, well circumscribed, solid + cystic, has fake papillary structures

Resection is curative

Question 20

What is the pathology?

Answer 20

Soild pseudopapillary neoplasm

*note that this doesn’t have mucin so don’t confuse w/ IPMN, and also these are fake papillae, not real ones like the IPMNs*

Question 21

Fill in the table below

Answer 21

See below

(you need to master this table + the symptoms of each)

Question 22

Review the slide below on locations of pancreatic cancers

Answer 22

Question 23

___ is the 4th leading cause of cancer death in the US and the major risk factor is smoking. Also characterized by jaundice and Trousseau syndrome

Answer 23

Ductal adenocarcinoma is the 4th leading cause of cancer death in the US and the major risk factor is smoking. Also characterized by jaundice and Trousseau syndrome

*migratory thrombophlebitis*

*precursor neoplasms: IPMNs and Mucinous cystic neoplasms (grossly visible) and Pancreatic intraepithelial neoplasia (microscopic)*

Question 24

What are the precursors to ductal adenocarcinoma? (3)

Answer 24

IPMNs

Mucinous cystic neoplasms

Pancreatic intraepithelial neoplasia (PanIN)

Question 25

Below are slides showing different grades of PanIN lesions. Name the grades

Answer 25

High grade: higher nucleus to cytoplasm ratio More nuclear variation Requires only a few more mutations to become invasive carcinoma

Question 26

Both oncogenes and tumor suppressor gene mutations are involved in ductal carcinoma. The most commonly altered oncogene is \_\_\_, and the 3 most commonly altered tumor suppresor genes are ___ (3)

Answer 26

Both oncogenes and tumor suppressor gene mutations are involved in ductal carcinoma. The most commonly altered oncogene is **KRAS** and the 3 most commonly altered tumor suppresor genes are **CDKN2A (p16), SMAD4, and p53**

Question 27

What is the pathology below?

Answer 27

Ductal adenocarcinoma

Question 28

Name the congenital anomalies of the gallbladder (4)

Answer 28

Abscence Duplication Bilobed Folded fundus

Question 29

\_\_\_ affects the extrahepatic bile ducts and occurs when there is complete or partial obstruction of the lumen of the biliary tree and is one of the most common causes of liver transplantation in children

Answer 29

**Biliary atresia** affects the extrahepatic bile ducts and occurs when there is complete or partial obstruction of the lumen of the biliary tree and is one of the most common causes of **liver transplantation in children** \*\*FA: most common reason for pediatric liver transplantation fibro-obliterative destruction of extrahepatic bile ducts presents as newborn jaundice after 2 wks of life, darkening urine, acholic stools,hepatomegaly (increased direct bili + GGT)

Question 30

\_\_\_\_ results from a fusiform dilation of the common bile duct, and can cause obstructive jaundice in children (mostly) and adults

Answer 30

**Choledochal cysts** results from a fusiform dilation of the common bile duct, and can cause **obstructive jaundice** in children (mostly) and adults \*Rx = excision w/ Roux-en-Y hepaticojejunostomy

Question 31

Review the following slide on gallstones

Answer 31

Question 32

Review the slide below on acute cholecystitis

Answer 32

Question 33

Review the slide below on chronic cholecystitis

Answer 33

Question 34

Review the slide below on gallbladder cancer

Answer 34

Not very common, more common in women and in Latin American countries Poor prognosis because only detected when advanced (review slide 45 for this lecture w/ microscopic eval; most gallbladder cancer - adenocarcinoma)

Question 35

Review the slidebelow on cholangiocarcinoma

Answer 35

\*increased risk in pts w/ ulcerative cholitis, PSC, parasitic infection, choledochal cyst\*

Question 36

Review the slide below on cholaniocarcinoma microscopy

Answer 36

firm, sclerotic mass, mostly adenocarcinoma, similar to gallbladder adenocarcinoma