Pancreas + Peritoneum Path - Nelson

Question 1

What is angiodysplasia?

Answer 1

Lesion of malformed submucosa and mucosa blood vessels

Question 2

HLA DQ2/DQ8

Knee jerk?

Answer 2

Celiac disease

Question 3

Describe the 4 types of diarrhea…

Secretory:
Osmotic:
Malabsorption:
Exudative:

Answer 3

Secretory: Ex. is cholera (toxin constantly activating cAMP with toxin causing Cl and H2O to go into the lumen)
Osmotic: Osmotic forces from unabsorbed lumenal solutes (like lactase deficiency)
Malabsorption: Global fail of nutrient absorption w/ steatorrhea (celiac, pancreatic insufficiency)
Exudative: Inflammatory process with bloody stools

Question 4

Pathophysiology of celiac sprue?

Answer 4

Eat gluten -> immune enteropathy in genetically predisposed -> Damages small bowel, villous atrophy, crypt elongation -> surface area loss leads to global malabsorption issues

Primarily this is a cytotoxic t-cell response

Question 5

What do you see on upper Gi endoscopy with a celiac disease patient?

Answer 5

Scalloped duodenal folds

Question 6

What is abetalipoproteinemia?

Answer 6

Autosomal recessive disease. A mutation in MTP, protein that normally allows transepithelial transport of TG’s and phospholipids

They accumulate in the cell cytoplasm.

Presents with fat soluble vitamin deficiency, lipid membrane defects in RBCs (burr/spur cells), diarrhea, FTT, steatorrhea

Question 7

What is Whipple Disease?

Answer 7

Systemic infection of Tropheryma Whippelii. Foamy macrophages accumulate filled with pathogen in the small bowel (duodenum usually)

Get diarrhea, weight loss, malabsorption and abdominal pain
(before this you get sx of infection: arthritis, fever, lymphadeno, neuro, endocarditis, pulm disease)

Question 8

How is fatty tissue and pacnreatic parenchyma injured in acute pancreatitis?

Answer 8

Inappropriately-released active pancreatic enzyme cause AUTODIGESTION.

Causes edema, fat necrosis, inflammation, proteolysis of parenchyma, and blood vessel destruction

Question 9

What does fat necrosis look like grossly?

Answer 9

Yellow/White chalky Ca deposit

Question 10

What kind of pancreatitis presents with a white fibrotic mass (sort of like pancreatic cancer) and microscopically as periductal lymphoplasmacytic inflammation?

Answer 10

Type 1 autoimmune pancreatitis

Question 11

How would you treat autoimmune pancreatitis doc?

Answer 11

Glucocorticoids

Question 12

Why do some consider IgG4-related disease to be similar to sarcoidosis?

Answer 12

Like sarcoidosis, it has been described in virtually every organ system, linked by the same histopatholgical features

Question 13

You are reading a patient chart and see that they’ve had a pancreatic pseudocyst.
What are the two ways they could have gotten one?

What is a good way to tell a psuedocyst from cancer histologically?

Answer 13

Acute Pancreatitis
OR
Trauma

Pseudocyst lacks an epithelial wall like a cancer would have. It is lined by fibrin and granulation tissue

Question 14

What does a gross specimen of serous cystadenoma look like?

Answer 14

Small 1-3mm cysts containing clear fluid, surrounded by cuboidal cells

Question 15

Mucinous cystic neoplasms generally occur in middle-aged women as a slow-growing painless mass.
Where in the pancreas do they occur?

Answer 15

Tail or body

Large multiloculated cysts filled with mucin

Question 16

Intraductal Papillary Mucinous Neoplasms (IPMN’s) - Arise specifically from pancreatic ducts, which means it communicates with the pancreatic duct system.

What part of the pancreas do IPMN’s affect?

Answer 16

The head of the pancreas

Question 17

Why on earth would someone compare IPMNs to bronchiectasis?

Answer 17

Similar to mucus-blockage which causes dilation of the lung airways, IPMNs cause the pancreatic duct system to widen due to mucus

Question 18

Pancreatic cancer is the 4th leading cause of cancer deaths, usually caused by ductal adenocarcinoma.

Your patient has a friend who died of this and he wants some advice on risk factors to avoid:

Answer 18

Risk factors:

smoking, obesity, inactivity, diabetes, pancreatitis,

Question 19

Where do ductal adenocarcinomas occur in the pancreas?

Why are they often unresectable?

Answer 19

The head of the pancreas

Often unresectable because they have already spread once they’ve been detected

Question 20

Typical presentation of ductal adenocarcinoma?

Answer 20

• 80% in people over 60

- Obstructive jaundice, weight loss, and belly pain

Question 21

What is the whipple procedure and what is it used for?

Answer 21

Use for pancreatic cancer

Basically you chop out the stomach, duodenum, gallbladder, common bile duct, and head of the pancreas.
Then you attach the hepatic duct to the jejunum as well as what’s left of the stomach. The pancreas is attached proximal to the hepatic duct

Question 22

What type of pancreatic tumor occurs in young women?

What type occurs in kids?

Answer 22

Young women:
-Solid-pseudopapillary tumor

Children:
-Pancreatoblastoma
(blast - kids)

Question 23

What is the difference in gross appearance of a pancreatic neuroendocrine tumor vs a pancreatic adenocarcinoma?

Answer 23

Pancreatic neuroendocrine

• body or tail
• well-circumscribed tumor

Pancreatic Adenocarcinoma

• head of pancreas
• ill defined

Question 24

Which has a better clinical course? Pancreatic neuroendocrine or adenocarcinomas?

Answer 24

Neuroendocrine usually better because they have longer course (5-10yrs), often adenocarcinomas invade adjacent tissue before they are discovered. (1-2 yrs)

Question 25

What types of syndromes can pancreatic neuroendocrine tumor produce through abnormal hormone secretion?

Answer 25

Hyperinsulin secretion: hypoglycemia

Zollinger-Ellison Syndrome: Increased gastric secretion and ulcers

VIP secretion: watery diarrhea

Question 26

Most common complication of ascites?

Answer 26

Spontaneous bacterial peritonitis

Question 27

To find the SAAG, you measure the concentration albumin in serum and subtract albumin in the ascites fluid.

What does a SAAG below 1.1 and a SAAG above 1.1 indicate?

Answer 27

Below 1.1
Exudative = malignancy, inflammation, TB, pancreatitis, nephrotic syndrome

Above 1.1
Transudate = cirrhosis, metastasis, budd-chiari, cardiac disease

Question 28

What is budd-chiari syndrome?

Answer 28

Budd–Chiari syndrome is a condition caused by occlusion of the hepatic veins that drain the liver.
It presents with the classical triad of abdominal pain, ascites and liver enlargement.

Question 29

Looking at your patient’s CT you see that there appears to be a mass in the peritoneum. You believe it is a metastatic tumor. What would be your first two bets for the origin of the metastasis?

Answer 29

Ovarian cancer and pancreatic cancer

Question 30

A 25 year old recent;y passed currant jelly stool. He complains of abdominal pain. On imaging study you see dilated loops of bowel with air-fluid level.

What is it?

Answer 30

Intussusception

Also target sign from the right angle