Pancreatic disease Flashcards
What is the role of the pancreas and what stimulates it
Produces 2L a day of enzymic HCO3- rich fluid
Secretin
Produced by s-cells of the duodenum, controls gastric acid secretion and buffering with HCO3-
CCK
Responsible for stimulating digestion of fat and protein. Made by I-cells in the
duodenum. Causes release of digestive enzymes.
Exocrine and endocrine functions and secretions
Exocrine
Function - digestive; proteases, lipases and amylase
Secretions - Secretes products into ducts e.g. digestive enzymes
Endocrine
Function - Islets of Langerhans
Alpha cells: glucagon increases blood glucose
Beta cells: insulin decreases blood glucose
Delta cells: somatostatin regulates the above cells
D1: a vasoactive peptide, stimulates the
secretion of H20 into pancreatic system
PP: pancreatic polypeptide, self regulates secretion activities
Secretions - secretes products into bloodstream
Criteria for metabolic syndrome
● Fasting hyperglycaemia >6 mmol/l. ● BP >140/90 ● Central obesity (>94cm in M, >80cm F) ● Dyslipidemia: Decreased HDL cholesterol <1mmol/l & Increased TGs >2mmol/l ● Microalbuminaemia
Diagnosis of diabetes mellitus
Diagnosis: fasting plasma glucose >7 mmol/L or random plasma glucose >11.1 mmol/L
• T1DM – autoimmune destruction of beta cells by CD4+ and CD8+ T-lymphocytes. May
present with DKA. Insulin dependent.
• T2DM – strongly linked to obesity and insulin resistance.
Both give polyuria (osmotic diuresis), polydipsia (raised plasma osmolality) and hyperglycaemia
predisposes to recurrent infections.
Complications of diabetes
Macrovascular
Cardiac - MI
Peripheral vascular disease - claudication, change in colour/temp, poor healing ulcer
Cerebral - CVA
Microvascular
Ocular - diabetic retinopathy
Renal - Glomerulonephritis, pyelonephritis
Neuropathy
Features of acute pancreatitis
Scored using GLASCOW Scale ≥3 -> Severe Pancreatitis
‘I GET SMASHED’: Idiopathic, Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune,
Scorpion venom, Hyperlipidaemia, ERCP, Drugs e.g. thiazides
• Presentation: severe epigastric (or central) pain radiating to back, relieved by sitting forward, vomiting prominent
NB: Amylase only transiently increased. Serum lipase is more sensitive.
• Can result in formation of pseudocyst (a pathological collection of fluid),
associated with alcoholic pancreatitis.
• Histology – Coagulative necrosis
Features of chronic pancreatitis
• Causes: Alcoholism, Cystic Fibrosis, hereditary, pancreatic duct obstruction e.g.
stones/tumour, autoimmune (IgG4 sclerosing)
• Presentation: epigastric pain radiating to back, malabsorption (weight loss and
steatorrhoea) and secondary DM (malabsorption due to lack of enzymes to digest food)
• Histology – very similar to Ca pancreas – fibrosis and loss of exocrine tissue, duct
dilatation with thick secretions, calcification
• Complications – Pseudocysts, diabetes, pancreatic cancer
Features of acinar cell carcinoma
• Rare, older adults, see enzyme production by neoplastic cells
• Presentation: non-specific Sx, abdo pain, wt loss, nausea & diarrhoea. About
• 10% get multifocal fat necrosis and polyarthralgia due to lipase secretion.
• Histopathology: neoplastic epithelial cells with eosinophilic granular
cytoplasm. Positive immunoreactivity for lipase, trypsin and chymotrypsin.
• Prognosis: median survival is 18 months from diagnosis. 5yr survival <10%
Epidemiology, site, risk factors, investigations, management of pancreatic carcinoma
E - 85% of all pancreatic malignancies, average age 60yrs, M>F
S - Normally head of the pancreas
RF - Smoking, diet, genetics (FAP, HNPCC)
I - Bloods (↓Hb, ↑Bili, ↑Ca2+), CT/MRI/ERCP, CA19.9>70IU/mL
M - Chemotherapy is palliative (5-FU), Surgery (15% of cases): Whipple’s procedure – surgical resection, Prognosis v poor: 5yr survival rate <5%
Clinical features of pancreatic carcinoma
Weight loss (cachexia) and anorexia
Upper abdominal and back pain (chronic, persistent and severe)
Jaundice (painless), pruritis, steatorrhoea
DM
Trousseau’s syndrome (25%)- recurrent superficial thrombophlebitis
Ascites
Abdominal mass
Virchow’s node
Courvoisier’s sign
Features of neuroendocrine tumours
Islet cell tumours
Normally body or tail of the pancreas.
Circumscribed 1-5cm. Cells arranged in nests or trabeculae with granular cytoplasm.
May be in MEN 1 patients (~15%). May be multiple lesions.
Unpredictable behaviour
The tumours lie on a spectrum (benign → malignant)
Functional vs. non-functional tumours:
• Functional – present with Sx related to hormone excess
o Insulinoma – hypoglycaemic attacks
o Gastrinoma – Zollinger-Ellison syndrome (high acid output): recurrent ulceration
o Others e.g. VIPoma – diarrhoea
o Glucagonoma – necrolytic migrating erythema
• Non-functional – picked up incidentally on imaging or when grow large enough to produce
symptoms of local disease or metastasis
Types of multiple endocrine neoplasia
A group of genetic syndromes where there are functioning hormone-producing tumours in multiple
organs e.g;
• MEN 1= ‘PPP’ - Parathyroid hyperplasia/adenoma, Pancreatic endocrine tumour (often
phaeo), Pituitary adenoma.
• MEN 2A- Parathyroid, Thyroid, Phaeo
• MEN 2B- Meduallary Thyroid, Phaeo, Neuroma. Marfanoid phenotype
Types and features of pancreatic malformations
• Ectopic Pancreas – esp. stomach, small intestine.
• Pancreas Divisum – failure of fusion of dorsal and ventral buds, increased risk of
pancreatitis.
• Annular pancreas – can present with duodenal obstruction approx. 1yo
