Pathology-Exocrine Pancreas Flashcards
A new mother brings her 1 month old boy to see you complaining of fussiness and loss of interest in feeding. He has not passed a stool in 7 days and she thought he should be seen. How could the pancreas be causing the child’s condition?
Annular pancreas. During development, the head of the pancreas wraps around the duodenum, causing obstruction.
A patient dies who had not seen a doctor in years. Autopsy of his pancreas revealed hemorrhage and liquefactive necrosis. What caused this change in the patient’s pancreas?
Acute pancreatitis. This happens when trypsinogen is prematurely activated and trypsin activates the other pancreatic enzymes inside the pancreas, resulting in autodigestion of the pancreatic parenchyma.
What types of necrosis do you see in acute pancreatitis?
1) Liquefactive necrosis from autodigestion of pancreatic parenchyma 2) Fat necrosis from saponification of fat surrounding the pancreas.
A 60 year old man presents with a boaring epigastric pain, nausea and vomiting. He says it radiates straight through to the right side of his midback. What are 7 aspects in his history that would lead you to believe he is experiencing acute pancreatitis?
1) Gallstone blockage of the ampulla of Vater 2) Alcohol causes contraction of the sphincter of Oddi 3) Hypercalcemia (activates enzymes) 4) Hyperlipidemia 5) Drugs 6) Scorpion venom 7) Mumps virus 8) Rupture of posterior duodenal ulcer.
A 6 year old boy presents with a boaring pain in the center of his abdomen. He says it radiates straight through to the right side of his mid back. What aspects of his history would lead you to believe he is experiencing acute pancreatitis?
Automobile accident
A 60 year old man presents with a boaring epigastric pain, nausea and vomiting. He says it radiates straight through to the right side of his mid back. He has a history of alcohol abuse and gallstones. What would you expect to see on physical exam and lab results in this patient?
He likely has acute pancreatitis. Physical exam may reveal periumbilical and flank hemorrhage. Labs may reveal elevated serum lipase (more specific for pancreatic damage) and amylase (could also indicate salivary gland pathology).
Why do patients with acute pancreatitis present with hypocalcemia?
Necrosis and saponification of the peripancreatic fat requires Ca2+. Note that hypocalcemia = poor prognosis.
A 60 year old man presents with a boaring epigastric pain, nausea and vomiting. He says it radiates straight through to the right side of his mid back. He has a history of alcohol abuse and gallstones. What complications is this patient at risk for?
Acute pancreatitis can cause shock (digestion of blood vessels in pancreas = hemorrhage), pancreatic pseudocyst (fibrous tissue surrounding pancreatic enzymes and liquefactive necrosis), pancreatic abscess (from E. coli)
A 60 year old man presents with a boaring epigastric pain, nausea and vomiting. He says it radiates straight through to the right side of his mid back. He has a history of alcohol abuse and gallstones. He is a tough guy and did not come in until he noticed an abdominal mass 2 months after symptoms began. What would you expect to see on labs of this patient? What serious complication is he at risk for?
Pancreatitis can result in formation of a pancreatic psuedocyts surrounding pancreatic enzymes and liquefactive necrosis. This would explain his new abdominal mass. Labs would reveal a persistent elevated serum amylase. If the pseudocyst ruptured, you would get release of all the enzymes within the abdominal cavity and he would be at risk for massive hemorrhage.
A 60 year old man presents with a boaring epigastric pain, nausea and vomiting. He says it radiates straight through to the right side of his mid back. He has a history of alcohol abuse and gallstones. He recently developed abdominal and a high fever. Labs reveal a persistently elevated serum amylase. What is causing his condition?
Pancreatic abscess due to E. coli infection.
A 60 year old man presents with a boaring epigastric pain, nausea and vomiting. He says it radiates straight through to the right side of his mid back. He has a history of alcohol abuse and gallstones. He is a tough guy and did not come in until he noticed an abdominal mass 2 months after symptoms began. What would happen if his pancreatic pseudocyst ruptured and enzymes got into his blood stream?
The enzymes would chew on coagulation factors, activating them, causing DIC. They can also chew on the alveolar-capillary interface, causing ARDS.
What causes chronic pancreatitis?
Recurrent bouts of acute pancreatitis cause fibrosis of pancreatic parenchyma, which chronically blocks pancreatic ducts.
Most common cause of chronic pancreatitis in adults? In kids?
Adults: alcohol. Kids: cystic fibrosis (slows ability of pancreas to drain due to thick secretions)
A 37 year old woman presents with epigastric abdominal pain radiating to the back. She has a history of similar episodes and chronically abuses alcohol. What will differentiate her from a patient with acute pancreatitis?
Pancreatic insufficiency (loss of enzyme secretion = fat soluble vitamin A,E,D & K deficiency, steatorrhea), dystrophic calcifications of pancreas, secondary diabetes mellitus (late complication), increased risk for pancreatic carcinoma.
What lab values are not useful in patients with chronic pancreatitis?
Amylase and lipase, much of the pancreas has been destroyed and will not secrete these enzymes.
A 77 year old woman presents with epigastric abdominal pain radiating to the back and weight loss. She has a history of similar episodes and chronically abuses alcohol and tobacco. How do you treat her?
Pancreatic cancer is treated with the Whipple procedure: removal of the pancreatic head and neck, duodenum and gallbladder.
