Pathology-Pancreas

Question 1

What is the most common congenital anomaly you see with the pancreas?

Answer 1

Pancreatic agenesis and annular pancreas are both very rare. Ectopic pancreas can be seen in 2% of the population in the stomach, duodenum or jejunum.

Question 2

What is the most common complication of ectopic pancreatic tissue?

Answer 2

Bleeding, most often it is exocrine ectopic pancreas.

Question 3

What congenital anomaly can cause pancreatitis?

Answer 3

Pancreas divisum. This happens as a result of failure of the dorsal and ventral pancreas to fuse. Instead of secretions draining through the duct of Wirsung like normal, they drain through the minor sphincter, which can become blocked easily.

Question 4

A patient presents with congenital, non-neoplastic cysts on the pancreas. What are two causes of this?

Answer 4

AD PKD and Von Hipple-Lindau disease.

Question 5

How can you tell the difference between a patient with acute pancreatitis vs. one with chronic pancreatitis by looking at pancreatic acini?

Answer 5

Acute: despite acute inflammation & clotting cascade, pancreatic acini will completely resolve. Chronic: repeated damage to pancreas results in pancreatic fibrosis and breakdown of acinar units.

Question 6

What makes up 80% of acute pancreatitis etiologies? What are some things that make up the other 20%?

Answer 6

Alcoholism (mostly males) and gallstones (mostly females) make up 80%. 10-20% are genetic mutations in PRSS1 and SPINK1 (trypsinogen and trypsin inhibitor).

Question 7

What is the spectrum of acute pancreatitis?

Answer 7

Mild: abdominal pain w/some inflammation. Severe: edema, ischemic damage (activation of clotting cascade), fat necrosis and hemorrhage.

Question 8

What is this section indicative of?

Answer 8

Fat necrosis in acute pancreatitis. Note the dark purple edge indicating hemorrhage and saponification peripherally to it.

Question 9

Mechanism of acute pancreatitis

Answer 9

Obstruction -> edema -> activation of clotting cascade -> ischemia -> release of proteolytic enzymes w/toxic damage from proteolysis (protease), fat necrosis (lipase) and hemorrhage (elastase)

Question 10

When is acute pancreatitis a medical emergency?

Answer 10

Acute abdomen, shock

Question 11

Hemoperitoneum signs of acute pancreatitis

Answer 11

*

Question 12

Which lab test can you do quickly to assess for pancreatitis?

Answer 12

P-amylase rises quicker than lipase.

Question 13

Why are pancreatic pseudocysts not real cysts?

Answer 13

They do not have an epithelial border.

Question 14

Is pseudocyst specific for chronic pancreatitis?

Answer 14

No, it can also form in acute pancreatitis

Question 15

How does fat necrosis differ in chronic vs. acute pancreatitis?

Answer 15

Chronic has fat necrosis through the pancreatic parenchyma. Acute has fat necrosis in the periphery.

Question 16

Hallmark histological sign of chronic pancreatitis.

Answer 16

Loss of glands, fibrosis and little acinar units. Islets of Langerhans may persist.

Question 17

Clinical aspects that will help you pin down acute pancreatitis.

Answer 17

Shock, ARDS, renal failure, DIC, pancreatic abscess, pancreatic pseudocyst and duodenal obstruction.

Question 18

Clinical aspects that will help you pin down chronic pancreatitis.

Answer 18

Pseudocyst, duct obstruction, malabsorption, steatorrhea, secondary diabetes

Question 19

Treatment of acute pancreatitis.

Answer 19

IV rehydration and pancreatic rest (no oral intake)

Question 20

Cystic pancreatic neoplasms most often found in the tail of the pancreas. How do you cure these?

Answer 20

1) Well-circumscribed serous cystadenoma (flat & cuboidal) 2) Well-circumscribed mutinous cyst adenoma (lots of mucus) 3) Solid-pseudopapillary neoplasm (very rare, female predominance). Surgery is curative for all of these.

Question 21

Pancreatic carcinoma

Answer 21

1) Ductal (main tumor) 2) Acinar 3) Pancreatoblastoma (seen in kids)

Question 22

Lifestyle risk factors for ductal pancreatic carcinoma

Answer 22

Cigarette smoking, chronic pancreatitis, diabetes, high fat diet.

Question 23

Hereditary risk factors for ductal pancreatic carcinoma

Answer 23

Hereditary non-polyposis colorectal carcinoma (Lynch II), hereditary breast/ovarian carcinoma (BRCA 2), hereditary pancreatitis (PRSS1, SPINK 1), Peutz-Jeghers (LKB1).

Question 24

Pancreatic cancer progression

Answer 24

Normal -> Pancreatic intraepithelial neoplasia (PanIN) 1A -> K-RAS mutation and telomere shortening -> PanIN-1B -> Inactivation of p16 -> PanIN-2 -> Inactivation of p53, SMAD4, BRCA2 -> PanIN-3 -> Invasive carcinoma

Question 25

Where do you see most ductal carcinomas?

Answer 25

60% Head > 15% body >5% tail. Consequently most present with obstructive jaundice as their first symptom.

Question 26

Why is pancreatic cancer so deadly?

Answer 26

The infiltrate deeply into the lymphatics from the get-go, metastasizes early and presents late.

Question 27

A patient who had a long history of chronic pancreatitis, weight loss, jaundice and abdominal pain dies. Autopsy is shown below of his pancreas. What did he die from?

Answer 27

Pancreatic adenocarcinoma. Note lots of space between acinar units indicating chronic pancreatitis and infiltrating malignant glands in the top image. Note how the tumor migrates along the nerves in the pancreas in the bottom image.

Question 28

Vascular symptoms that may accompany pancreatic adenocarcinoma.

Answer 28

Migratory thrombophlebitis

Question 29

How do you treat pancreatic adenocarcinoma?

Answer 29

Take out the head of pancreas, duodenum and gallbladder…Whipple procedure.

Question 30

Why is pancreatic carcinoma the 4th leading cause of death?

Answer 30

Less than 20% resectable and less than 5% 5 year survival rate…everyone who is diagnosed with this will die.