Histopathology - Pancreas and gallbladder

Question 1

Which component of the pancreas is the first to be affected in chronic pancreatitis?

Answer 1

Exocrine component

Question 2

The islets of Langerhans are part of which component of the pancreatic system?

Answer 2

The endocrine system

A cells - glucagon to increase blood glucose
B cells - insulin to decrease blood glucose
D cells - somatostatin to regulate a and B cells
D1 - vasoactive peptide, stimulates secretion of water into pancreatic system
PP - pancreatic polypeptide, self regulates secretion activities

Question 3

Which cells are part of the exocrine system?

Answer 3

Ducts and acinar cells

Question 4

Commonest causes of acute pancreatitis

Answer 4

Gallstones 50%
Duct obstruction —> bile reflux up the pancreatic duct — damage of acinar cells — release of pro enzymes which then become activated

Alcohol 33%
Spasm of the sphincter of Oddi — formation of protein reich pancreatic fluid — obstruction of the pancreatic duct

Question 5

Electrolyte imbalance that causes pancreatitis + electrolyte imbalance that is cause by pancreatitis

Answer 5

Hypercalcaemia causes pancreatitis

Pancreatitis causes hypocalcaemia (released FFA bind to free calcium)

Therefore if hypercalcaemia is the cause of acute pancreatitis, calcium levels falls down to normal in acute pancreatitis

Question 6

Periductal vs perilobular injury in acute pancreatitis

Answer 6

Periductal - secondary to obstruction (necrosis of acinar cells near ducts)

Perilobular - due to ischaemia (necrosis at the edges of the lobules)

(Panlobular develops from both periductal and perilobular

Question 7

Which scoring system is used is used to score pancreatitis?

Answer 7

Glasgow

> = 3 indicates severe pancreatitis

Question 8

Commonest cause of chronic pancreatitis

Answer 8

Alcohol 80%

Question 9

Pathogenesis of acute pancreatitis

Answer 9

Duct obstruction (gallstones + alcohol)

Direct acinar injury (all the rest)

Question 10

Presentation of chronic pancreatitis

Answer 10

Epigastric pain
Malabsorption - weight loss, steatorrhoea
DM

Question 11

Chronic pancreatitis hsitology

Answer 11

Loss of exocrine tissue
Calcification (diagnostic of chronic pancreatitis)
Fibrosis
Duct strictures with calcified stones with secondary duct dilations

Question 12

What is a pancreatic pseudocyst?

Answer 12

Lined by fibrous tissue
Contain pancreatic enzymes or necrotic material
Connect with pancreatic ducts

Question 13

Antibody related to autoimmune pancreatitis

Answer 13

IgG4

Produced by IgG4 plasma cells

Question 14

Commonest tumour of the pancreas

Answer 14

Ductal (85%) (k-ras mutation)

The rest are acinar (increased serum lipase)

Question 15

Marker of pancreatic damage

Answer 15

Lipase > amylase

Question 16

Which cells do most cancers of the pancreas arise form?

Answer 16

The acinar cells
But the most common pancratic cancer is ductal carcinoma

This is due to acinar-ductal dysplasia where acinar cells become ductal cells

Question 17

Acinar cell carcinoma histology

Answer 17

Neoplastic cells with oesonophilic granular cytoplasm

Positive immunoreactivity for lipase, trypsin, chymotrypsin

Question 18

Dysplastic ductal lesions giving rise to ductal carcinoma

Answer 18

Pancreatic Intraductal Neoplasia
Intraductal Mucinous Papillary Neoplasm

K-ras mutations in 95% of cases

Question 19

What is Trousseaur’s syndrome?

Answer 19

Migratory thrombophlebitis

Can be a sign of ductal pancreatic carcinoma

Question 20

Electrolyte abnormality in ductal pancreatic carcinoma

Answer 20

Hypercalcamia

Question 21

Ductal carcinoma microscopic appearance

Answer 21

Adenocarcinoma - mucin secreting glands set in desmoplastic stroma

Question 22

Characteristic invasion of pancreatic carcinomas

Answer 22

Perineural invasion

Question 23

Commonest site of ductal carcinoma

Answer 23

Head > body > tail

Tumours on the head present earlier

Question 24

Commonest site of pancreatic endocrine tumours/ neuroendocrine tumours (e.g. islet cell tumour)

Answer 24

Tail > body > head

Question 25

Commonest type of secretory pancreatic tumour

Answer 25

Insulinoma

Derived form b cells

Sx - Whipple’s triad
Glucose <50mg/dl
Symptoms + signs of hypoglycaemia
Relief of symptoms on glucose administration

Question 26

Give some other examples of neuroendocrine tumours

Answer 26

Gastrinoma - Zollinger Ellison syndrome - high acid output = recurrent ulceration
VIPoma (diarrhoea)
Glucagonoma - necrolytic migrating erythema

Question 27

What do neuroendocrine tumours stain with?

Answer 27

Stained with neuroendocrine markers e.g. chromogranin stain

Question 28

Most neuroendocrine tumour are…

Answer 28

Non-secretory

Question 29

Which MEN syndrome might pancreatic endocrine tumours be associated with?

Answer 29

MEN1

Pituitary
Parathyroid
Pancreatic endocrine tumours

Question 30

MEN1 vs MEN2A vs MEN2B

Answer 30

MEN 1 - pituitary, parathyroid, pancreatic endocrine tumours
MEN2A - parathyroid, thyroid, phaeo
MEN2B - medullary thyroid, phaeo, neuromas, Marfanoid habitus

Question 31

Types of gallstones

Answer 31

Cholesterol

• radio-Lucent — needs USS
• single

Pigement

• radio-opaque — XR
• mulitple
• conatin calcium salts of unconjugated bilirubin

Question 32

Gallbladder cancer type and cause

Answer 32

Adenocarcinoma

90% associated with gallstones

Question 33

What are Rokitansky Aschoff sinuses

Answer 33

Diverticula of the gallbladder

Cause by the gallbladder contracting against an obstruction
Feature of chronic cholecystitis (in chronic cholecystitis the gallbladder will be small and fibrosed)