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Block 10 Week 4 > Usera > Exocrine Pancreas > Flashcards

Usera > Exocrine Pancreas Flashcards

1
Q

what does “pankreas” mean in greek?

A

“all flesh”

obviously this is the most important card of the deck

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2
Q

where does the pancreas extend from & to?

A

from the C loop of the duodenum

to the hilum of the spleen

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3
Q

how long is the pancreas & how much does it weigh?

A

20 cm long

85-90 g

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4
Q

what % of the pancreas is exocrine?

A

80-85%

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5
Q

what are the 5 parts of the pancreas?

A 
uncinate
head
neck
body
tail
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6
Q

what are the 2 ducts and the 1 papilla you need to care about?

A

DUCTS: santorini & wirsung

Papilla of Vater

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7
Q

which duct is superior & which is inf?

A 
superior = santorini
inf = wirsung
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8
Q

what is pancreatic agenesis?

A

congenital absence of the pancreas

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9
Q

what gene is assoc w/ pancreatic agenesis?

A

PDX1

pancreatic & duodenal homeobox-1 gene

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10
Q

what chromosome holds PDX1?

A

13q12.1

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11
Q

what is pancreatic agenesis assoc w/?

A

usu assoc w/ other congenital anomalies that are incompatible w/ life

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12
Q

what 2 dzs can pancreatic agenesis cause?

A

DM

malabsorption

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13
Q

what are the 4 possible congenital pancreatic anomalies?

A
  1. agenesis
  2. pancreas divisum
  3. annular pancreas
  4. ectopic pancreas
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14
Q

which congenital pancreatic abnormality is the most common?

A

pancreas divisum

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15
Q

what is the incidence of pancreas divisum?

A

3-10%

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16
Q

what is pancreas divisum?

A

failure of fusion of fetal duct systems of dorsal & ventral pancreatic primordia
(i.e. santorini & wirsung don’t connect)

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17
Q

where does the majority of pancreatic drainage happen in pancreas divisum?

A

dorsal pancreatic duct & minor papilla (what should be the duct of santorini)

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18
Q

where does the head of the pancreas drain in pancreas divisum?

A

duct of wirsung & papilla of vater (major papilla)

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19
Q

what is annular pancreas?

A

pancreas completely (or not) encircles 2nd portion of duodenum, occasionally obstructing the proximal duodenum

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20
Q

what gender is more commonly affected by annular pancreas?

A

male

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21
Q

is annular pancreas rare?

A

YES

& it may not become apparent until later in life

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22
Q

how does the pancreas develop?

A

from 2 buds
big = dorsal bud = body & tail
small = ventral bud = head + parts of hepatic duct & gallbladder

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23
Q

how does annular pancreas form?

A

(believed to be d/t)

abnormalities in migration of the ventral bud so that the 2 buds join to encircle the duodenum

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24
Q

what is the drainage of an annular pancreas?

A

pancreatic duct may drain into main duct or just the duodenum

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25
Q

when does annular pancreas commonly present?

A

4th-5th decade of life

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26
Q

what are the sx of annular pancreas?

A 
commonly asymptomatic
in adults:
upper abd colicky pain
postprandial fullness
vomiting
pancreatitis
peptic ulcers
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27
Q

what is annular pancreas assoc w/?

A

duodenal stenosis/atresia

50% assoc w/ other congenital issues w/ heart, trachea, esophagus, & intestinal malrotation

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28
Q

what is ectopic pancreas?

A

pancreatic tissue in locations other than the pancreas

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29
Q

what % of autopsies have ectopic pancreas?

A

2%

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30
Q

where does ectopic pancreas usu happen?

A

SUBMUCOSA of the stomach, duodenum, jejunum, meckel diverticulum, or ileum

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31
Q

what structures are in ectopic pancreas?

A

acini

occasional goblet cells

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32
Q

what is pancreatitis?

A

inflammation of the pancreas w/ injury of the exocrine pancreatic tissue

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33
Q

what is the range of sx of pancreatitis?

A

mild self-limited dz to life-threatening acute inflammatory process

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34
Q

what is the duration of pancreatitis?

A

ranges from transient attack to permanent loss of fxn

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35
Q

how does acute pancreatitis resolve?

A

treat underlying cause > exocrine tissue can return to normal fxn

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36
Q

how does chronic pancreatitis end up?

A

irreversible injury w/ loss of pancreatic exocrine tissue

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37
Q

define “acute pancreatitis”

A

reversible pancreatic parenchymal injury assoc w/ inflammation

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38
Q

is acute pancreatitis rare?

A

no, it’s common

annual incidence = 10-20 cases/100,000 in western countries

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39
Q

what accounts for 80% of acute pancreatitis cases?

A

biliary tract dz & alcohol

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40
Q

what happens in 35-60% of acute pancreatitis cases?

A

presents w/ gallstones

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41
Q

about 5% of pts w/ gallstones will develop what?

A

acute pancreatitis

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42
Q

what are the male:female ratios of biliary tract dz & alcohol?

A

biliary: 1:3
alcohol: 6:1

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43
Q

what are the 7 causes of acute pancreatitis?

A
  1. obstruction of pancreatic ductal system
  2. meds
  3. infxn
  4. metabolic disorders
  5. ischemic injury
  6. trauma
  7. genetic
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44
Q

what med can cause acute pancreatitis?

A

azathioprine

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45
Q

what infxn can cause acute pancreatitis?

A

mumps

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46
Q

what are 4 causes of pancreatic ductal system obstruction?

A
  1. periampullary neoplasm (cx in pancreatic head)
  2. choledochocele
  3. biliary sludge
  4. parasites
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47
Q

what is choledochocele?

A

congenital cystic dilatation of the CBD

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48
Q

what parasites can obstruct pancreatic ducts?

A

ascaris

clonorchis

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49
Q

what metabolic disorders can cause acute pancreatitis?

A

HYPERLIPOPROTEINEMIA
alcohol
hypercalcemia

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50
Q

what can cause ischemic injury to result in acute pancreatitis?

A

shock
vasculitis
atheroembolism

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51
Q

what types of trauma can cause acute pancreatitis?

A

gallstones

iatrogenic (operative injury or procedures w/ dye)

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52
Q

what is a genetic cause of acute pancreatitis?

A

PRSS1 & SPINK1

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53
Q

what does PRSS1 code for?

A

cationic trypsinogen

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54
Q

what does SPINK1 code for?

A

trypsin inhibitor

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55
Q

what 5 things can you find on histology of acute pancreatitis?

A
  1. microvascular leakage > edema
  2. fat necrosis
  3. neutrophils
  4. proteolytic destruction
  5. BV destruction
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56
Q

what causes fat necrosis in acute pancreatitis?

A

lipolytic enzymes

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57
Q

what causes acute inflammation in acute pancreatitis?

A

neutrophils

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58
Q

what is destroyed via proteolytic destruction in acute pancreatitis?

A

pancreatic parenchyma

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59
Q

what are the 2 most common sx of acute pancreatitis?

A

abdominal & back pain

epigastric tenderness

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60
Q

what are the 4 less common sx of acute pancreatitis?

A

N/V
low-grade fever
HoTN
subQ fat necrosis

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61
Q

what are the lab findings assoc w/ acute pancreatitis?

A

LIPASE

serum amylase

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62
Q

how does serum amylase act in acute pancreatitis?

A

rises w/i 2-24 hours of onset, returns to normal w/i 2-3 days
high sensitivity, low spec

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63
Q

T/F: higher amylase levels indicate more severe acute pancreatitis

A

FALSE

but they DO increase specificity

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64
Q

if you have a persistently elevated serum amylase, what is most likely happening?

A

NOT acute pancreatitis

maybe pseudocyst

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65
Q

what test is specific for acute pancreatitis?

A

LIPASE!

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66
Q

how does lipase act in acute pancreatitis?

A

rise parallels the inc in amylase, but lipase REMAINS ELEVATED for up to 2 weeks

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67
Q

T/F: full-blown acute pancreatitis is an emergency

A

TRUE

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68
Q

what are 5 serious complications of acute pancreatitis that make it an emergency?

A
  1. leukocytosis
  2. hemolysis
  3. DIC
  4. ARDS
  5. diffuse fat necrosis
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69
Q

what are the 3 treatments for acute pancreatitis?

A
  1. “REST”
  2. IV fluids
  3. analgesics
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70
Q

what is “REST”?

A

total restriction of oral intake (NPO)

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71
Q

what are the top 3 sequelae of acute pancreatitis?

A
  1. death
  2. pancreatic abscess
  3. pancreatic pseudocyst
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72
Q

define “chronic pancreatitis”

A

inflammation of the pancreas w/ irreversible destruction of the exocrine pancreatic parenchyma, fibrosis
later stages: destruction of endocrine pancreatic parenchyma

73
Q

what is the prevalence of chronic pancreatitis?

A

0.4-0.5%

74
Q

what is the most common cause of chronic pancreatitis?

A

chronic alcohol abuse

75
Q

who gets chronic pancreatitis most often?

A

middle-aged men

76
Q

what % of chronic pancreatitis cases have unk etiology?

A

40%

77
Q

what is tropical pancreatitis?

A

poorly characterized heterogeneous dz in Africa & Asia

78
Q

besides alcohol, what are 4 causes of chronic pancreatitis?

A
  1. long-standing obstruction
  2. hereditary pancreatitis
  3. CFTR gene mutations
  4. tropical pancreatitis
79
Q

what can cause a long-standing obstruction & result in chronic pancreatitis?

A 
pseudocysts
calculi
trauma
neoplasm
pancreas divisum
80
Q

what are the 2 types of hereditary pancreatitis that can result in chronic pancreatitis?

A

germline mutations in…
PRSS1 (auto dom)
SPINK1 (auto rec)

81
Q

25-30% of pts w/ chronic pancreatitis have what kind of gene mutation?

A

CFTR

82
Q

how does a CFTR gene mutation cause chronic pancreatitis?

A

DEC bicarb secretion from pancreatic ductal cells > protein plugging of ducts/tubules

83
Q

what are the 2 pathogeneses (genesises?) of chronic pancreatitis?

A
  1. ductal obstruction by concretions

2. toxic effects

84
Q

what can cause BOTH types of chronic pancreatitis pathogenesis?

A

alcohol
inc protein in ductal juice > calcify > obstruct
metabolize & cause toxic effects

85
Q

what are the 6 components of alcohol-induced oxidative stress in the pancreas?

A
  1. free radicals in acinar cells
  2. activate transcription factors > chemokines
  3. lysosome + zymogen granule fusion
  4. acinar cell necrosis
  5. inflammation
  6. fibrosis
86
Q

what are the gross findings assoc w/ chronic pancreatitis?

A

fibrosis

calcification

87
Q

what are the histo findings assoc w/ chronic pancreatitis?

this is important

A
  1. parenchymal FIBROSIS
  2. less acini w/ islet sparing (preservation of lobule structure)
  3. dilatation of pancreatic ducts
  4. chronic inflammation
88
Q

how are the islets & acini affected in chronic pancreatitis?

A

reduced # & size of acini, but islets are mostly spared

89
Q

why is there variable dilatation of the pancreatic ducts in chronic pancreatitis?

A

protein plugs/concretions
epithelial atrophy or hyperplasia
squamous metaplasia

90
Q

what is the infiltrate of autoimmune pancreatitis?

A

duct-centric mixed inflammatory cell infiltrate

91
Q

what type of cells are increased in autoimmune pancreatitis?

A

IgG4-producing plasma cells

92
Q

what kind of -itis is assoc w/ autoimmune pancreatitis?

A

venulitis

93
Q

what is the treatment for autoimmune pancreatitis?

A

steroids

94
Q

how does chronic pancreatitis present?

A
  1. repeated ATTACKS of mild-severe abd pain
  2. persistent abd & back pain
  3. jaundice
95
Q

what can precipitate an attack of chronic pancreatitis?

A

booze
overeating
drugs that inc tone of the sphincter of oddi

96
Q

T/F: chronic pancreatitis is usu life-threatening

A

FALSE

usu not

97
Q

what is the 20-25 year mortality rate of chronic pancreatitis?

A

50%

98
Q

what are the sequelae of chronic pancreatitis?

A
  1. pancreatic exocrine insuff w/ malabsorption
  2. diabetes
  3. chronic pain
  4. pancreatic pseudocysts
99
Q

what does chronic pancreatitis maybe predispose you to?

A

cancer

100
Q

what are the 5 types of cystic lesions of the pancreas?

A
  1. congenital
  2. pseudo
  3. mucinous cystic lesions
  4. nonmucinous cystic lesions
  5. solid pseudopapillary tumors
101
Q

how do you get a congenital pancreatic cyst?

A

anomalous dvlpmnt of the pancreatic ducts

102
Q

what is the gross morphology of a congenital pancreatic cyst?

A

unilocular
thin walls
up to 5cm diameter

103
Q

what type of cells line a congenital pancreatic cyst?

A

uniform cuboidal epithelium

104
Q

what encloses a congenital pancreatic cyst?

A

thin fibrous capsule

105
Q

what is a congenital pancreatic cyst filled w/?

A

clear serous fluid

106
Q

are congenital pancreatic cysts sporadic or inherited?

A

sporadic

107
Q

what 2 syndromes are congenital pancreatic cysts assoc w/?

A
  1. ADPKD

2. von hippel lindau

108
Q

what encases a pancreatic pseudocyst?

A

granulation tissue

no epithelial lining bc it’s a PSEUDO cyst

109
Q

what is a pancreatic pseudocyst?

A

fluid collection >4wks old, surrounded by a defined wall

110
Q

what is in a pancreatic pseudocyst?

A

necrotic-hemorrhagic material rich in pancreatic enzymes (juice)

111
Q

T/F: pancreatic pseudocysts are always single

A

FALSE

can be single or multiple

112
Q

how big are pancreatic pseudocysts?

A

can be small or large, up to 30 cm diameter

113
Q

most pancreatic pseudocysts communicate w/ what?

A

pancreatic ductal system

114
Q

75% of pancreatic cysts are what type of cyst?

A

pancreatic pseudocyst

115
Q

what can cause a pancreatic pseudocyst?

A

acute or chronic pancreatitis

trauma

116
Q

what happens if a pancreatic pseudocyst expands?

A

abd pain
duodenal/biliary obstruction
vascular occlusion
fistula formation into adj viscera, pleural space, pericardium

117
Q

what are 4 complications of pancreatic pseudocysts?

A
  1. spontaneous infxn
  2. pseudoaneurysm
  3. pancreatic ascites
  4. pleural effusion
118
Q

how do you dx pancreatic pseudocyst?

A

aspirated fluid will have
INC amylase
DEC CEA
INC CA19-9

119
Q

what are some clinical clues for pancreatic pseudocyst?

A

pancreatic ascites or pleural effusion

absence of septae w/i cyst

120
Q

what are the 2 types of mucinous cystic lesions?

A
  1. mucinous cystic neoplasm

2. intraductal papillary mucinous neoplasm +/- invasive carcinoma

121
Q

what sex is disproportionately affected by mucinous cystic neoplasm?

A

WOMEN get 95% of these!

122
Q

what can mucinous cystic neoplasm be assoc w/?

A

invasive carcinoma

123
Q

where do mucinous cystic neoplasms usu arise in the pancreas?

A

in the body or tail

124
Q

how do mucinous cystic neoplasms present?

A

painless slow-growing masses

125
Q

what do mucinous cystic neoplasms look like grossly?

A

large

filled w/ thick mucin

126
Q

T/F: mucinous cystic neoplasms connect w/ the pancreatic ductal system

A

FALSE

they do NOT

127
Q

what is the lining of mucinous cystic neoplasms?

A

COLUMNAR mucinous epithlium overlying an OVARIAN type stroma

128
Q

how do you treat mucinous cystic neoplasm?

A

complete removal > distal pancreatectomy

129
Q

what should you do after you remove the pancreas in a pt w/mucinous cystic neoplasm?

A

pathologic eval for invasive malignancy

130
Q

what is IPMN?

A

intraductal papillary mucinous neoplasm

131
Q

T/F: IPMN produces mucin

A

TRUE

132
Q

what sex gets IPMN more often?

A

men

133
Q

where in the pancreas does an IPMN usu occur?

A

head

134
Q

10-20% of IPMN exhibit THIS behavior

A

multifocal

lol this card suxxx sorry

135
Q

what do IPMNs involve?

A

a larger pancreatic duct

136
Q

after you surgically resect an IPMN, what should you do?

A

evaluate for invasive malignancy

137
Q

T/F: serous cystadenoma is malignant

A

FALSE

benign cystic neoplasm

138
Q

what type of cells line a serous cystadenoma?

A

glycogen-rich cuboidal cells

139
Q

how big is a serous cystadenoma?

A

1-3mm

i think it’s like a lot of little cysts

140
Q

what do serous cystadenomas contain?

A

clear serous fluid

141
Q

25% of all cystic neoplasms of the pancreas are what type of neoplasm?

A

serous cystadenoma

142
Q

what sex does serous cystadenoma occur in twice as often?

A

women

143
Q

when does serous cystadenoma occur?

A

7th decade of life

144
Q

how does serous cystadenoma present?

A

abd pain or masses

145
Q

how do you CURE serous cystadenoma?

A

surgical resection

146
Q

what is the gross morphology of a solid pseudopapillary neoplasm?

A

large
well-circumscribed
SOLID & CYSTIC components

147
Q

what are the cystic areas of a solid pseudopapillary neoplasm filled w/?

A

hemorrhagic debris

148
Q

what is the behavior of the neoplastic cells of a solid pseudopapillary neoplasm?

A

neoplastic cells in sheets or papillary projections

149
Q

how do solid pseudopapillary neoplasms present?

A

abd discomfort

150
Q

what mutation is assoc w/ solid pseudopapillary neoplasm?

A

activating mutation of B-catenin

151
Q

how do you CURE solid pseudopapillary neoplasm?

A

surgical resection

152
Q

what is the 4th leading cause of death in the US?

A

pancreatic ductal adenocarcinoma

lol okay phil

153
Q

most pancreatic pts die w/i what length of time?

A

6 months

154
Q

80% of cases of pancreatic cancer are in what age group?

A

60-80 yo

155
Q

what are risk factors for pancreatic cancer?

A 
smoking
fatty diet
chronic pancreatitis
diabetes
BOOZE
156
Q

what are the 4 ways in which pancreatic cancer exhibits familial clustering (i.e. what mutations/syndromes)?

A
  1. BRCA2
  2. P16/CDKN2A
  3. hereditary pancreatitis
  4. peutz-jeghers syndrome
157
Q

what is P16/CDKN2A assoc w/?

A

familial atypical mole/melanoma syndrome

158
Q

where are most pancreatic cancers (what part of the pancreas)?

A

60% in the head
15% in body
5% in tail
20% are diffuse

159
Q

what is the gross morphology of pancreatic cancer?

A 
masses are usually...
hard
gray-white
stellate
poorly defined
160
Q

most pancreatic carcinomas are what type?

A

ductal

161
Q

T/F: pancreatic carcinomas have the same histology regardless of where they arise in the pancreas

A

TRUE

162
Q

T/F: pancreatic carcinoma is rarely invasive

A

FALSE

highly invasive!

163
Q

what type of response does a pancreatic carcinoma have?

A

intense fibroblastic response
aka
“desmoplastic response”
(idk what this is)

164
Q

pancreatic carcinomas often grow along WHAT?

A

nerves

165
Q

what can pancreatic carcinoma invade to metastasize?

A

lymphovascular spaces

166
Q

how do pancreatic carcinomas behave?

A

they try to recapitulate normal ductal epithelium & they form glands & secrete mucin

167
Q

what is a variant of pancreatic carcinoma?

A

adenosquamous carcinoma

168
Q

what is the cellular structure of pancreatic carcinoma?

A

abortive tubular structures or cell clusters growing in a deeply infiltrative pattern

169
Q

what type of cells are involved in pancreatic carcinoma?

A

pleomorphic cuboidal to columnar epithelial cells

170
Q

how does pancreatic carcinoma present clinically?

A

silent until it invades other structures, then it gets painful

171
Q

when will pancreatic carcinoma cause jaundice?

A

if cancer arises in the head of the pancreas & if it obstructs the common bile duct

172
Q

what are some general sx of pancreatic carcinoma (once it presents)?

A

weight loss
fatigue
general malaise
weakness

173
Q

what is Trousseau sign?

A

migratory thrombophlebitis present in 10% of pancreatic carcinoma pts

174
Q

what % of pancreatic adenocarcinomas are considered resectable at time of dx?

A

only 20% :(

175
Q

under what circumstances can the 5 year survival of pancreatic cancer be 40%?

A

if the surgeon achieves negative margins when resecting

176
Q

what is the name of the procedure used to resect pancreatic cancer?

A

Whipple

177
Q

what is the Whipple procedure?

A

remove the head of the pancreas next to the duodenum + duodenum + part of common bile duct + gallbladder
then you reconnect the remaining intestine, bile duct, and pancreas

178
Q

what is the classical presentation of solid pseudopapillary neoplasm?

A

young female pt w/ a HOP lesion (HOP = head of pancreas)

Block 10 Week 4 (9 decks)

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