Hepatobiliary IV - Pancreas

Question 1

Congenital Abnormalities [2]

Answer 1

Pancreas Divisum

• Dorsal and Ventral primordium fail to fuse
• most of pancreas drains into minor duct - predisposing to chronic pancreatitis

Annular (ring) Pancreas
- Band-like ring encircling Duodenum - obstruction

Question 2

Pancreas protective mechanisms [3]

Answer 2

• Inactive enzymes - zymogens
• Trypsin needs enterokinase from small intestine to activate
• Trypsin inhibitors secreted;

Question 3

Top acute causes [2]

+ Give VITAMIN

Answer 3

Top: biliary diseases and alcohol !!!

V - Shock, thromboembolism;
I - Mumps
T - Trauma; Toxin - alcohol
A - Autoimmune - SLE
Metab - Hypercalcemia, Hyperlipid (FFA is toxic);
– Recall giving [Fibrates, Niacin] inhibitors for this
Idiopathic
N - Neoplasm, obstruction, Pancreas Divisum

Question 4

Link obstruction and stasis to Pancreatitis plus Alcohol effects

Pathogenesis [4]

Answer 4

Obstruction
Alcohol
- Protein thick secretions,
- ROS,
- increase sphincter of Oddi tone
- interstitial oedema, impair blood flow, ISCHEMIA, Acinar cell injury, release enzymes
- Trypsinogen activated by lysosomal enzymes

Question 5

Pancreatitis presentation [4+1]

Answer 5

Back Pain, Shoulder
– however, when the tail of the pancreas is involved pain tends to be referred to the left shoulder due to its innervation by C3-5.

Glycosuria (recall Type 3c diabetes)

Serum amylase and lipase

Hypocalcemia (from soaps)

Severe - SIRS due to release of enzymes and cytokines
[Note sepsis is SIRS + infection}
(note pseudocysts rupture possibility)

Question 6

Acute Pancreatitis Pathology [5]

Chronic Pancreatitis Pathology [4]

Answer 6

• Fat necrosis, soap calcification
• Liquefactive necrosis - amorphous, viscous mass
  note LQF necrosis due to hydrolytic enzymes - can be from neutrophils
• inflammation, neutrophils
• microvascular leak and edema {IMPORTANT}
• PSEUDOCYSTS- acute pancreatic pseudocyst is made of pancreatic fluids with a wall of fibrous tissue or granulation [IMPORTANT]
• DILATED DUCTS from protein plus, calcium concretions;
• fibrosis
• acini atrophy first then islets
• Pseudocysts

Question 7

Pancreatitis Complications, Systemic presentations

think anatomy

Answer 7

SIRS - shock, ARDS - lung inflammation, Acute renal failure, DIC

Type 3c diabetes (also known as pancreatogenic diabetes), secondary to pancreatic diseases

Splenic Vein thrombosis: In acute pancreatitis, splenic vein thrombosis is frequently initiated by local, pro-thrombotic, inflammatory changes in the vascular endothelium, extrinsic splenic vein compression by PSEUDOCYSTS, relatively low pancreatic perfusion, or later in the course of disease pancreatic fibrosis. Perivenous inflammation too

Pancreatic ascites and pleural effusion can result from disruption of the pancreatic duct, leading to fistula formation to the abdomen or chest, or rupture of a PSEUDOCYSTS with tracking of pancreatic JUICE into the peritoneal cavity or pleural space.

Question 8

Chronic Pancreatitis causes, feature; Presentation; Diagnosis

Answer 8

Alcohol; chronic stones, inflammation, autoimmune
- fibrosis, pancreatic stellate cells

Presentation

• malabsorption from exocrine insufficiency
• DM from endocrine insufficiency type 3c
• Pain, pseudocytes
• weight loss

CT scan calcifications

Question 9

Non-neoplastic mass [2]

Answer 9

Pseudocyst - no epithelial lining, collection of necrotic debri w enzymes (pancreatic fluid) + fibrosis layer/ granulation tissue
- follows acute pancreatitis

Congenital - cuboidal epithlieum from ducts

Question 10

Neoplastic {2}

Answer 10

Pancreatic Carcinoma - ductal adenocarcinoma
- from ducts then Pancreatic Intraepithelial Neoplasia (PaIN)

Pancreatic Neuroendocrine Tumour PanNET
- islet tumours; insulinoma most common
MENI association
- Salt-and-pepper chromatin is typically seen in endocrine tumours such as medullary thyroid carcinoma [MENII association + Amyloid}, neuroendocrine tumours and pheochromocytoma