Diseases and the Pancreas and Gallbladder

Question 1

What are the cells of the pancreas

Answer 1

Pancreatic acinar cell

Centroacinar cell

Question 2

What is the basic structure of the pancrease

Answer 2

Pancreatic acinus stemming from intercalated ducts

Question 3

What are the two components of the pancreas

Answer 3

Exocrine component

Endocrine component

Question 4

Acute pancreatitis

Answer 4

Acute inflammation of the pancreas caused by aberrant release of pancreatic enzymes
Relatively common, increasing incidence

Question 5

Causes of acute pancreatitis

Answer 5

Duct obstruction: gallstones, trauma, tumours.
Metabolic/toxic: alcohol, drugs (thiazides), hypercalcaemia, hyuperlipidaemia
Poor blood supply: shock, hypothermia
Infection/inflammation: viruses (mumps)
Autoimmune
Idiopathic

Question 6

What proportion of alcoholics develop acute pancreatitis

Answer 6

5%

Question 7

Pathogenesis of acute pancreatitis due to ductal obstruction

Answer 7

Gallstone stuck distal to where the common bile duct and pancreatic ducts join leads to:
reflux of bile up the pancreatic duct followed by damage to acini with release of proenzymes which then become activated

Question 8

Pathogenesis of acute pancreatitis due to alcohol

Answer 8

Alcohol leads to spasm/oedema of sphincter of oddi and the formation of a protein rich pancreatic fluid which obstructs the pancreatic ducts

Question 9

Pattern of injury in acute pancreatitis

Answer 9

Periductal: necrosis of acinar cells near ducts (usually secondary to obstruction)
Perilobular: necrosis at the edges of the lobules (usually due to poor blood supply)
Panlobular - develops from periductal and perilobular damage

Question 10

Pattern of injury in acute pancreatitis

Answer 10

Activated enzymes –> acinar necrosis –> enzyme release, etc…
Ranges from stromal oedema, to haemorrhagic necrosis

E.g. lipases –> fat necrosis (calcium ions bind to free fatty acids forming soaps which are seen as yellow-white foci)

Question 11

Complications of acute pancreatitis

Answer 11

Pancreatic: pseudocyst, abscess
Systemic: shock, hypoglycaemia, hypocalcaemia

Question 12

Prognosis of acute pancreatitis

Answer 12

Overall mortality up to 50% for hemorrhagic pancreatitis

Question 13

Chronic pancreatitis

Answer 13

Relapsing or persistent, associated with acute pancreatitis in half of cases
Relatively uncommon

Question 14

Mortality from chronic pancreatitis

Answer 14

3% per year

Question 15

Causes of chronic pancreatitis

Answer 15

Metabolic/toxic: alcohol (80%), haemochromatosis
Duct obstruction: gallstones, abnormal pancreatic duct anatomy, cystic fibrosis (mucoviscoidosis)
Tumours
Idiopathic: autoimmune

Question 16

Pattern of injury for chronic pancreatitis

Answer 16

Pathogenesis of the same as for acute pancreatitis
Chrnoci inflammation with parenchymal finbrosis and loss of parenchyma
Duct strictures with calcified stones with secondary dilations

Question 17

Complications of chronic pancreatitis

Answer 17

Malabsorption
Diabetes mellitus
Pseudocyts
Carcinoma of the pancreas

Question 18

What is diagnostic of chronic pancreatitis

Answer 18

Abdominal radiograph with pancreatic calcifications

Question 19

Pancreatic pseudocysts

Answer 19

Associated with acute and/ or chronic pancreatitis
Lined by fibrous tissue (no epithelial lining), contain fluid rich in pancreatic enzymes) or necrotic material
Connect with pancreatic ducts
May resolve, compress adjacent structures, become infected or perforate

Question 20

Histology of pancreatic pseudocyst

Answer 20

The cyst lining is composed of granulation tissue & infiltrating cells without a discrete epithelial lining. A thickened fibrotic wall with prominent vascualrity is present

Question 21

Autoimmune pancreatitis

Answer 21

Characterised by large numbers of IgG4 positive plasma cells.
May involve the pancreas, bile ducts and almost any other part of the body.
Often called “IgG4 Disease”.

Question 22

Histology of autoimmune pancreatitis

Answer 22

IgG4 positive plasma cells

Question 23

Tumours of the pancreas

Answer 23

Carcinomas: ductal (85%), acinar
Cystic neoplasma: serous cystadenoma, mucinous cystic neoplasm
Pancreatic neuroendocrine tumours (islet cell tumour)

Question 24

Ductal pancreatic carcinoma

Answer 24

5% of cancer deaths
Increasingly common with age. 2M:F
5 year survival is 5%

Question 25

Risk factors for pancreatic carcinoma

Answer 25

Smoking BMI and dietary factors Chronic pancreatitis Diabetes

Question 26

Ductal pancreatic carcinoma

Answer 26

Arise from dysplastic ductal lesions: pancreatic intraductal neoplasia (PanIN) K-Ras mutations in 95% of cases

Question 27

Ductal carcinoma of the pancreas macroscopic appearance

Answer 27

Gritty and grey Invades adjacent structure Tumours in the head present earlier

Question 28

Ductal carcinoma of the pancreas microscopic appearance

Answer 28

Adenocarcinomas: mucin secreting glands set in desmoplastic strome

Question 29

Sites of ductal carcinoma of pancreas

Answer 29

Head 60% Body Tail Diffuse

Question 30

How does a ductal carcinoma of the pancreas typically spread

Answer 30

Direct: bile ducts, duodenum Lymphatic: lymph nodes Blood: liver Serosa: peritoneum

Question 31

Complications of ductal carcinoma of the pancreas

Answer 31

Due to spread Chronic pancreatitis Venous thrombosis (migratory thrombophlebitis)

Question 32

Histology of ductal adenocarcinoma of the pancreas

Answer 32

Findings diagnostic of ductal adenoCa. Perineural invasion is virtually diagnostic of invasive Ca provided the epithelial structures are gland forming.

Question 33

Cystic tumours of the pancreas

Answer 33

Usually multilocular Contain serious or mucin secreting epithelium (CF ovarian tumours) Usually benign

Question 34

Pancreatic endocrine neoplasms

Answer 34

Usually non-secretory Contain neuroendocrine markers e.g. chromogranin Behaviour difficult to predict, May be associated with the Multiple Endocrine Neoplasia (MEN) 1 syndrome

Question 35

Insulinomas

Answer 35

Derived from beta cells in the pancreas | The commonest type of secretory tumour

Question 36

Histological pattern of insulinoma

Answer 36

Nested pattern

Question 37

Gallbladder pathology

Answer 37

Gallstones Inflammation Cancer

Question 38

Gallstones (i.e. cholelithiasis) prevalence

Answer 38

20% of adults in the West are affected

Question 39

Risk factors for gallstones

Answer 39

Age and gender: increasing age, F>M Ethnic and geographic: e.g. Native Americans Hereditary: e.g. disorders of bile metabolism Drugs e.g. oral contraceptive Acquired disorders e.g. rapid weight loss FAT, FOURTY, FEMALE

Question 40

Types of gallstones

Answer 40

Cholesterol (more than 50% cholesterol), may be single, mostly radiolucent Pigment (contain calcium salts of unconjugated bilirubin), multiple, mostly radio-opaque

Question 41

Complications of gallstones

Answer 41

Bile duct obstruction Acute and chronic cholecystitis Gall bladder cancer Pancreatitis

Question 42

Acute cholecytitis

Answer 42

Acute inflammation of the gallbladder | 90% associated with gallstones

Question 43

Chronic cholecystitis

Answer 43

Chronic inflammation of the gallbladder Fibrosis Diverticula - Rokitansky-Aschoff sinuses 90% contain gallstones

Question 44

Gallbladder cancer

Answer 44

Adenocarcinomas | 90% are associated with gallstones