Histopathology 7 - Diseases of the pancreas and gall bladder

Question 1

Where are insuline and glucagon secreted from?

Answer 1

ducts & ascini of exocrine pancreas

Question 2

Recall the components of exocrine vs endocrine pancreas

Answer 2

Exocrine = ducts and ascini

Endocrine = islets of Langerhans

Question 3

Recall the mnemonic for the causes of acute pancreatitis

Answer 3

I GET SMASHED

**Idiopathic

Gallstones
Ethanol**

Trauma

Steroids
Mumps
Autoimmune
Scorpion sting
Hyperlipidaemia/hypercalcaemia/hyperparathyroidism
ERCP
Drugs

Question 4

which drugs can cause acute pancratitis?

Answer 4

thiazides

Question 5

Recall two causes of pancreatitis via duct obstruction

Answer 5

gallstones (50%)

trauma

tumours

Question 6

How does pancreatitis affect calcium?

Answer 6

Pancreatitis CAUSES hypocalcaemia

released FFAs bind free calcium→ ↓ free calcium; so, if this is the cause, calcium drops to a NORMAL level in the acute phase

Question 7

Recall the pathophysiology of injury seen in acute pancreatitis

Answer 7

Duct Obstruction:

• Gallstone distal to where CBD + pancreatic ducts join → reflux of bile up pancreatic duct → acini damage → release of proenzymes which become activated
• Alcohol → spasm/oedema of sphincter of Oddi and formation of protein-rich pancreatic fluid which obstructs pancreatic ducts

other causes -> direct acinar injury

Question 8

What does a periductal pattern of injury suggest in acute pancreatitis?

Answer 8

necrosis of acinar cells near ducts (usually secondary to obstruction)

obstruction → inflammation starts around ducts

Question 9

What does a perilobular pattern of injury suggest in acute pancreatitis?

Answer 9

necrosis at edges of lobules (poor blood supply)

cells most likely to die because of poor blood supply are furthest away from blood supply

Question 10

Why are yellow/white foci seen in acute pancreatitis?

Answer 10

Lipases cause fat necrosis
Calcium ions bind to free fatty acids forming soaps (which are white yellow)

Question 11

Recall 2 pancreatic and 3 systemic complications of acute pancreatitis

Answer 11

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

Question 12

What is the most common cause for chronic pancreatitis

Answer 12

alcohol (80%) > gallstones

Question 13

Recall 2 metabolic/toxic causes of chronic pancreatitis

Answer 13

alcohol (80%)

haemochromatosis

Question 14

What is the defiining pattern of injury in chronic pancreatitis?

Answer 14

Duct strictures with calcified stones with secondary dilatations - Pancreatic calcifications are diagnostic of chronic pancreatitis

Chronic inflammation with parenchymal fibrosis and loss of parenchyma (ascini atrophic)

Question 15

Recall 4 complications of chronic pancreatitis

Answer 15

Malabsorption
Diabetes mellitus (later as endocrine surives longer than exocrine)
Pseudocysts
Carcinoma of the pancreas

Question 16

What is a pseudocyst?

Answer 16

collection of fluid without epithelial lining - can become infected -> abscess

fibrous tissue

Question 17

What is a cyst?

Answer 17

Dilated space lined by epithelium

Question 18

What is contained within a pancreatic pseudocyst?

Answer 18

Pancreatic enzymes and necrotic material (which is why it’s so bad when they perforate - it causes peritonitis)

Question 19

Which immunoglobin is implicated in autoimmune acute pancreatitis?

Answer 19

IgG4

Question 20

What type of cancer makes up 85% of pancreatic neoplasms?

Answer 20

Ductal carcinoma

Question 21

What mutation is very common in ductal carcinoma?

Answer 21

K-Ras (95%) - >pre-malignant bridges

Question 22

What are the features of pancreatic acinar carcinoma?

Answer 22

Associated with ↑ serum lipase

Although most carcinomas in pancreas look like they arise from ducts (composed of ductal epithelium), most of them actually arise from acini → acinar-ductal metaplasia (where acinar cells become ductal cells).

Question 23

What are the 2 types of pancreatic cystic neoplasms?

Answer 23

Serous cystadenoma

Mucinous cystic neoplasm

Question 24

What are the 2 types of precancerous dysplastic ductal lesions in the pancreas?

Answer 24

1. PanIn (pancreatic intraductal neoplasm)
2. Intraductal mucinous papillary neoplasm

both lead to DC

doNOT invade BM

Question 25

Which type of tumour has a "gritty and grey" macroscopic appearance?

Answer 25

Ductal carcinoma

Question 26

What are the most common sites of pancreatic ductal carcinomas?

Answer 26

Head (60%) Body Tail Diffuse (neuroendocrine tumours are most common tail \> body \> head – e. the reverse)

Question 27

Recall 3 complications of ductal carcinoma

Answer 27

1. Liver metastasis 2. Chronic pancreatitis 3. Venous thrombosis ("migratory thrombophlebitis"/ Trousseau syndrome) = mucin activating coagulation in circulatory system causing thrombosis

Question 28

Define adenocarcinoma

Answer 28

Mucin-secreting glands set in desmoplastic stroma (means: strong stromal reaction)

Question 29

Which type of pancreatic tumours are usually benign?

Answer 29

Cystic tumours

Question 30

Which type of pancreatic tumour is associated with MEN1?

Answer 30

Pancreatic endocrine neoplasms

Question 31

Recall a neuroendocrine marker in pancreatic endocrine neoplasms

Answer 31

Chromogranin

Question 32

Which type of pancreatic tumour is associated with MEN1?

Answer 32

Pancreatic endocrine neoplasms

Question 33

What is the most common type of secretory pancreatic tumour?

Answer 33

Insulinomas (from beta cells)

Question 34

In which portion of the pancreas are neuroendocrine tumours most common?

Answer 34

Tail

Question 35

What is Whipple's triad?

Answer 35

glucose \<50mg/dL, S/S hypo, relief on glucose administration

Question 36

What are the risk factors for gallstones?

Answer 36

Female, Fair, Fat, Fertile, Forty Female, 40yo Ethnicity (e.g. Native Americans) Hereditary factors (e.g. disorders of bile metabolism) Drugs (e.g. oral contraceptive) Acquired disorders (e.g. rapid weight loss)

Question 37

What are the 2 types of gallstone?

Answer 37

Cholesterol Pigment

Question 38

What do pigment gallstones contain?

Answer 38

Calcium salts of unconjugated bilirubin

Question 39

Which type of gallstones are radiolucent/radio opaque

Answer 39

Cholesterol: radiolucent (NOT seen on AXR → USS) Pigment: radio-opaque, often multiple

Question 40

Recall 4 potential complications of gallstones

Answer 40

Bile duct obstruction Cholecystitis Gall bladder cancer Pancreatitis

Question 41

What is the most common cause of acute/chronic cholecystitis?

Answer 41

Gallstones (accounts for 90%)

Question 42

What is a key histopathological finding in chronic cholecystitis?

Answer 42

Diverticula (Rokitansky-Aschoff sinuses) – gallbladder contracting against obstruction → diverticula

Question 43

What is the most common cause of gallbladder cancer?

Answer 43

Gallstones

Question 44

What are the 3 patterns of injury that may be seen in acute pancreatitis?

Answer 44

Periductal (necrosis of acinar cells near ducts) Perilobular (necrosis at the edges of lobules) Panlobular (develops from either of the above)

Question 45

What is IgG4 related disease?

Answer 45

A type of autoimmune disease that may affect the pancreas, surrounding structure or pretty much anywhere else in the body

Question 46

What are the 4 different types of pancreatic tumour?

Answer 46

Carcinomas: 1. Ductal 2. Acinar Cystic neoplasms: 1. Serous cystadenomas 2. Mucinous cystic neoplasms

Question 47

What is the typical microscopic appearance of ductal carcinoma of the pancreas?

Answer 47

Desmoplastic stroma

Question 48

What type of cancer is most common in the gallbladder?

Answer 48

Adenocarcinoma technically a cholangiocarcinoma