L16- GIT Pathology VIII (pancreas)

Question 1

Pancreatic Insufficiency:

• describe as (1) syndrome
• (2) are the most common causes
• (3) indicates clinical significance

Answer 1

1- malabsorption syndrome

2- pancreatitis, CF

3- >90% functions is lost

Question 2

Pancreatic Insufficiency, describe exocrine dysfunction

Answer 2

fat malabsorption = steatorrhea:

• lipolytic activity dec faster than proteolysis
• loose, greasy, foul-smelling stool
• vitADEK malabsorption (fat soluble)

Question 3

Pancreatic Insufficiency, describe endocrine dysfunction

Answer 3

glucose intolerance / DM (not as common as exocrine)

Question 4

CF, Cl ion transport (CFTR) is defective in (efflux/influx), and leads to (2) and (3)

Answer 4

1- influx

2- high sweat salt concentration

3- thick luminal secretions from GIT, respiratory system, salivary glands, reproductive system

Question 5

CF:

• (often/occasionally) affects pancreas
• (2) changes are most serious
• (3) is very common complication / occurrence

Answer 5

1- often, 85-90% cases [via obstruction of biliary tree + pancreatic / secretion insufficiency]
2- pulmonary changes
3- superimposed infections

Question 6

Acute Pancreatitis:

• (1) is the main presenting symptoms
• mostly caused by (2) or (3)- include brief mechanisms

Answer 6

1- abdominal pain (due to enzymatic necrosis + inflammation of pancreas)

2- gallstones: obstruction causes interstitial edema –> BV compression –> ischemia

3- alcohol: direct acinar cell injury

Question 7

list the ‘other’ causes of acute pancreatitis

Answer 7

• Infections: mumps, coxsackie, myoplasma
• Acute Ischemia: shock, trauma, vascular thrombosis, embolism, vasculitis
• Hyperlipoproteinemias
• Drugs: diuretics, azathioprine, estrogens, sulfonamides
• Hypothermia

Question 8

Compare presentations of acute and chronic pancreatitis

Answer 8

Acute:

• acute inflammation
• abdominal pain
• elevated pancreatic enzymes in serum
• self-limiting (possibly fatal)

Chronic:

• chronic inflammation and abdominal pain
• progressive loss of endocrine / exocrine function

Question 9

Acute Pancreatitis:

• (1) is the main presenting symptom with (2) as associated symptoms
• (3) is the cause of the episode progression

Answer 9

1- mild to severe epigastric pain referring to upper back

2- n/v

3- release of enzymes, toxins, CKs —> systemic inflammatory response

Question 10

list some other not as evident or common acute pancreatic symptoms / clinical features

Answer 10

• leukocytosis
• DIC
• peripheral vascular collapse
• shock (DIC)
• tetany (hypocalcemia)

Question 11

list lab findings for acute pancreatitis

Answer 11

• raised amylase in first 24hrs
• raised lipase in 48-72hrs
• hypocalcemia

Question 12

list complications of acute pancreatitis

Answer 12

• ARDS
• ATN
• pancreatic abscess (up to wks after episodes)

Note- recurrent bouts may lead to chronic pancreatitis

Question 13

Acute Pancreatitis Morphology:

• (1) are the important changes noted
• in severe cases (2) is involved and (3) is usually evident

Answer 13

1- focal fat necrosis (pancreas, peri-pancreas, abdominal cavity) w/ Ca deposition (saponification)

2- necrosis of all pancreatic tissue (acini, ducts, islets)
3- hemorrhage = hemorrhagic pancreatitis

Question 14

Chronic Pancreatitis:

• caused by (1), common in (2) patients
• (3) list the other causes

Answer 14

1- repeated bouts of mild/moderate pancreatic inflammation (loss of pancreatic parenchyma + replacement with fibrotic tissue)

2- alcoholism (alcohol use)

3- pancreatic divisum (12%)
Rarely: tropical pancreatitis, hereditary pancreatitis, CFTR mutation associated

Note- 40% of the time there is no obvious cause

Question 15

Chronic pancreatitis:

• possible progression to (1) and (2)
• the malabsorption may be corrected by (3)
• (4) are radiography features
• inc risk of (5)
• 10% of patients have (6)

Answer 15

1- pancreatic insufficiency
2- DM
3- pancreatic enzyme supplements

4- calcifications (X-ray, CT)
5- carcinoma (especially alcohol cases)
6- pseudocysts (10%)

Question 16

Pancreatic Adenocarcinoma:

• (1) is most common association / possible cause and (2) factors
• strong association with (3), although very rare
• (4) describe location distribution

Answer 16

1- smoking
2- alcohol, fatty rich diet (inconsistent findings)
3- familial relapsing pancreatitis

4- head 60-70%, tail 10-15%, body 5-10%

Question 17

Pancreatic Adenocarcinoma:

• (1) is main initial symptom, but (2) is considered the first symptom
• (3) is the common marker used (explain any possible drawbacks)
• generally (good/poor) prognosis

Answer 17

1- silent / asymptomatic
2- pain (due to invasion into posterior abdominal wall / nerves)

3- CA19.9: nonspecific, also raised in ovarian cancer
4- poor prognosis

Question 18

Pancreatic Adenocarcinoma:

• tumor releases (1)
• (2) are complications from tumor of head of pancreas
• (3) complication may be present

Answer 18

1- platelet activating factors + procoagulants

2- obstructive jaundice

3- Trosseau’s syndrome = migratory thrombophlebitis

Question 19

list the progression of pancreatic adenocarcinoma (include related mutations)

Answer 19

(PanIN = pancreatic intraepithelial neoplasm)
-PanIN-1A / PanIN-1B: telomere shortening, K-RAS mutation (activating)

• PanIN-2: inactivation of CDKN2A
• PanIN-3: inactivation of p53, SMAD4, BRCA2
• invasive adenocarcinoma

Question 20

Pancreatic NET = (1):

• tumor of (2) cells in pancreas
• either in (3) or (4) form

Answer 20

1- neuroendocrine tumor (Steve Jobs tumor)
2- islet cell tumors

3- functional: insulinoma, gastrinoma, glucagonoma
4- non-functional

Question 21

Insulinoma:

• cancer of (1) cells
• usually (solitary/multiple) and (benign/malignant)
• (3) is the main symptom that changes with (4- explain)

Answer 21

1- β-cells
2- solitary, benign
3- hypoglycemia
4- accentuated by fasting, relieved by food

Question 22

Insulinoma Whipple Triad

Answer 22

• low blood glucose
• presence of hypoglycemic Sxs
• resolution when blood glucose is normalized

Note- elevated insulin recognized by high C-peptide

Question 23

Gastrinomas:

• found in (1) locations
• (2) is main finding leading to (3)
• (4) is usually present at diagnosis
• (5) and (6) is a common associated syndrome

Answer 23

1- pancreas, duodenum, peripancreatic tissue
2- hypergastrinemia
3- multiple ulcers (esophagus, stomach, duodenum, jejunum)
4- local invasion / metastasis
5- Zollinger-Ellison Syndome
6- MEN-1 (multiple endocrine neoplasia)

Question 24

list main features of Zollinger-Ellison syndrome

Answer 24

• multiple duodenal peptic ulcers
• prominent gastric rugal folds due to inc oxyntic gland mass
• steatorrhea