Usera > Exocrine Pancreas Flashcards
(178 cards)
1
Q
what does “pankreas” mean in greek?
A
“all flesh”
obviously this is the most important card of the deck
2
Q
where does the pancreas extend from & to?
A
from the C loop of the duodenum
to the hilum of the spleen
3
Q
how long is the pancreas & how much does it weigh?
A
20 cm long
85-90 g
4
Q
what % of the pancreas is exocrine?
A
80-85%
5
Q
what are the 5 parts of the pancreas?
A
uncinate head neck body tail
6
Q
what are the 2 ducts and the 1 papilla you need to care about?
A
DUCTS: santorini & wirsung
Papilla of Vater
7
Q
which duct is superior & which is inf?
A
superior = santorini inf = wirsung
8
Q
what is pancreatic agenesis?
A
congenital absence of the pancreas
9
Q
what gene is assoc w/ pancreatic agenesis?
A
PDX1
pancreatic & duodenal homeobox-1 gene
10
Q
what chromosome holds PDX1?
A
13q12.1
11
Q
what is pancreatic agenesis assoc w/?
A
usu assoc w/ other congenital anomalies that are incompatible w/ life
12
Q
what 2 dzs can pancreatic agenesis cause?
A
DM
malabsorption
13
Q
what are the 4 possible congenital pancreatic anomalies?
A
- agenesis
- pancreas divisum
- annular pancreas
- ectopic pancreas
14
Q
which congenital pancreatic abnormality is the most common?
A
pancreas divisum
15
Q
what is the incidence of pancreas divisum?
A
3-10%
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)
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)
18
Q
where does the head of the pancreas drain in pancreas divisum?
A
duct of wirsung & papilla of vater (major papilla)
19
Q
what is annular pancreas?
A
pancreas completely (or not) encircles 2nd portion of duodenum, occasionally obstructing the proximal duodenum
20
Q
what gender is more commonly affected by annular pancreas?
A
male
21
Q
is annular pancreas rare?
A
YES
& it may not become apparent until later in life
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
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
24
Q
what is the drainage of an annular pancreas?
A
pancreatic duct may drain into main duct or just the duodenum
25
when does annular pancreas commonly present?
4th-5th decade of life
26
what are the sx of annular pancreas?
```
commonly asymptomatic
in adults:
upper abd colicky pain
postprandial fullness
vomiting
pancreatitis
peptic ulcers
```
27
what is annular pancreas assoc w/?
duodenal stenosis/atresia
| 50% assoc w/ other congenital issues w/ heart, trachea, esophagus, & intestinal malrotation
28
what is ectopic pancreas?
pancreatic tissue in locations other than the pancreas
29
what % of autopsies have ectopic pancreas?
2%
30
where does ectopic pancreas usu happen?
SUBMUCOSA of the stomach, duodenum, jejunum, meckel diverticulum, or ileum
31
what structures are in ectopic pancreas?
acini
| occasional goblet cells
32
what is pancreatitis?
inflammation of the pancreas w/ injury of the exocrine pancreatic tissue
33
what is the range of sx of pancreatitis?
mild self-limited dz to life-threatening acute inflammatory process
34
what is the duration of pancreatitis?
ranges from transient attack to permanent loss of fxn
35
how does acute pancreatitis resolve?
treat underlying cause > exocrine tissue can return to normal fxn
36
how does chronic pancreatitis end up?
irreversible injury w/ loss of pancreatic exocrine tissue
37
define "acute pancreatitis"
reversible pancreatic parenchymal injury assoc w/ inflammation
38
is acute pancreatitis rare?
no, it's common
| annual incidence = 10-20 cases/100,000 in western countries
39
what accounts for 80% of acute pancreatitis cases?
biliary tract dz & alcohol
40
what happens in 35-60% of acute pancreatitis cases?
presents w/ gallstones
41
about 5% of pts w/ gallstones will develop what?
acute pancreatitis
42
what are the male:female ratios of biliary tract dz & alcohol?
biliary: 1:3
alcohol: 6:1
43
what are the 7 causes of acute pancreatitis?
1. obstruction of pancreatic ductal system
2. meds
3. infxn
4. metabolic disorders
5. ischemic injury
6. trauma
7. genetic
44
what med can cause acute pancreatitis?
azathioprine
45
what infxn can cause acute pancreatitis?
mumps
46
what are 4 causes of pancreatic ductal system obstruction?
1. periampullary neoplasm (cx in pancreatic head)
2. choledochocele
3. biliary sludge
4. parasites
47
what is choledochocele?
congenital cystic dilatation of the CBD
48
what parasites can obstruct pancreatic ducts?
ascaris
| clonorchis
49
what metabolic disorders can cause acute pancreatitis?
HYPERLIPOPROTEINEMIA
alcohol
hypercalcemia
50
what can cause ischemic injury to result in acute pancreatitis?
shock
vasculitis
atheroembolism
51
what types of trauma can cause acute pancreatitis?
gallstones
| iatrogenic (operative injury or procedures w/ dye)
52
what is a genetic cause of acute pancreatitis?
PRSS1 & SPINK1
53
what does PRSS1 code for?
cationic trypsinogen
54
what does SPINK1 code for?
trypsin inhibitor
55
what 5 things can you find on histology of acute pancreatitis?
1. microvascular leakage > edema
2. fat necrosis
3. neutrophils
4. proteolytic destruction
5. BV destruction
56
what causes fat necrosis in acute pancreatitis?
lipolytic enzymes
57
what causes acute inflammation in acute pancreatitis?
neutrophils
58
what is destroyed via proteolytic destruction in acute pancreatitis?
pancreatic parenchyma
59
what are the 2 most common sx of acute pancreatitis?
abdominal & back pain
| epigastric tenderness
60
what are the 4 less common sx of acute pancreatitis?
N/V
low-grade fever
HoTN
subQ fat necrosis
61
what are the lab findings assoc w/ acute pancreatitis?
LIPASE
| serum amylase
62
how does serum amylase act in acute pancreatitis?
rises w/i 2-24 hours of onset, returns to normal w/i 2-3 days
high sensitivity, low spec
63
T/F: higher amylase levels indicate more severe acute pancreatitis
FALSE
| but they DO increase specificity
64
if you have a persistently elevated serum amylase, what is most likely happening?
NOT acute pancreatitis
| maybe pseudocyst
65
what test is specific for acute pancreatitis?
LIPASE!
66
how does lipase act in acute pancreatitis?
rise parallels the inc in amylase, but lipase REMAINS ELEVATED for up to 2 weeks
67
T/F: full-blown acute pancreatitis is an emergency
TRUE
68
what are 5 serious complications of acute pancreatitis that make it an emergency?
1. leukocytosis
2. hemolysis
3. DIC
4. ARDS
5. diffuse fat necrosis
69
what are the 3 treatments for acute pancreatitis?
1. "REST"
2. IV fluids
3. analgesics
70
what is "REST"?
total restriction of oral intake (NPO)
71
what are the top 3 sequelae of acute pancreatitis?
1. death
2. pancreatic abscess
3. pancreatic pseudocyst
72
define "chronic pancreatitis"
inflammation of the pancreas w/ irreversible destruction of the exocrine pancreatic parenchyma, fibrosis
later stages: destruction of endocrine pancreatic parenchyma
73
what is the prevalence of chronic pancreatitis?
0.4-0.5%
74
what is the most common cause of chronic pancreatitis?
chronic alcohol abuse
75
who gets chronic pancreatitis most often?
middle-aged men
76
what % of chronic pancreatitis cases have unk etiology?
40%
77
what is tropical pancreatitis?
poorly characterized heterogeneous dz in Africa & Asia
78
besides alcohol, what are 4 causes of chronic pancreatitis?
1. long-standing obstruction
2. hereditary pancreatitis
3. CFTR gene mutations
4. tropical pancreatitis
79
what can cause a long-standing obstruction & result in chronic pancreatitis?
```
pseudocysts
calculi
trauma
neoplasm
pancreas divisum
```
80
what are the 2 types of hereditary pancreatitis that can result in chronic pancreatitis?
germline mutations in...
PRSS1 (auto dom)
SPINK1 (auto rec)
81
25-30% of pts w/ chronic pancreatitis have what kind of gene mutation?
CFTR
82
how does a CFTR gene mutation cause chronic pancreatitis?
DEC bicarb secretion from pancreatic ductal cells > protein plugging of ducts/tubules
83
what are the 2 pathogeneses (genesises?) of chronic pancreatitis?
1. ductal obstruction by concretions
| 2. toxic effects
84
what can cause BOTH types of chronic pancreatitis pathogenesis?
alcohol
inc protein in ductal juice > calcify > obstruct
metabolize & cause toxic effects
85
what are the 6 components of alcohol-induced oxidative stress in the pancreas?
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
what are the gross findings assoc w/ chronic pancreatitis?
fibrosis
| calcification
87
what are the histo findings assoc w/ chronic pancreatitis?
| this is important
1. parenchymal FIBROSIS
2. less acini w/ islet sparing (preservation of lobule structure)
3. dilatation of pancreatic ducts
4. chronic inflammation
88
how are the islets & acini affected in chronic pancreatitis?
reduced # & size of acini, but islets are mostly spared
89
why is there variable dilatation of the pancreatic ducts in chronic pancreatitis?
protein plugs/concretions
epithelial atrophy or hyperplasia
squamous metaplasia
90
what is the infiltrate of autoimmune pancreatitis?
duct-centric mixed inflammatory cell infiltrate
91
what type of cells are increased in autoimmune pancreatitis?
IgG4-producing plasma cells
92
what kind of -itis is assoc w/ autoimmune pancreatitis?
venulitis
93
what is the treatment for autoimmune pancreatitis?
steroids
94
how does chronic pancreatitis present?
1. repeated ATTACKS of mild-severe abd pain
2. persistent abd & back pain
3. jaundice
95
what can precipitate an attack of chronic pancreatitis?
booze
overeating
drugs that inc tone of the sphincter of oddi
96
T/F: chronic pancreatitis is usu life-threatening
FALSE
| usu not
97
what is the 20-25 year mortality rate of chronic pancreatitis?
50%
98
what are the sequelae of chronic pancreatitis?
1. pancreatic exocrine insuff w/ malabsorption
2. diabetes
3. chronic pain
4. pancreatic pseudocysts
99
what does chronic pancreatitis maybe predispose you to?
cancer
100
what are the 5 types of cystic lesions of the pancreas?
1. congenital
2. pseudo
3. mucinous cystic lesions
4. nonmucinous cystic lesions
5. solid pseudopapillary tumors
101
how do you get a congenital pancreatic cyst?
anomalous dvlpmnt of the pancreatic ducts
102
what is the gross morphology of a congenital pancreatic cyst?
unilocular
thin walls
up to 5cm diameter
103
what type of cells line a congenital pancreatic cyst?
uniform cuboidal epithelium
104
what encloses a congenital pancreatic cyst?
thin fibrous capsule
105
what is a congenital pancreatic cyst filled w/?
clear serous fluid
106
are congenital pancreatic cysts sporadic or inherited?
sporadic
107
what 2 syndromes are congenital pancreatic cysts assoc w/?
1. ADPKD
| 2. von hippel lindau
108
what encases a pancreatic pseudocyst?
granulation tissue
| no epithelial lining bc it's a PSEUDO cyst
109
what is a pancreatic pseudocyst?
fluid collection >4wks old, surrounded by a defined wall
110
what is in a pancreatic pseudocyst?
necrotic-hemorrhagic material rich in pancreatic enzymes (juice)
111
T/F: pancreatic pseudocysts are always single
FALSE
| can be single or multiple
112
how big are pancreatic pseudocysts?
can be small or large, up to 30 cm diameter
113
most pancreatic pseudocysts communicate w/ what?
pancreatic ductal system
114
75% of pancreatic cysts are what type of cyst?
pancreatic pseudocyst
115
what can cause a pancreatic pseudocyst?
acute or chronic pancreatitis
| trauma
116
what happens if a pancreatic pseudocyst expands?
abd pain
duodenal/biliary obstruction
vascular occlusion
fistula formation into adj viscera, pleural space, pericardium
117
what are 4 complications of pancreatic pseudocysts?
1. spontaneous infxn
2. pseudoaneurysm
3. pancreatic ascites
4. pleural effusion
118
how do you dx pancreatic pseudocyst?
aspirated fluid will have
INC amylase
DEC CEA
INC CA19-9
119
what are some clinical clues for pancreatic pseudocyst?
pancreatic ascites or pleural effusion
| absence of septae w/i cyst
120
what are the 2 types of mucinous cystic lesions?
1. mucinous cystic neoplasm
| 2. intraductal papillary mucinous neoplasm +/- invasive carcinoma
121
what sex is disproportionately affected by mucinous cystic neoplasm?
WOMEN get 95% of these!
122
what can mucinous cystic neoplasm be assoc w/?
invasive carcinoma
123
where do mucinous cystic neoplasms usu arise in the pancreas?
in the body or tail
124
how do mucinous cystic neoplasms present?
painless slow-growing masses
125
what do mucinous cystic neoplasms look like grossly?
large
| filled w/ thick mucin
126
T/F: mucinous cystic neoplasms connect w/ the pancreatic ductal system
FALSE
| they do NOT
127
what is the lining of mucinous cystic neoplasms?
COLUMNAR mucinous epithlium overlying an OVARIAN type stroma
128
how do you treat mucinous cystic neoplasm?
complete removal > distal pancreatectomy
129
what should you do after you remove the pancreas in a pt w/mucinous cystic neoplasm?
pathologic eval for invasive malignancy
130
what is IPMN?
intraductal papillary mucinous neoplasm
131
T/F: IPMN produces mucin
TRUE
132
what sex gets IPMN more often?
men
133
where in the pancreas does an IPMN usu occur?
head
134
10-20% of IPMN exhibit THIS behavior
multifocal
| lol this card suxxx sorry
135
what do IPMNs involve?
a larger pancreatic duct
136
after you surgically resect an IPMN, what should you do?
evaluate for invasive malignancy
137
T/F: serous cystadenoma is malignant
FALSE
| benign cystic neoplasm
138
what type of cells line a serous cystadenoma?
glycogen-rich cuboidal cells
139
how big is a serous cystadenoma?
1-3mm
| i think it's like a lot of little cysts
140
what do serous cystadenomas contain?
clear serous fluid
141
25% of all cystic neoplasms of the pancreas are what type of neoplasm?
serous cystadenoma
142
what sex does serous cystadenoma occur in twice as often?
women
143
when does serous cystadenoma occur?
7th decade of life
144
how does serous cystadenoma present?
abd pain or masses
145
how do you CURE serous cystadenoma?
surgical resection
146
what is the gross morphology of a solid pseudopapillary neoplasm?
large
well-circumscribed
SOLID & CYSTIC components
147
what are the cystic areas of a solid pseudopapillary neoplasm filled w/?
hemorrhagic debris
148
what is the behavior of the neoplastic cells of a solid pseudopapillary neoplasm?
neoplastic cells in sheets or papillary projections
149
how do solid pseudopapillary neoplasms present?
abd discomfort
150
what mutation is assoc w/ solid pseudopapillary neoplasm?
activating mutation of B-catenin
151
how do you CURE solid pseudopapillary neoplasm?
surgical resection
152
what is the 4th leading cause of death in the US?
pancreatic ductal adenocarcinoma
| lol okay phil
153
most pancreatic pts die w/i what length of time?
6 months
154
80% of cases of pancreatic cancer are in what age group?
60-80 yo
155
what are risk factors for pancreatic cancer?
```
smoking
fatty diet
chronic pancreatitis
diabetes
BOOZE
```
156
what are the 4 ways in which pancreatic cancer exhibits familial clustering (i.e. what mutations/syndromes)?
1. BRCA2
2. P16/CDKN2A
3. hereditary pancreatitis
4. peutz-jeghers syndrome
157
what is P16/CDKN2A assoc w/?
familial atypical mole/melanoma syndrome
158
where are most pancreatic cancers (what part of the pancreas)?
60% in the head
15% in body
5% in tail
20% are diffuse
159
what is the gross morphology of pancreatic cancer?
```
masses are usually...
hard
gray-white
stellate
poorly defined
```
160
most pancreatic carcinomas are what type?
ductal
161
T/F: pancreatic carcinomas have the same histology regardless of where they arise in the pancreas
TRUE
162
T/F: pancreatic carcinoma is rarely invasive
FALSE
| highly invasive!
163
what type of response does a pancreatic carcinoma have?
intense fibroblastic response
aka
"desmoplastic response"
(idk what this is)
164
pancreatic carcinomas often grow along WHAT?
nerves
165
what can pancreatic carcinoma invade to metastasize?
lymphovascular spaces
166
how do pancreatic carcinomas behave?
they try to recapitulate normal ductal epithelium & they form glands & secrete mucin
167
what is a variant of pancreatic carcinoma?
adenosquamous carcinoma
168
what is the cellular structure of pancreatic carcinoma?
abortive tubular structures or cell clusters growing in a deeply infiltrative pattern
169
what type of cells are involved in pancreatic carcinoma?
pleomorphic cuboidal to columnar epithelial cells
170
how does pancreatic carcinoma present clinically?
silent until it invades other structures, then it gets painful
171
when will pancreatic carcinoma cause jaundice?
if cancer arises in the head of the pancreas & if it obstructs the common bile duct
172
what are some general sx of pancreatic carcinoma (once it presents)?
weight loss
fatigue
general malaise
weakness
173
what is Trousseau sign?
migratory thrombophlebitis present in 10% of pancreatic carcinoma pts
174
what % of pancreatic adenocarcinomas are considered resectable at time of dx?
only 20% :(
175
under what circumstances can the 5 year survival of pancreatic cancer be 40%?
if the surgeon achieves negative margins when resecting
176
what is the name of the procedure used to resect pancreatic cancer?
Whipple
177
what is the Whipple procedure?
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
what is the classical presentation of solid pseudopapillary neoplasm?
young female pt w/ a HOP lesion (HOP = head of pancreas)
