Normal Pancreas - UBC Histology - University of British Columbia
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Transcript Normal Pancreas - UBC Histology - University of British Columbia
Pathology of the
Exocrine Pancreas
Tyler Verdun, PGY3 General Pathology
University of British Columbia
November 5, 2013
Objectives
Brief review of normal pancreatic anatomy
Overview of acute and chronic pancreatitis
Introduction to pancreatic adenocarcinoma
This session will not cover:
Endocrine pancreas pathology
Congenital abnormalities
Cystic lesions
Benign tumors (SPPT, cystadenomas, etc.)
Neuroendocrine tumors
The Normal Pancreas
Normal Pancreas
http://upload.wikimedia.org/wikipedia/commons/f/fc/Pancreas_4.jpg
Normal Pancreas
Wait! There’s something wrong with this picture…
No islets: this is actually parotid salivary gland
Sourced from http://www.youtube.com/watch?v=1Kavxv3jHzA
Dr. John Minarcik’s excellent “Shotgun Histology” series
Normal Pancreas
Pancreatitis
Acute Pancreatitis
1. The pancreas is (metaphorically) a box of
corrosive chemicals
2. Damage to the pancreas by some etiologic
factor releases these chemicals from cells
3. Digestion, saponification, and calcification of
neighboring healthy tissue
On gross examination/autopsy – greasy, chalk-white
deposits
Acute Pancreatitis - Etiologies
I – Idiopathic
G – Gallstones
E – Ethanol abuse
T – Trauma: anything that compromises the blood supply
Important
S – Steroids
M – Microbiological (bacterial, viral, or parasitic infections)
A – Autoimmune diseases
S – Scorpion bite: Tityus trinitatis in Trinidad and Tobago Impress your staff !
H – Hypercalcemia or hyperlipidemia
Not so much
E – ERCP: endoscopic procedure; can cause pancreatitis
D – Drugs: too many to list…
FYI: in a pinch, never doubt the “The Big 3”©
Antibiotics, antiepileptics/antipsychotics, anti-inflammatories
Acute Pancreatitis – Diagnosis
Clinical presentation:
Imaging
Moderate to severe epigastric pain radiating to back
Nausea and vomiting
Fever, ↑HR, ↑RR, ↓BP
Rarely: abdominal or flank bruising (Cullen & Grey-Turner)
CT scan and abdominal ultrasound showing inflammation or
cystic structures around pancreas
Labs
Elevated amylase and lipase
Elevated glucose
May see elevated liver markers
Acute Pancreatitis – Radiologic
Findings
http://upload.wikimedia.org/wikipedia/commons/9/97/Pankreatitis_exsudativ_CT_axial.jpg
Acute Pancreatitis – Histology
Horror Show
Normal pancreas
Acute Pancreatitis – Histology
Hemorrhage
Necrosis
Background pancreas
Neutrophils
Acute Pancreatitis - Prognosis
Mild
Resolves with minimal supportive care within days
Severe
Significant fluid depletion and electrolyte abnormalities
Systemic inflammatory response and disseminated
coagulation
Pseudocyst formation
Necrosis and hemorrhage
Abscess formation and sepsis
May require ICU and surgical management
Chronic Pancreatitis
Consequence of long-standing inflammation
Usually will have had recurring episodes of acute pancreatitis
~80% will have history of alcoholism
Clinical presentation
Chronic epigastric pain
Persistent nausea and vomiting
Other common findings
Weight loss
Fatty stools
Low or normal plasma amylase and lipase levels
Chronic Pancreatitis – Radiologic
Findings
http://upload.wikimedia.org/wikipedia/commons/7/7b/Chronische_Pankreatitis_mit_Verkalkungen_-_CT_axial.jpg
Chronic Pancreatitis – Histology
Residual pancreas
Fibrosis and lymphocytic
inflammation
Chronic Pancreatitis
Functional pancreatic tissue is destroyed
1. Enzyme levels are decreased or misleadingly
normal
2. Loss of enzymes decreased food digestion and
nutrient absorption in small bowel
Fatty stools
3. Weight loss
Pancreatic
Adenocarcinoma
Pancreatic Adenocarcinoma –
Diagnosis
Risk factors
Signs and symptoms:
Painless jaundice
Pain that radiates to back
Weight loss
Physical exam
Chronic pancreatitis
Smoking
Obesity
Sometimes no major findings
Ascites and hepatomegaly due to metastases
Abdominal and rectal nodules from metastases
Approximately 75% will present at an advanced stage
Pancreatic Adenocarcinoma –
Radiologic Findings
http://upload.wikimedia.org/wikipedia/commons/f/f6/MBq_cystic-carcinoma-pancreas.jpg
Pancreatic Adenocarcinoma –
Whipple Resection
Duodenum
(cut open)
Common bile duct
Head of pancreas
(cut open)
http://upload.wikimedia.org/wikipedia/commons/1/17/Macroscopic_image_of_pancreas_adenocarcinoma_removed_by_Whipple_procedure.jpg
Pancreatic Adenocarcinoma –
Histology
Cancerous glands with mucin production
Pancreatic Adenocarcinoma –
Histology
Residual pancreas
Tumor with mucin
Pancreatic Adenocarcinoma –
Histology
Pleomorphic (ugly) cells
Mitoses
Pancreatic Adenocarcinoma Prognosis
http://progressreport.cancer.gov/doc_detail.asp?pid=1&did=2009&chid=95&coid=927&mid
Pancreatic Adenocarcinoma Prognosis
Why so poor?
Pancreatic anatomy
Anatomically isolated
Lacks a capsule contiguous with surrounding fat
Rich vascular supply
Cancer cells respond poorly to chemotherapy
Thick connective tissue in tumor prevents diffusion
of chemo drugs?
Thank You