Pancreas

Pancreas

1. Neoplasms

   • Pancreatic Carcinoma (adenocarcinoma)
     • Smoking
     • Chronic pancreatitis
     • (KRAS), p16, SMDA4 mutations
     • initially: painLESS obstructive JAUNDICE (dark urine, icterus, steatorrhea)
     • Later: painFUL d/t perineural invasion
     • Diabetes (islets of langerhan destruction (endocrine))
     • Trousseau's sign: recurrent migratory thromboplebitis _ Renal vein thrombosis (mucin is thrombogenic)
     • Metastasis to mesenteric lymph nodes and LIVER
     • Treatment: Wipple's procedure + chemo (poor prognosis)
     • C 19.9 _ Ultrasound, CT
     • Mucinous
       • Cystic neoplasms
         • tall columnar mucin secreting cells
           • with surrounding ovarian type stroma
             • Tail
               • not connected to the ducts
                 • women ONLY
     • Acinar Cell Carcinoma
       • subcutaneous fat necrosis and panniculitis due to lipase
         • Whites
     • Intra-ductul papillary mucinous neoplasm (IPMN)
       • duct is dilated and filled with mucin
         • HEAD
           • NO ovarian type stroma
   • Endocrine tumors
     • Insulinoma
       • Benign, solitory tumors from BETA CELLS
         • Increase insulin
           • WIPPLE'S TRIAD
             • Symptoms of Hypoglycemia
               • confusion, blurred vision, muscle weakness, sweating, palpitations
             • relieved by glucose intake and accentuated by fasting
             • Low blood glucose
     • Gastrinoma

2. Inflammatory lesions

   • Acute Pancreatitis
     • liquidative necrosis _ of exocrine pancreas ONLY
       • NO DIABETES
       • fever, nausea, vomiting, CONSTANT epigastric pain radiating to the back
     • Fat necrosis (because Trypsin is activated first
       • amylase and lipase break down fats >> FAs >> combine with Ca2+
         • Saponification (Chaly White deposits on surface
           • Radio-OPAQUE on X-ray
           • Hypercalcemia and tetany
     • investigation
       • amylase _ sensitive _ not specific (24-48 hours)
       • Lipase _ specific_ not sensitive (72-96 hours)
       • CT >> fat and liquifactive necrosis
     • Complication
       • ARDS
       • secondary bacterial infection w/ sepsis
         • hypovolemic shock
           • acute tubular necrosis
             • acute renal failure
         • DIC
       • Pseudocysts
       • Hemorrhage
     • GET SMASHED
       • Alcohol
         • contracts sphincter of Oddi _ alcohol increases protein concentration >> increased this thickness of pancreatic enzymes >> obstruction
           • premature activation of the enzymes INSIDE the pancreas
       • Gallstones
         • acinar cell injury and duct obstruction
       • HypERcalcemia
       • Trauma
       • Scorpion toxin
       • mumps
       • Autoimmune
       • Steroids
       • hyperlipidemia
       • Endoscopic Retrograde Colangiocreatography
       • Drugs
   • Chronic Pancreatitis
     • Chronic bouts of acute pancreatitis
       • pancreatic parenchyma becomes fibrotic and atrophies
         • no production of pancreatic enzymes (NO INTRALUMINAL HYDROLYSIS)
           • malabsorption (corrected by enzyme supplements) / steatorrhea
             • No Vit D
               • Hypercalcemia
                 • Cardiac arythmia
         • Obstruction
           • JAUNDICE
       • Reduced number and size of acini dilation of the main duct
       • dystrophic calcification
     • alcohol
       • toxin
         • oxidative stress
     • CFTR
     • CT
     • Pseudocysts
       • fluid filled cavities NOT lined by epithelium - fibrous scar
     • Pancreatic insufficiency
     • islets of langerhans are USUALLY spared but if they're damaged
       • Diabetes
     • pain ATTACKS from perineural fibrosis
     • Cancer
     • pleural effusion

3. Congenital

   • Pancreas divisor
   • Ectopic Pancreatic tissue in GIT

4. Autoimmune Pancreatitis (Lymphoplasmacytic sclerosing pancreatitis / duct-destructive pancreatitis

   • Type 1: lymphoplasmacytic infiltrate centered around LARGE & medium sized interlobular ducts
     • Periductual & perivenular fibrosis
     • OBLITERATIVE PHLEBITIS (arteries are spared)
     • IgG4 plasma cells
     • Male in 60's
   • Type 2: lymphoplasmacytitc infiltrate centered around small ducts
     • Granulytic epithelial lesions with partial/complete duct obstruction/ obliteration
     • NO IgG4
     • both genders, 40's
   • JAUNDICE, abdominal pain, MASS-LIKE LESION (differentiate it from Chronic pancreatitis), Diabetes Mellitus, weight loss
   • increase pancreatic enzymes and IgG4
   • auto-Ab (ANA, lactoferrin (ALF) , anti-carbonic anhydrase I (ACA-II), Rheumatoid factor (Rh) )