Pathology of the exocrine pancreas

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Pathology of the exocrine pancreas
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Enzimes secreted by the pancreas

• Trypsin (act. enterokinase, inh. acinic, ductal
  secretions )
• Chymotripsin
• Aminopeptidae
• Elastase
• Amylase
• Lipase
• Phospholipase
• Nuclease

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Examination of the pancreas

• Laboratory
• US
• CT
• MR
• Cytology - US or CT guided, percutanious
• US endoscopy
• ERCP-pancreatic juice
• Bile duct scrape
• Intraoperative

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Biopsy

• intaoperative-84
• US guided-15
• US endoscopy-1

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Developmental anomalies

• Agenesia
• Pancreas annulare ( mechanical obstruction -
  duodenum)
• Pancreas divisum (pancreatitis)
• Wirsung-Santorini division (surgery !)
• Ectopic pancreas (microscopical size bleeding,
  2 of the islet cell tumors arise in )

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MALFUSION PANCREAS DIVISUM
ANOMALOUS DUODENO PANCREATIC JUNCTION outside the
duodenal wall Ampullary common duct gt 1,5 cm
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Pancreatitis

• Acute interstitial pancreatitis
• Acute necrotising haemorrhagic pancreatitis
• Chronic pancreatitis

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Acute pancreatitis

• Inc. 10-20/100000
• Gallbladder stones in 35-65 of cases
• 5 of patients having gallbladder stones
• Alcoholism - frequency - 65-5 (????)
• M/F 1/3 in case of gallbladder stones
• M/F 6/1 in case of alcoholism

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Acute pancreatitis - etiology

• Gallbladder stones
• Alcohol
• Dietery fault
• Hyperparathyreosis- hypercalcaemia
• Hyperlipoproteinaemia (I, V type)
• Iatrogén /ERCP, postoperative/
• Infection / mumps, coxsackie virus, Mycoplasma /
• Trauma
• Vascular (PAN, SLE, Henoch-Schönlein, shock)
• Drugs ( thiazids, azathioprine, oestrogen,
  sulfonamide, furosemide, methyldopa, pentamidine,
  procainamide)
• Idiopathic (10-20)

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Acut pancreatitis - morphology

• Fat necrosis
• Haemorrhage
• Necrosis
• Pseudocyst
• Abscess
• Blood vessel erosion

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Acute pancreatitis - symptoms

• Pain radiating to the upper back
• Vomit
• Fever
• Passage disturbancies
• Shock
• DIC, hemolysis
• Acute renal tubular necrosis
• ARDS
• Serum amilase, lipase, elevation, hypocalcaemia

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Acut pancreatitis shock - causes

• Blood loss
• Endotoxaemia
• Vasoactive agents in the blood (bradykinine,
  prostaglandine, NO, PAF)

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Acut pancreatitis differential-diagnosis

• Cholelithiasis/cholecystitis
• Ulcer
• Mesenterial embolisation
• Appendicitis
• AMI
• Nephrolithiasis

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Chronic pancreatitis

• Chronic progressive disease
• Both functional and morphological alterations
• Low mortality
• Bad quality of life

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Chr. pancreatitis etiology

• Alcohol
• Hypercalcaemia/hyperlipoproteinaemia
• Hereditary (pancreas divisum)
• Gallstones
• Drugs
• In 40 of the cases etiology cannot be shown
  (autoimmune?)

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Chr. pancreatitis pathomechanism

• Ductus obstruction protein plugs, may be
  calcified
• Decrease of lithostatine secretion
• Oxidative stress damage of the acini
  abnormalprotein secretion
• Progressive fibrosis- (vitious circle)-
• intrapancreatic lipide metabolits
• Autosome herediter pancreatitis
• (tripsin cannot be inactivated due to point
  mutation)

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Chronic pancreatitis - symptoms

• Pain - diverse intensity - radiating to the
  back
• Weight loss - malabsorbtion
• Diarrhea - steatorrhea
• Passage disturbancy
• Jaundice
• Diabetes
• Calcification
• Laboratory findings alterations depend on the
  amount of preserved functioning exocrine tissue

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Chronic pancreatitis morphology

• Atrophy of the acini
• Fibrosis
• Calcification
• Ductectasy
• Ductus proliferation -metaplasia, dysplasia
• Lymphocytic infiltration
• Amputation neuromas

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Pancreas pseudocyst

• Local accumulation of pancreatic juice - occur
  after pancreatitis

Pancreas - abscess
Occur after pancreatitis, Cause colliquation
necrosis Sterile, in case, no secondary
infection occurs
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PanIN R.H. Hruban and colleaguesAm J Surg
Pathol 25/5/579-586,2001http//pathology.jhu.edu
/pancreas_panin

• PanIN - pancreas intraepithelial neoplasia
• Precursor lesions of pancreas ductal
  adenocarcinomas

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Tumors of the pancreas

• Benign
• Malignant

Causative agents smoking alcohol high energy
diet
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Malignant pancreatic tumors

• Ductal adenocarcinoma
• Acinic cell cc.
• Anaplastic cc.
• Metastasic tumors
• Lymphomas
• Sarcomas

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Pancreas carcinoma symptoms(head-tail)

• Jaundice - Curvoisier sign
• Weight loss
• Pain
• Passage disturbances
• Migrating thrombophlebitis (Trousseau)
• Pancreatitis
• Metastasis

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Pancreatic tumors with low malignancy

• Mucinous cystic tumoros
• Solid and cystic papillary neoplasia (tumor)
  (SPT)
• Intraductal papillary mucinous neoplasia

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Intraductal papillary mucinous neoplasia

• Arises in the Wirsungian duct papillary
  prolifration of the columnar mucin secreting
  cells, that form the ducts

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Benign tumors of the pancreas

• Serous cystadenoma
• Cystic teratoma
• Lymphangioma
• Insuloma
• Mesenchymal tumors

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Islet cell tumors

• Hormone production in 50 of the cases
• Uncertain biological behaviour
• Round, well circumscribed lesions
• Insulinoma
• Glukagonoma
• VIP-oma
• Gastrinoma
• Somatostatinoma