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Pathology of the Exocrine Pancreas

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Presentation on theme: "Pathology of the Exocrine Pancreas"— Presentation transcript:

1 Pathology of the Exocrine Pancreas
Tyler Verdun, PGY3 General Pathology University of British Columbia November 5, 2013

2 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

3 The Normal Pancreas

4 Normal Pancreas

5 Normal Pancreas Wait! There’s something wrong with this picture…
No islets: this is actually parotid salivary gland Sourced from Dr. John Minarcik’s excellent “Shotgun Histology” series

6 Normal Pancreas

7 Pancreatitis

8 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

9 Acute Pancreatitis - Etiologies
M A H D I – Idiopathic G – Gallstones E – Ethanol abuse T – Trauma: anything that compromises the blood supply S – Steroids M – Microbiological (bacterial, viral, or parasitic infections) A – Autoimmune diseases S – Scorpion bite: Tityus trinitatis in Trinidad and Tobago H – Hypercalcemia or hyperlipidemia 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  Important  Impress your staff!  Not so much

10 Acute Pancreatitis – Diagnosis
Clinical presentation: Moderate to severe epigastric pain radiating to back Nausea and vomiting Fever, ↑HR, ↑RR, ↓BP Rarely: abdominal or flank bruising (Cullen & Grey-Turner) Imaging CT scan and abdominal ultrasound showing inflammation or cystic structures around pancreas Labs Elevated amylase and lipase Elevated glucose May see elevated liver markers

11 Acute Pancreatitis – Radiologic Findings

12 Acute Pancreatitis – Histology
Horror Show Normal pancreas

13 Acute Pancreatitis – Histology
Hemorrhage Necrosis Background pancreas Neutrophils

14 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

15 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

16 Chronic Pancreatitis – Radiologic Findings

17 Chronic Pancreatitis – Histology
Residual pancreas Fibrosis and lymphocytic inflammation

18 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

19 Pancreatic Adenocarcinoma

20 Pancreatic Adenocarcinoma – Diagnosis
Risk factors Chronic pancreatitis Smoking Obesity Signs and symptoms: Painless jaundice Pain that radiates to back Weight loss Physical exam Sometimes no major findings Ascites and hepatomegaly due to metastases Abdominal and rectal nodules from metastases Approximately 75% will present at an advanced stage

21 Pancreatic Adenocarcinoma – Radiologic Findings

22 Pancreatic Adenocarcinoma – Whipple Resection
Duodenum (cut open) Common bile duct Head of pancreas (cut open)

23 Pancreatic Adenocarcinoma – Histology
Cancerous glands with mucin production

24 Pancreatic Adenocarcinoma – Histology
Residual pancreas Tumor with mucin

25 Pancreatic Adenocarcinoma – Histology
Pleomorphic (ugly) cells Mitoses

26 Pancreatic Adenocarcinoma - Prognosis
Sourced from:

27 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?

28 Thank You

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