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

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Presentation on theme: "Pathology of the Exocrine Pancreas Tyler Verdun, PGY3 General Pathology University of British Columbia November 5, 2013."— 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 Brief review of normal pancreatic anatomy Overview of acute and chronic pancreatitis Overview of acute and chronic pancreatitis Introduction to pancreatic adenocarcinoma Introduction to pancreatic adenocarcinoma This session will not cover: This session will not cover: Endocrine pancreas pathology Endocrine pancreas pathology Congenital abnormalities Congenital abnormalities Cystic lesions Cystic lesions Benign tumors (SPPT, cystadenomas, etc.) Benign tumors (SPPT, cystadenomas, etc.) Neuroendocrine tumors Neuroendocrine tumors

3 The Normal Pancreas

4 Normal Pancreas

5 Normal Pancreas Wait! There’s something wrong with this picture… Wait! There’s something wrong with this picture… No islets: this is actually parotid salivary gland No islets: this is actually parotid salivary gland Sourced from Sourced from Dr. John Minarcik’s excellent “Shotgun Histology” series 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 1. The pancreas is (metaphorically) a box of corrosive chemicals 2. Damage to the pancreas by some etiologic factor releases these chemicals from cells 2. Damage to the pancreas by some etiologic factor releases these chemicals from cells 3. Digestion, saponification, and calcification of neighboring healthy tissue 3. Digestion, saponification, and calcification of neighboring healthy tissue On gross examination/autopsy – greasy, chalk-white deposits On gross examination/autopsy – greasy, chalk-white deposits

9 Acute Pancreatitis - Etiologies I – Idiopathic I – Idiopathic G – Gallstones G – Gallstones E – Ethanol abuse E – Ethanol abuse T – Trauma: anything that compromises the blood supply T – Trauma: anything that compromises the blood supply S – Steroids S – Steroids M – Microbiological (bacterial, viral, or parasitic infections) M – Microbiological (bacterial, viral, or parasitic infections) A – Autoimmune diseases A – Autoimmune diseases S – Scorpion bite: Tityus trinitatis in Trinidad and Tobago S – Scorpion bite: Tityus trinitatis in Trinidad and Tobago H – Hypercalcemia or hyperlipidemia H – Hypercalcemia or hyperlipidemia E – ERCP: endoscopic procedure; can cause pancreatitis E – ERCP: endoscopic procedure; can cause pancreatitis D – Drugs: too many to list… D – Drugs: too many to list… FYI: in a pinch, never doubt the “The Big 3”© FYI: in a pinch, never doubt the “The Big 3”© Antibiotics, antiepileptics/antipsychotics, anti-inflammatories Antibiotics, antiepileptics/antipsychotics, anti-inflammatories I G E T S M A S H E D  Important  Not so much  Impress your staff!

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

11 Acute Pancreatitis – Radiologic Findings

12 Acute Pancreatitis – Histology Normal pancreas Horror Show

13 Acute Pancreatitis – Histology Neutrophils Necrosis Background pancreas Hemorrhage

14 Acute Pancreatitis - Prognosis Mild Mild Resolves with minimal supportive care within days Resolves with minimal supportive care within days Severe Severe Significant fluid depletion and electrolyte abnormalities Significant fluid depletion and electrolyte abnormalities Systemic inflammatory response and disseminated coagulation Systemic inflammatory response and disseminated coagulation Pseudocyst formation Pseudocyst formation Necrosis and hemorrhage Necrosis and hemorrhage Abscess formation and sepsis Abscess formation and sepsis May require ICU and surgical management May require ICU and surgical management

15 Chronic Pancreatitis Consequence of long-standing inflammation Consequence of long-standing inflammation Usually will have had recurring episodes of acute pancreatitis Usually will have had recurring episodes of acute pancreatitis ~80% will have history of alcoholism ~80% will have history of alcoholism Clinical presentation Clinical presentation Chronic epigastric pain Chronic epigastric pain Persistent nausea and vomiting Persistent nausea and vomiting Other common findings Other common findings Weight loss Weight loss Fatty stools Fatty stools Low or normal plasma amylase and lipase levels 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 Functional pancreatic tissue is destroyed 1. Enzyme levels are decreased or misleadingly normal 1. Enzyme levels are decreased or misleadingly normal 2. Loss of enzymes  decreased food digestion and nutrient absorption in small bowel 2. Loss of enzymes  decreased food digestion and nutrient absorption in small bowel Fatty stools Fatty stools 3. Weight loss 3. Weight loss

19 Pancreatic Adenocarcinoma

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

27 Pancreatic Adenocarcinoma - Prognosis Why so poor? Why so poor? Pancreatic anatomy Pancreatic anatomy Anatomically isolated Anatomically isolated Lacks a capsule  contiguous with surrounding fat Lacks a capsule  contiguous with surrounding fat Rich vascular supply Rich vascular supply Cancer cells respond poorly to chemotherapy Cancer cells respond poorly to chemotherapy Thick connective tissue in tumor prevents diffusion of chemo drugs? Thick connective tissue in tumor prevents diffusion of chemo drugs?

28 Thank You


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