Pancreatic Pathology
PANCREAS: GENERAL
--a lobulated, pinkish-gray structure under/behind the stomach and intestine in LUQ
--pancreatic dz dx'd late bcs organ can't be palpated and has high functional reserve
--85% of exocrine tissue destroyed before Sx
--autodigestion prevented by organized enzyme cascade
--trypsinogen is activated only by contact with duodenal enterokinase
--trypsin activates the other pancreatic zymogens
--exceptions: amylase and lipase are active when secreted
ACUTE PANCREATITIS
--bad bad bad
--pt must be hospitalized
--inflam of exocrine panc, dstrx of acinar cells
--most severe forms: acute necrotizing & acute hemorrhagic-->fat necrosis & hemorrhage
--ETIO:
----65% of pts heavy alc consumption, alcohol increases prots in secretions-->ductal concretions
----35-60% have gallstones or sludge-->damage sphincter of Oddi/obstruct common bile duct
--ETIO: helminths (ascaris lumbricoides-->appdx too), exposure to diesel fumes, solvents, trichloroethylene (dry cleaning), viruses, mycoplasma, drugs (steroids, estrogens, aziothioprine, diuretics, sulfonamides), hyperlipidemia types I and V (high TG's normal chol, no prob w/ heart dz), hypercalcemia, perforated gastric ulcer, vasculitis, ishemia, renal failure, hereditary, trauma
--MORPH: autodigestion by protease and lipase, necrotic fat cells fill with debris, calcium & fat-->soaps, edema and inflam, elastase digests vasculature-->hemorrhage, ascites is brown with fat droplets (chicken soup), after acute may form pseudocysts (fibrous tissue around dissolved areas, may migrate, may get infx and become an abscess, seen on US or CT)
--S/Sx: mild to severe CONSTANT epigastric abdominal pain, may radiate to mid back, leaning fwd may reduce pn
--Signs: (late) Collins: discolor/bruise on L flank, Gray-turner: periumbilical discoloration
--LABS: elevated amylase & lipase in serum or urine, hypocalcemia below 8.5 dt Ca++ binding with fat
--COMPLICations: fatal shock from peripheral vascular collapse, renal failure, ARDS, duodenal obstrx
CHRONIC PANCREATITIS
--chronic relapsing pancreatitis
--ETIO: scarring from repeat acutes, TG's in 700's
--MORPHology: loss of acinar cells, dense fibrous deposition, duct obstrx, calcified fat or prot, pseudocysts
--S/Sx: chronic abdominal or back pain triggered by alcohol, overeat, drugs (esp opiates)
--S/Sx: steatorrhea, DM I, mb mild jaundice
NEOPLASMS OF PANCREAS
--mucinous cystadenoma, benign, almost always in women
--cystadenocarcinoma, malig
CARCINOMA OF THE PANCREAS
--cancer of exocrine pancreas
--fatal, usu within 2-3 mo of dx
--5-year survival 3%
--alive now with this: Patric Swayze stage IV, Ruth Bader Ginsburg stage I?
--INCIDence: tripled in last 40 years, more in males, blacks, diabetics, over 50, with hereditary chronic
--ETIO: heavy tobacco smoking, high fat & meaty diet, partial gastrectomy, exposed to a-napthylamine and benzine (also etio for leukemia), alcohol??, diabetes esp in female, chronic pancreatitis, cirrhosis, coffee??
--MORPH: adenocarcinoma originates in DUCTAL CELLS, 60% occur in head of panc, local invasion from head to duodenum, CBD and liver, body and tail tumors impinge on vertebrae, retroperitoneal spaces: spleen, adrenals
--Sx: painless jaundice, thoracic/abdominal pain, anorexia/N/V/weight loss, indigestion, depression
--Sx: Trousseau syndrome: migratory thrombophlebitis
--Sx: Courvoisier sign: actue, painless dilation (palpable) of gall bladder accompanied by jaundice
--DX: usu very late, head lesions dxed earlier because they obstruct ducts and cause acute or jaundice
--Dx: CT, Bx, endoscopic US. Cytology from fine needle aspiration is very diagnostic.
--ERCP = endoscopic retrograde cholangiopancreatography
--TX: allopathic tx of little value, Whipple's procedure occasionally curative, more often kills pt within 11 days, removal of head, neck, and "everything around it", hook part of the intestine straight to what remains of the panc. Sometimes stint placement may help, get enzymes from remaining healthy panc cells to duodenum, reduce jaundice