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19 The Pancreas
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What is the main pancreatic duct? What does the Duct of Wirsung drain to? What is the accessory duct? Does the duct of Santorini drain proximal or distal to ampulla of Vater? What type of cell make up exocrine pancreas? These exocrine enzymes, how are they secreted? What is pancreatitis? Why do we see acute pancreatitis? How would you treat acute pancreatitis? What is the difference between chronic and acute pancreatitis? Cysts in kidney, liver, and pancreas frequently co-exist in what condition? Pancreatic Pseudocysts lack what? Which of the following are you more likely to find cancer in What type of pancreatic cancer should be suspected if the patient develops metastatic fat necrosis due to lipase release? Are intra-ductal papillary muncinous neoplasms benign or cancerous/malignant? When digestive enzymes come down, what is the main enzyme that needs to be activated? What activates trypsin? What is a pancreas divisum, and what can it predispose you to?
Duct of Wirsung ampulla of Vater Duct of Santorini proximal
acinar cells inactive form inflammation of pancreas associated with injury to exocrine parenchyma biliary tract disease and alcoholism, and gallstones restrict oral intake of food; Will be supported with IV fluids, etc acute is reversible and chronic is not polycystic disease a true epithelial lining serous or mucinous cystadenomas - mucinous cystadenomas acinar cell carcinoma
7. 8. 9.
enterokinase - is the most common congenital anomaly of the pancreas - This anomaly is caused by a failure of fusion of the fetal duct systems of the dorsal and ventral pancreatic primordial → the bulk of the pancreas (formed by the dorsal pancreatic primordium) drains through the dorsal pancreatic duct and the small-caliber minor papilla (see Fig. 19-1B). - The duct of Wirsung in persons with divisum, normally is very short (1 to 2 cm) and drains only a small portion of the head of the gland through the larger caliber major papilla of Vater. - Clinical significance of pancreatic divisum, the relative stenosis caused by the bulk of the pancreatic secretions passing through the minor papilla predisposes individuals to the development of chronic pancreatitis amylase (first), then lipase alcoholism/long-term alcohol abuse
Diagnosis of acute pancreatitis (lab tests for...) What is the most common cause of chronic pancreatitis?
Know how chronic pancreatitis develops (proposed list) pg 896 PANCREATIC CARCINOMA Morphology (pg 902-903 Blue Box >>):
1) Ductal obstruction by concretions 2) Toxic effects 3) Oxidative stress
- Approximately 60% of cancers of the pancreas arise in the head of the gland - Grossly, Carcinomas of the pancreas are usually hard, stellate, gray-white, poorly defined masses - The vast majority are ductal adenocarcinomas that recapitulate to some degree normal ductal epithelium by forming glands and secreting mucin. - Two features are characteristic of pancreatic cancer: 1) It is highly invasive 2) elicits "desmoplastic response" - an intense non-neoplastic host reaction composed of fibroblasts, lymphocytes, and extracellular matrix - Most carcinomas of the head of the pancreas obstruct the distal common bile duct → marked distention of the biliary tree and most develop jaundice. In marked contrast, carcinomas of the body and tail of the pancreas do not impinge on the biliary tract and hence remain silent for some time. - Pancreatic cancers often grow along nerves and invade into the retroperitoneum. Peripancreatic, gastric, mesenteric, omental, and portahepatic lymph nodes are frequently involved. Distant metastases occur, principally to the liver, lungs, and bones - Microscopically, the appearance is usually a moderately to poorly differentiated adenocarcinoma forming abortive tubular structures or cell clusters and showing an aggressive, deeply infiltrative growth pattern. Dense stromal fibrosis accompanies the invasive cancer, and there is a proclivity for perineural invasion within and beyond the organ. Lymphatic and large vessel invasion are also commonly seen. The malignant glands are poorly formed and are usually lined by pleomorphic cuboidal- to-columnar epithelial cells. Well-differentiated carcinomas are the exception - adenosquamous carcinomas - colloid carcinoma - hepatoid carcinoma - medullary carcinoma - signet-ring cell carcinoma - undifferentiated carcinoma - undifferentiated carcinomas with osteoclast-like giant cells
>> What are the microscopic characteristics of pancreatic carcinoma (from morphology -- blue box)? >> What are the less common variants of pancreatic cancer?
Figure 19-13 Carcinoma of the pancreas. (pg 902)
- A) A cross-section through the tail of the pancreas showing normal pancreatic parenchyma and a normal pancreatic duct (left), an ill-defined mass in the pancreatic substance (center) with narrowing of the pancreatic duct, and dilatation of the pancreatic duct upstream (right) from the mass. - B) Poorly formed glands are present in densely fibrotic stroma within the pancreatic substance; there are some inflammatory cells.
What is the most common congenital anomaly of the pancreas?
List the two most common causes of Acute Pancreatitis. True or False? Acute necrotizing pancreatitis is the most severe form of acute pancreatitis. Why are pancreatic pseudocysts not true cysts? List the four types of cystic neoplasms of the pancreas
- Biliary tract disease - Alcoholism False (Hemorrhagic pancreatitis is the most severe form) They lack a true epithelial lining - Serous cystadenoma - Mucinous cystic neoplasm - tail B/M - Intraductal papillary mucinous neoplasms (IPMNs) - head B/M - Solid-pseudopapillary neoplasm PanINs (Pancreatic intraepithelial neoplasias) Smoking Pancreatoblastoma
What is the precursor lesion to pancreatic carcinoma? What is the greatest environmental influence predisposing an individual to pancreatic carcinoma? What malignant pancreatic neoplasm occurs primarily in children between the ages of 1 and 15? List the four structures that you would receive in a Whipple's specimen.
- Head of the pancreas - Duodenum - Distal common bile duct - Ampulla of Vater
What are the margins on a whipple specimen?
- Pancreatic head (submit enface for FS) - Duodenal: proximal and distal - Ducts: CBD, PD, trace to AoV