Endocrine Pancreas

DIABETES MELLITUS

metabolic disorders sharing the common underlying feature of hyperglycemia.

Pathogenesis

• Type I Diabetes Mellitus

Autoimmune (Failure or self tolerance in T cell)

Caused by:
• Autoimmune Genetic susceptibility; in class II MHC molecules on 6p2/(HLA-D).
• Environmental Factors: especially infections, may involved in type diabetes (mumps, rubella, and coxsackie
viruses, in particular)

▪ Type 2 Diabetics Mellitus:

Type 2 diabetes is a multifactorial disease.
• Environmental factors. such as a sedentary lifestyle and dietary habits.
• Genetic factors are also involved in the pathogenesis.
The two metabolic defects that characterize type 2 diabetes are:

(I) Insulin resistance;

- Decreased ability of peripheral tissues to respond to insulin.
- Obesity→ cytokines from adipose tissue affects receptors of insulin (theory)

(2) Beta cell dysfunction:

Excess nutrients such as FFAs and glucose can promote the secretion of proinflammatory cytokines
from beta cells, → inflammation ( insulinitis) → B cell death in late stages
Amyloid replacement of islets is a characteristic finding in persons 'with longstanding type 2
diabetes and is present in more than 90% of diabetic islets examined

Complications of Diabetes
The pathogenesis of the long-term complications of diabetes:
1. glycation end products (AGEs): responsible for atherosclerosis acceleration and basement membrane
thickening that is characteristic of diabetic microangiopathy.
2. activation of intracellular protein kinase C. → neovascularization seen in diabetic retinopathy.

transforming growth factor-ß, → Fibrosis and basement membrane thickening

3. Disturbances in polyol pathways leading to oxidative stress (Free radicals)

Morphology:
Diabetes and Its Late Complications
Pancreas:
• Reduction in the number and size of islets (most often in type 1 diabetes)
• Leukocytic infiltration of the islets (Bothe type 1&2 DM)
• Amyloid replacement of islets in long -standing type 2 diabetes
Type 1 Type 2
Inflammation (insulinitis) Inflammation (insulinitis)
Reduction of Islets Less prominent
-- Amyloidosis
Diabetic Macrovascular Disease:
The hallmark of diabetic macrovascular disease is accelerated atherosclerosis affecting the aorta and large and medium-sized
arteries e.g. coronary arteries , lower extremities blood vessels, renal arteries

Hyaline arteriolosclerosis (thick arterioles)

The vascular lesion associated with hypertension is both more prevalent and more severe in
diabetics than in nondiabetics.

Diabetic Microangiopathy:
- One of the most consistent morphologic features of diabetes is diffuse thickening of
basement membranes either in capillaries or nonvascular structures.
- the basal lamina is thickened by hyaline material ( type IV collagen).
- capillaries are more leaky than normal to plasma proteins.
- Leading to : diabetic nephropathy, retinopathy, and some forms of neuropathy.

Diabetic Nephropathy:
It may lead to:
1- Glomerular lesion: diabetic glomerulosclerosis.
2- Renal vascular lesions: renal arteriosclerosis.
3- Pyelonephritis including necrotizing papillitis. papillary necrosis.

❖ Diabetic glomerulosclerosis occurs in patients with long standing diabetes mellitus for 12 years
or more. It may take the form of:
- Diffuse glomerulosclerosis
- Nodular glomerulosclerosis (Kimmelstiel-Wilson lesion)

Clinical Features:
- polyuria, polydipsia, polyphagia, ketoacidosis
- CVS: myocardial infarction,
-Brain: stroke (cerebrovascular accident) are the most common contributors to mortality.
- Diabetic nephropathy leads to nephrotic syndrome or chronic renal failure
- Visual impairment, patients also have an increased propensity for retinopathy, glaucoma,
cataract formation and sometimes even total blindness.

-Diabetic neuropathy
• Hand and feet (Glove and stocking) polyneuropathy.
• autonomic neuropathy (bladder, bowel or sexual impotence)

- Diabetic patients have an enhanced susceptibility to infections of the skin, as well as

to tuberculosis, pneumonia, and pyelonephritis.
 PANCREATIC NEURO-ENDOCRINE TUMORS(PanNETs)

also known as islet cell tumors, are rare in comparison with tumors of the exocrine
pancreas, accounting for only 2%% of all pancreatic neoplasms These
tumors arise from islets of Langerhans’s which contain different types of cells:

❖ Alpha or A cells which produce glucagon.

❖ Beta or "B" cells which produce insulin,
❖ Della or "D" cells which produce somatostatin.
❖ "G" cells which produce gastrin

occur in adults and may be single or multifocal.

Insulinomas:
. Beta cell tumors (insulinomas) are the most common type of PanNET.

Clinically: This tumor produces excessive amounts of insulin which induce significant
hypoglycemia → mental confusion and loss of consciousness.
Behavior: 90 % benign - 10% malignant

Morphology:
Gross:
Majority are solitary, small (less than 2 cm in diameter) and localized to the pancreas
Microscopic:
- giant islets, of monotonous cells + Vascular stroma + Amyloid

Gastrinomas
Marked hypersecretion of gastrin usually has its origin in gastrin-producing tumors
(gastronomas).
Site: It arises from pancreas (G cells), duodenum and peripancreatic soft tissues
Behavior: 50% of gastrinomas are malignant.
Clinically:
"Zollinger Ellison syndrome"
▪ Pancreatic islet cell tumor "Gastrinoma".
▪ Gastric acid hypersecretion.
▪ Peptic ulcerations the stomach, duodenum and jejunum.
N.B: The ulcers often are multiple and unresponsive

Morphology:
Gross:
single in sporadic cases, multifocal in MEN1.
Microscopic:
bland looking cells, rare anaplasia.