Pathology of Pancreas

DR Marwa Mohamed
⚫ References
Robbins Basic Pathology 10th edition
(Electronic edition USA)
Intended learning outcomes:
By the end of this lecture, students should be able to

1. List causes and types of pancreatitis.

2. Explain the pathogenesis of acute and chronic pancreatitis.

3. Analyze the clinicopathological and morphological features of acute pancreatitis due to various causes to
arrive at appropriate diagnosis and explain its clinical outcome.

4. Differentiate between the benign and malignant neoplasms of pancreas with reference to morphological &
clinicopathological features to arrive at appropriate diagnosis.
 Acute pancreatitis

• Definition: Acute inflammation of the pancreas

• Etiological factors :
-Alcoholism
-Gall stones (impaction of gallstones within the common bile duct, impeding the flow of
pancreatic enzymes through the ampulla of Vater)
- Trauma during surgery
-Ischemia due to thrombosis.
- Infections with mumps virus.
Alcohol consumption

1- Direct toxic effects on acinar cells with release of digestive enzymes

causing autodigestion of pancreas

2- Secretion of protein-rich pancreatic fluid (protein plugs) leading to

obstruction of small pancreatic ducts.
3- Increases contraction of the sphincter of Oddi impeding the flow of
pancreatic enzymes through the ampulla of Vater
• Pathogenesis:
Acute pancreatitis appears to be caused by autodigestion of the

pancreas.

This results from acinar cells injury that cause inappropriate release and

activation of pancreatic enzymes, which destroy pancreatic tissue and

cause an acute inflammatory reaction

 Pathological picture
Gross:
The pancreas shows red-black hemorrhagic areas and yellow-white chalky foci
(saponification).
Microscopic:
(1) Pan-acinar necrosis and Acute inflammatory reaction
(2) Fat necrosis (enzymatic destruction of fat cells; the released fatty acids
combine with calcium)
(3) Destruction of pancreatic parenchyma
(5) Destruction of blood vessels ----- hemorrhage.
• Clinical picture:
❖ Acute pancreatitis is a medical emergency that presents by acute abdomen .

❖ The pain is intense and referred to the upper back.

❖ Systemic Release of digestive enzymes into the circulation, resulting in Shock

❖acute respiratory distress (due to diffuse alveolar damage)

❖renal failure due to acute tubular necrosis

❖Elevated plasma levels of amylase ( first 24 h) and lipase ( 72-96 h)

• Complications:
1. Pancreatic abscess.
2. Pancreatic Pseudocysts (composed of necrotic debris surrounded by fibrosis, lacking an epithelial
lining).
 Chronic pancreatitis
Definition: Long-standing inflammation that leads to irreversible destruction of the exocrine
pancreas, followed eventually by loss of the islets of Langerhans.

Etiology: -Long term alcohol abuse.

Gross : The Pancreas is firm due to fibrosis

Microscopic: Atrophy of acini, chronic inflammatory cells and fibrosis, Squamous metaplasia
of ductal epithelium

Clinical picture: Repeated attacks of abdominal pain, or persistent abdominal and back pain

Complications: Diabetes mellitus, Chronic malabsorpation ,Pancreatic cancer

 Pancreatic Carcinoma

Predisposing factor:
1-Smoking.
2- Alcohol.
3- Chronic pancreatitis
4- Genetic mutations e.g. K Ras
Site:
- 60% in head of the pancreas
- 15% in the body.
- 5% in the tail.
- 20%, diffusely involves the entire gland.
Gross:
Irregular ,non capsulated, greyish white
mass with areas of hemorrhage and
necrosis

Microscopic:
- Adenocarcinoma formed of malignant
acini(irregular shape with irregular lumen)
showing malignant criteria.
- Marked desmoplastic (fibrotic)stroma

Immunohistochemistry:
positive for CA19-9
• Clinical picture:
1- Carcinomas of the head of the pancreas obstruct the distal common bile duct producing
distention of the biliary tree and jaundice.

2- Carcinomas of the body and tail of the pancreas do not impinge on the biliary tract (silent
for long time)
• Spread:
1- Direct:
a. Carcinoma of head: spreads to
- Common bile duct causing obstructive jaundice
- Duodenum leads to obstruction.
b. Carcinoma of body and tail: spreads to spleen, kidney and vertebra.
2.Lymhatic: to regional lymph nodes.
3. Blood: to lungs, bones.