Download - Minarcik robbins 2013_ch19-pancreas
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PANCREAS
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OBJECTIVES• Understand the etiology/risk
factors, pathogenesis, morphology, clinical features and outcome of pancreatic inflammations and neoplasms
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Ventral Bud
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Chapter 19
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Posterior view of duodenum/pancreas
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Arterial supply and venous drainage of the pancreas and spleen
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Lymphatic drainage of the distal pancreas and spleen
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Hepaticopancreatic ampulla(Ampulla of Vater)
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L2
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makes HCO3¯
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Pancreatic Enzymes• Amylase
• Lipase
• DNA-ase
• RNA-ase
• Zymogens: Trypsinogen Chymotrypsinogen Procarboxypeptidase A, B
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PANCREAS DISEASES• Congenital
•Inflammatory–Acute–Chronic
• Cysts
•Neoplasms
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Congenital• Agenesis (very rare)
• Pancreas Divisum (failure of 2
ducts to fuse) (common)
• Annular Pancreas (pancreas
encircles duodenum) (rare)
• Ectopic Pancreas (very common)
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PANCREATITIS• ACUTE (VERY SERIOUS)
• CHRONIC (Calcifications, Pseudocyst)
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CONSEQUENCES of ACUTE and CHRONIC pancreatitis
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ACUTE PANCREATITIS• ALCOHOLISM
• Bile reflux• Medications (thiazides)
• Hypertriglyceridemia, hypercalcemia
• Acute ischemia
• Trauma, blunt, iatrogenic
• Genes: PRSS1, SPINK1
• Idiopathic, 10-20%
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CLINICAL FEATURES• ABDOMINAL PAIN
• EXTREME emergency situation
• HIGH mortality
• …but MOST important lab test is……….?????
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AMYLASE
!!!!!!!
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MORPHOLOGY• EDEMA
• FAT NECROSIS
• ACUTE INFLAMMATORY INFILTRATE
• PANCREAS AUTODIGESTION
• BLOOD VESSEL DESTRUCTION
• “SAPONIFICATION” (stearates, Na+, Ca++)
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CHRONIC PANCREATITIS
• Pancreatic duct obstruction, LONGSTANDING
• Tropical
• Hereditary (PRSS1, SPINK1 mutations)
• IDIOPATHIC (40%)
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CHRONIC PANCREATITIS
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CLINICAL FEATURES• Abdominal Pain
• Vague abdominal symptoms
• Nothing
• CT calcifications (why?), amylase elevated, chronic diarrhea if chronic pancreatic insuffiency develops, high likelihood of pseudocysts
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PDEUDOCYSTS• Why “pseudo”?
• STRONGLY linked with pancreatitis
• Can be as big as a football and often are.
• Can cause obstruction
• Can get infected
• Do NOT become malignant
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Pancreas Neoplasms• Serous
• Mucinous
• Cystic
• Microcystic
• Papillary
• Benign
• Malignant (dense sclerosis is the rule)
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SEROUS
CYSTADENOMA
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MUCINOUS
CYSTADENOMA
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INTRADUCTAL
PAPILLARY
MUCINOUS
“NEOPLASM”
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CARCINOGENESISof PANCREATIC
ADENOCARCINOMA
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Pancreatic CA
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Pancreatic
Adenocarcinoma
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FATE:• Regional lymph nodes• Liver• Often L-2 spine• Lungs
Grading (WMP), Staging, TNM
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Final TIP of the day• Painless jaundice in an
elderly person is CARCINOMA of the head of the pancreas until proven otherwise