Pancreas

1. Pancreas

2. Pancreas

3. Pancreas Pancreatic acini, radial orientation of the pyramidal exocrine acinar cells. cytoplasm is for the synthesis and packaging of digestive enzymes for secretion into a central lumen

4. Pancreas Congenital anomalies: 1.Agenesis = incompatible with life 2. Pancreas Divisum = persistence as dorsal and ventral pancreas Predisposes to Chronic Pancreatitis 3. Annular pancreas = pancreatic head encircles the duodenum Risk of Intestinal obstruction 4. Aberrant (or Ectopic) pancreas = located in the stomach, SI, Meckel’s Diverticulum, submucosal, yellow-gray nests

5. Pancreas - Pancreas Divisum

6. Pancreas - Annular pancreas

7. Pancreas Acute Pancreatitis= acute abdominal pain, radiating to the back Types Acute interstitial pancreatitis= Mild form with edema Acute necrotizing pancreatitis = Severe pancreatitis with tissue necrosis Acute hemorrhagic pancreatitis = Most severe form with extensive hemorrhage raised levels of pancreatic enzymes (amylase and lipase) in Blood or Urine MCC= cholelithiasis and alcoholism Alcohol = proposed mechanism of acinar cell injury misdirected intracellular transport of Proenzymes protein plugs within pancreatic ducts, local obstruction and inflammation Clinical Medical emergency with acute abdomen, constant and intense abdominal pain with upper back radiation, peripheral vascular collapse and shock Death occurs from shock, ARDS, Acute renal failure

8. Pancreas Acute Pancreatitis Lab findings first 24 hours -marked elevation of the serum amylase within 72 to 96 hours -rising serum lipase, Glycosuria occurs in 10% of cases, Hypocalcemia, if persistent- poor prognostic sign Complications pancreatic abscess Pseudocyst

9. Acute Pancreatitis Microscopic field shows a region of fat necrosis on the right

10. Pathways of Acute pancreatitis

11. Acute Pancreatitis hemorrhage in the head of the pancreas fat necrosis

12. Pancreas Chronic Pancreatitis= Repeated bouts pancreatitis with loss of pancreatic parenchyma & pancreatic function Replacement by fibrous tissue (islets of Langerhans are spared) Causes Ductal obstruction by concretions (as with alcohol) decreased acinar secretion of lithostatine (inhibit intraluminal precipitation of calcium carbonates) Complications Pseudocyst diarrhea (malabsorption) diabetes

13. Chronic Pancreatitis A, Extensive fibrosis and atrophy has left only residual islets (left) and ducts (right), with a sprinkling of chronic inflammatory cells and acinar tissue. B, A higher-power view demonstrating dilated ducts with inspissated eosinophilic ductal concretions in a patient with alcoholic chronic pancreatitis.

14. Sequelae of Acute and Chronic Pancreatitis

15. Pancreatitis

16. Pancreas Pancreatic Cysts Non-neoplastic =MC (75%) –Pseudocyst (Acquired) Complication after acute or chronic pancreatitis, Unilocular cyst, no epithelial lining Congenital =Part of Poly cystic disease congenital polycystic disease =coexist with kidney and liver cysts Neoplastic Benign – Unilocular Malignant – Multilocular Von-Hippel-Lindau disease = Congenital pancreatic cysts and angiomas of the CNS (Retina, Cerebellum)

17. Cystic Neoplasms

19. Unilocular Vs Multilocular cysts

20. Pancreatic pseudocyst A, Cross-section through this previously bisected lesion revealing a poorly defined cyst with a necrotic brown-black wall. B, Histologically, the cyst lacks a true epithelial lining and instead is lined by fibrin and granulation tissue

21. Serous cystadenoma A, Cross-section through a serous cystadenoma. Only a thin rim of normal pancreatic parenchyma remains. The cysts are relatively small and contain clear, straw-colored fluid. B, The cysts are lined by Cuboidal epithelium without atypia.

22. Mucinous Cystic Tumor A, Cross-section through a mucinous multiloculated cyst in the tail of the pancreas. The cysts are large and filled with tenacious mucin. B, The cysts are lined by columnar mucinous epithelium, and a dense "ovarian“ like stroma is noted

23. 3. Intraductal papillary Mucinous Neoplasm A, Cross-section through the head of the pancreas showing a prominent papillary neoplasm distending the main pancreatic duct. B, The papillary mucinous neoplasm involved the main pancreatic duct (left) and extending down into the smaller ducts and ductules (right).

24. Pancreas Carcinoma Pancreas = carcinomas of the exocrine pancreas 5% of all cancer deaths in the US at age of 60 and 80’s arising from ductal epithelial cells, ? incidence in smokers and alcoholics Genetics K-ras mutations in 90% cases (MC altered oncogene) p53 mutations in 60 to 80% cases P16- MC inactivated tumor suppressor gene Site= MC in in the head (60%) Microscopically = (adenocarcinoma-MC type) Prognosis five-year survival - 5%

25. Pancreas 1.Carcinoma Pancreas first year mortality >80%, Clinically weight loss, pain & obstructive jaundice massive metastasis to the liver occurs via splenic vein invasion, migratory thrombophlebitis (Trousseau syndrome) Biochemical tests = Carcinoembryonic antigen (CEA) and CA19-9 antigen Diagnosis= endoscopic ultrasonography and CT& FNAC 2. Pancreatoblastoma =rare neoplasms in children, fully malignant 3. Periampullary carcinomas = pancreatic carcinomas at ampulla of Vater 85% are unresectable at presentation,

26. Carcinoma - Pancreas

27. Carcinoma - Pancreas A, A cross-section through the head of the pancreas and adjacent common bile duct showing both an ill-defined mass in the pancreatic substance (arrowheads) and the green discoloration of the duct resulting from total obstruction of bile flow. B, Poorly formed glands are present in densely fibrotic stroma within the pancreatic substance; there are some inflammatory cells

28. Case A 40-year-old woman developed increasingly severe abdominal pain over a two day period. In the emergency room, physical examination demonstrated board-like rigidity of her abdomen along with extreme tenderness. A plain film radiograph of the abdomen demonstrated dilated loops of bowel, several radiopaque gallstones in the gallbladder, but no free air. The total bilirubin was 3.8 mg/dL, AST 25 U/L, ALT 30 U/L, albumin 3.5 g/dL, total protein 5.8 g/dL, glucose 120 mg/dL, calcium 7.8 mg/dL, phosphorus 3.3 mg/dL, and lipase 2,250 U/L. The gross photograph depicts the process (image 7.1). The microscopic appearance is seen in images 7.2 and 7.3.

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