(14) Pathology Pancreas and Gallbladder Dr.

Guo

Acute Pancreatitis:

MOA: inappropriate activation of pancreatic enzymes causing

autodigestion of pancreatic parenchyma and damage to the
peripancreatic tissues and vascular network
Histology:
o Parenchymal necrosis, edema (inflamm infiltrate),
hemorrhagic features, fat necrosis, ghost outlines of
fat cells
o Fat necrosis d/t lipase released digesting fat cells
releasing free FA saponify w/ Ca2+ salts to form
soaps hypocalcemia
Etiology:
o Men > women; middle age
Causes:
o Gallstones (45%)
o Alcohol (35%)
o Other: metabolic, trauma, infection, etc
Symptoms:
o Largely a clinical diagnosis
o Abdominal pain (LUQ or mid-epigastrum)
Pain radiates to back, sudden onset
Described as severe, deep piercing pain
Aggravated by eating
Not relieved by vomiting
Labs:
o Hypo-calcemia
o Elevated amylase (rises during first 24 hours)
o Elevated lipase (rises w/n 72-96 hours)
o Note: ALP AST typically assoc w/ hepatitis
Radiology:
o US or CT = shows enlarged pancreas w/ distinct
border and non-uniform density
Systemic complications:
o Shock, DIC, Pulmonary insufficiency/ARDS
Local complications:
o Pseudocyst (cyst filled w/ pancreatic juice & digestive
enzymes lined by non-epithelial wall), necrosis,
abscess, pseudoaneurysm, splenic vein thrombosis

Pancreatic psuedocyst (below):

Chronic Pancreatitis:

Hemorrhage & fat necrosis (below):

Continuous inflammatory disease of the pancreas characterized

by irreversible morphologic changes of both the parenchyma
and ducts; typically coupled with permanent loss of function
and/or pain. (exocrine parenchyma destroyed first, then
endocrine)
Symptoms:
o Abdominal pain diffuse and localized to the upper
abd region; worse after meals and nocturnal symptoms
o Weight loss, DM (pccurs when 80% of gland function
is lost), Steatorrhea (occurs when 90% gland fn lost)
Causes: Alcohol (60-70%), usually in 35-55yo (mortality over
20 year course of disease)
Diagnosis: (requires high levels of clinical suspicion)
o Amylase and lipase could be nl or slightly elevated
o Increased bilirubin, hyperglycemia
o Should do a stool or fat analysis
Histology = sclerosis of parenchyma (ie: fibrotic changes)

chronic pancreatitis: fibrotic, shrunken pancreas w presence of stones

Acute and Chronic Pancreatitis Summary:

Neoplasms:

Congenital Anomalies:

Pancreatic Carcinoma (ductal adenocarcinoma):

o Arises from the HOP (head of the pancreas)
o Serum tumor markers: elevated CA 19-9, CEA
o General:
4th leading cause of death by cancer
95% from exocrine pancreas
5-10% are genetic
60% = head = obstruction of bile duct,
jaundice, pruritus, vomiting
20% = body/tail = back pain, weight loss
(30-50lbs) and fatigue
90% already metastasized by time of dx
o
o

Etiology: incidence in Black males

Risk Factors:
Age, Chronic pancreatitis, Tobacco, DM,
Hereditary predisposition, Obesity/Diet
Histology: infiltrative irregular complex glands;
cytologic atypia; desmoplastic stromal change,
prominent nucleloli
Sx = whipple procedure (Now watch me whipple,
now watch me NeyNey

Agenesis, pancreas divisum, annular pancreas, ectopic pancreas

Very rare

Gallstones (cholelithiasis):

Pathophysiology:
o D/t a combination of supersaturation, hypomotility,
crystal inculcation and accretion.
o Form from the bile pigments combination of
cholesterol and bilirubinate stones. Can lead to
hundreds of small stones.
o Can obstruct the gallbladder duct (choledocolithiasis)
Symptoms:
o Mid-epigastric pain that radiates to the right
subscapular region, N/V, fever, chills, jaundice (acute
hepatitis). Often related to eating (fatty foods)!
Labs: Elevated alkaline phosphatase, total bilirubin, amylase,
lipase, WBC
Diagnosis: US to visualize the stones. May need Sx to remove
the stones endoscopically.

Below: loss of polarity with nuclear stratification, nuclear

hyperchromasia and prominent nucleoli.

Gallbladder Adenocarcinoma

Serous cystadenoma:
o Almost always benign! (curable w/ surgery)
o Twice as common in women (~70 y/o)
Mucinous cystic neoplasm:
o Almost always arise in women (95%)
o Usually in the body or tail of the pancreas
o Assoc. w/ invasive carcinoma (33%)
Intraductal papillary mucinous neoplasm
o More frequently in men
o More frequently involve the head of the pancre
Solid-pseudopapillary neoplasm:
o Mainly in young women
o Cause abdominal discomfort d/t large size
o The -catenin/adenomatous polyposis coli genetic
pathway seems to be almost universally altered in
these neoplasms often due to the presence of
activating mutations of -catenin.
o Cured w/ surgery

Rare, and non-specific tumor; 6th leading cause of GI death

Infiltrative glands below the muscle layer
Cellular atypia and loss of polarity