Topic 09 Pancreas - Paula D\'Amore PDF

Preview

Summary

Paula D'Amore...

Description

CLS308-Pancr eas Pancr eas CLS308,D’ Amor e Fal l 2017,Week15 OUTLI NE 1.Nor malAnat omyandPhy s i ol ogy 2.Ov er vi ewofMaj orDi seases 3.Speci al Pat hol ogy Nor malAnat omyandPhysi ol ogy

Maj orenz ymessec r et edbyac i narcel l s : Amyl as e–di ges t sst ar ch Li pase–di ges t sf at Tr y ps i n,Chy mot r y ps i n–di gest spr ot ei n Duc tcel l ssec r et eNaHCO3,muc i n

98%ex ocr i ne di ges t i v ej ui cesflowi nt oduodenum t hr u Sphi nct erofOddi ( v al v et hatal l owsbi l eand panc r eat i cmat er i ali nt oduod) Thepanc r easi nr el at i ont ot hel i v er , duodenum,ands t omac h.Thei ns ets howst he ac i ni ,duct s,andi sl et .( Fr om Appl egat eEJ:The Anat omyandPhy si ol ogyLear ni ngSy s t em,4t h ed,St .Loui s ,2011,Saunder s. - Ac i narcel l smak ec hemi cal st hathel p wi t hdi ges t i on

Sphi nct erOfOddi mus c ul arv al v et hat cont r ol st heflowofdi ges t i v ej ui ces( bi l eand panc r eat i cj ui ce)t hr ought heampul l aofVat er

CLS308-Pancr eas •

• • •

Tumor sofheadofpanc r easc an obs t r uc tt hebi l educt( obst r uc t i v e j aundi c e) Tumor sofendocr i nepanc r eas Di abet esmel l i t us I mpr operdi etofov er eat i ng,f at t yf oods andal cohol abus et hepanc r eas can l eadt ol os sofpar enchymal cel l sl eads t omal absor pt i onanddi ar r hea

Speci alPat hol ogy

Fourmai nenz ymesofpanc r eas : Amyl as e Li pase Tr y ps i n,Chy mot r y ps i n NaHCO3,muc i n Duod. CCK,sec r et i n Ex ocr i nepanc r eas amyl as e,l i pase, pept i dases s y nt hes i z edi nac i narcel l sandr el eas edi nt o panc r eat i cduc t -i ni nact i v ef or m( pr oenz ymes ) -Act i v ef or mi ss ost r ongt hati tcandi gestt he panc r eas s ec r et i oncont r ol l edbyv agusner v e, s ec r et i n( al s ost i mul at esbi c ar br el eas e)and CCK( c hol eocy s t ok i ni n)whenac i di candf at f oodsent erst omac hl umen pr oenzymesandbi car bac t i v at edi nl umenof duodenum byent er opept i dasesandal k al i ni ci t y ofs odi um bi car bar bonat e Bi car bonat ebuffer sac i di cpH CCK-al sos t i m cont r act i onofgal l bl adder Sec r et i ns t i mul at espr odofbi l ei nl i v er -Heavymet al si nl i pi dr i c hf oodscan ov er bur denpanc r eas

Over vi ew ofMaj orDi seases • Pancr eat i t i s – Ac ut epanc r eat i t i s – Chr oni cpanc r eat i t i s • Tumor sofex ocr i nepanc r eas

Pancr eat i t i s  Pancr eat i t i ss t er i l ec hemi cal i nfl ammat i on  Caus edbyani nj ur yordamaget o panc r eat i ccel l sandduct s,causi nga l eakageofpanc r eat i cenz ymesi nt ot he panc r eat i ct i ss ue  Theseenz ymescauseaut odi ges t i onof panc r eat i ct i ss ueandl eaki nt ot he bl oods t r eam t ocausei nj ur yt obl ood v essel sandot heror gans Ac ut ePancr eat i t i s St er i l ec hemi cal i nfl ammat i on,s ec ondar y r eact i ont odes t r uc t i onbydi ges t i v eenzy mes r el eas ed necr os i s Ac ut e-hemor r hagi ct ypemos tof t en CommonCauses • Al cohol • Gal lst ones( obst r uct i on-r efl uxofbi l e i nt opanc r eas ) • Unknown Rar eCauses • Tr auma • Sur ger y • Dr ugs • Met abol i cdi seases • I nf ec t i ons – Mumps

CLS308-Pancr eas

- Obs t r uc t i on:gal l st ones ,t hi ckmuc usof CF,t umor ,?duc ts pam - Ac i narcel l i nur y :al cool ,v i r usi nf ec t i on, dur gs,t r auma - Cl i ni c al l y : o Aut oenz ymesl eakoutof panc r easandgeti nt ot he bl oods t r eam o I nt hebl oods t r eam,t her e’ sa l ar gei nc r easei namyl as e( cl as s i c f orpanc r eat i cpr obl ems/acut e panc r eat i t i s)andl i pase o I nt het i ssues ,t her e’ sf atnec r os i s andt hebl oodv essel swi l l be des t r oy edbypr ot eas e ac ut e panc r eat i t i s

Aut odi gest i on Obst r uc t i onofpanc r eat i cduct -bygal l st ones , papi l l aofVat ercanl eadt or efl uxofbi l ei nt o panc r eas( ac t i v at i onofpr oenz y mesbybi l e) Pr oenzymesi npanc r easi fact i v at edl eadst o s econdar ydes t r uc t i onofpanc r eas aut odi ges t i on Theor i es duet ot r aumas eatbel t s ,sur ger yni ck ed i nc r easedsec r et i onwi t hf at t yf oodsby ov er st i mul at i on 80% acut epancr eat i t i sduet ogal l st ones andal coholabuse* * Sec r et i on-ov erst i mul at i onofpanc r eat i ccel l sobes e,eat i ngf at t yf oods Ac t i onofsecr et i ncanbeduet oal cohol Enzymat i c ac t i v at i on-l eadst ol i quef ac t i on andac cumat i onofflui ds Pseudocyst s

CLS308-Pancr eas

Anucl eat edadi poc yt eswi t ht hi ck ened, s hadowycel l membr anesknownas“ ghost cel l s( ci r cl ed;causedbyl i paseeat i ngf at ) Feat ur es&Compl i cat i ons:Ac ut ePancr eat i t i s • Fatnecr osi s ,cal c i fi cat i ons, hy poc al cemi aduet onec r ot i ct i ssue at t r ac t scal c i um • As ci t es ,st er i l eper i t oni t i s ,l eakof enz ymesI nt oabdomi nalcav i t y • Shock • Mas si v enecr os i s:ps eudocy st( cont ent canbecomei nf ect ed) • Abs cessf or mat i on • Chr oni cpanc r eat i t i s–l at ecompl i cat i on, candev el op • Di abet esmel l i t us

Acut epancr eat i t i s.A,Gr os sappear anceof t hepanc r eas .Not et hemas s i v ehemor r hage i nt ot hepanc r eas,whi c happear s s wol l en.B,Nec r ot i cf oc iar es cat t er ed t hr oughoutt hepar enchy ma. di s r upt i onsoft hepanc r eat i cductduet o panc r eat i t i sandex t r av as at i onofenz ymat i c mat er i al Ac ut ePancr eat i t i s:Mi cr os copi cFeat ur es

Per i t oni t i s Lar geps eudoc y stc ancompr es sst omac h, duodenum I nf ec t edbybac t er i a,abscesswi t hpus Ti s suegr anul at i on,fibr os i s canbecomechr oni cpanc r eat i t i s i ns uffic i enc y Abdpai n,naus ea,di s t ent i on Pat i entdi spl ayst r es s ,s weat i ng,sev er epai n, per i t oneal r i gi di t y I nc r easedWBC,i nc r eas edenz ymei nbl ood andur i ne

CLS308-Pancr eas CTsc an Ac ut er i skofr ecur r ence Remov egal l st ones ,el i mi nat eal cohol andhi gh f at sdi et Pancr eat i cps eudoc y st DI C–ex c es spoi ntofcl ot t i ngal l ov erbody ;us e upcoagf ac t or s ex c es si v ebl eedi ng

• • • • •

Pancr eat i cps eudoc y st .Af t erdr ai nageofi t s cont ent ,t hepseudocy sti nt het ai l oft he panc r easappear sasafi br oussac .( Fr om Damj anovI ,Li nderJ:Pat hol ogy :ACol orAt l as, St .Loui s ,2000,Mos by . ) Us ual l yappearsev er al weeksaf t ert he panc r eat i t i s di s r upt i onsoft hepanc r eat i cductduet o panc r eat i t i sandex t r av as at i onofenz ymat i c mat er i al

r epl ac edbyfibr oust i ss ue70% hav e s i gnsofDi abet es Pai nduet oent r apmentofner v esi n fi br ot i ct i ssue Los sofwei ght Pancr eat i cduct -di l at edandfil l edwi t h s t ones Ex c es si v efibr os i sex ocr i neand endocr i nei ns uffic i enc y Cancons t r i ctbi l educt s

- Ther oundobj ect sar ecal c i ficat i ons - Thel i nesi ndi cat efi br ot i ct i ss ue Cy s t i cFi br os i s

Chr oni cPancr eat i t i s Caus es:Chr oni cPanc r eat i t i s

Pat hol ogy • Fi br os i sofpanc r eas • At r ophy ,l os sofac i ni ex oc r i ne i ns uffic i enc y • I nt r aduct al s t ones • Par enchy mal cal ci ficat i ons • I sl et sofLanger hanspr es er v ed;buti n l at est agesnumber sar er educ ed,

• • •

I nher i t edpr obl em ofc hl or i depump Thi ckmuc us Cl ogs – Bowel – Pancr eas • Fi br os i s

CLS308-Pancr eas • Mal absor pt i on – Br onc hi

• • • • • •

Chr oni cpanc r eat i t i s:Cl i ni cal Feat ur es • I ns i di ousons et • Pai ni nupperabdomen;r adi at esi nt o back • Mal absor pt i oncaus edbypanc r eat i c i ns uffic i enc y • Xr ayev i denc eofcal ci ficat i ons • Sec ondar ydi abet esmel l i t us • Mal absor pt i onofpr ot ei n • Li pasedefic i enc y–decr eas edf at absor pt i on,f at t yst ool s • Fat sol ubl ev i t ami ns( vi t ami nA,D,E,K) -mi ni mal absor pt i on • Hyper gl y cemi a( duet ol os sof pr oduc t i onofi ns ul i n) • Lot sofcal ci ficat i onandfibr os i s • Ner v ei sent r appedandt angl ed • * * I nc r easedr i skf orpanc r eat i ccancer Pancr eat i cNeopl as ms I n95% ofal l cas es ,t umor sar e: • Ex ocr i ner at hert hanendoc r i ne • Der i v edf r om duct sr at hert hanac i ni or i sl et s • Sol i dr at hert hancy s t i c • Mal i gnantr at hert hanbeni gn • Funct i onal l ys i l entr at hert han hor monal l yac t i v e* * Adenocar c i nomaoft hePancr eas

Four t hmaj orcauseofcancerdeat hi n men;fi f t hi nwomen Eachy ear25, 000newcas esr epor t edi n U. S. Smok i ngi nc r eas esr i skx 3 Chr oni cpanc r eat i t i si nc r easesr i skx 2 Rar ebef or e40y ear sol d,buti nc i denc e i nc r eas eswi t hage Pr ognos i si spoor ;mos tdi ewi t hi n2 y ear s

- Tel omer eshor t enwi t hage o KRASi sagr owt hf act or :cel l s becomemor ecol umnar and moundup o P16( t umorsuppr essorgene) cel l si z eandshapec hange, nucl earc hange o P53( t umorsuppr essorgene) mal i gnantc ar ci noma o Br eakst hr uandbec omes i nv as i v eandgot oot herar eas

CLS308-Pancr eas

Fibrotic tissue look like the squamous cell

Some of the duct cells are showing

Pancreatic ducts are the areas with big white spaces

Met ast as i z eear l ypr i mar i l yt ol ymphnodesand s omet ol i v er Car ci nomaofPancr eas :Cl i ni c al Feat ur es ( coupl emont hst oweek sawayf r om deat h) • Wei ghtl os s ,l os sofappet i t e,naus ea • J aundi c e:i fl oc at edi nheadofpanc r eas • Cour v oi si er ’ ss i gn( gal l bl adder di st ent i on) • Pai n:i fl ocat edi nt ai lofpanc r eas • Met ast as es( common) :l y mphnodes , l i v er • Endos copi cr et r ogr ade c hol angi opancr eat ogr aphy( ERCP)wi t h as pi r at i onc yt ol ogy :i mpor t antf or di agnos i s

CLS308-Pancr eas Tumor soft heEndoc r i nePancr eas( I s l etCel l Tumor s) • I ns ul i noma:hypogl y c emi a,s y nc ope, pr of us es weat i ng,r ev er sedbyi nf us i on ofgl uc os e • Gast r i noma:Zol l i nger El l i sons y ndr ome wi t hmul t i pl eul cer sunr espons i v et o medi cal t her apy ;maybepar tofMEN1 • Gl ucagonoma • Somat os t at i noma • VI Poma

cel l st hat s ec r et e i ns ul i n Ser um i ns ul i n Low Nor mal l ev el Tr eat ment I ns ul i n Di et ;ex er c i se; or al hy pogl y cemi cs ; i ns ul i n Pat hogenesi sofHy per gl y cemi a

Tr eat ment :Par ent er al t ypeofdi ges t i on - Tr yt ol i mi tamtoff oodi nst omac h - Abs or bnut r i ent st hr ubl oods t r eam Di abet esMel l i t us • Pr i mar y – Ty pe1( i ns ul i ndependent ) : ac qui r edi nc hi l dhood – Ty pe2( non–i ns ul i ndependent ) : expl os i oni nt hel as t40y ear s , comor bi dwi t hobes i t y • Sec ondar y – Pancr eat i cdi s ease – Endoc r i nedi s eases – Dr ugr el at ed – Genet i cs y ndr omes : hemoc hr omat os i s ,hyper l i pi demi a Compar i s onofType1&Ty pe2Di abet es Char act er i s t i c Ty pe1 Ty pe2 Ageofonset 30y ear s( now y ear s s eei ngt hi si n c hi l dr enb/ cof obesi t y epi demi c) Speedof Sudden Gr adual ons et Bodybui l d Nor mal Obes e( 90%) , espi nWest er n count r i es Fami l yhi st or y 60% Twi n Low Hi gh concor danc e Ant i bodi est o ++(almostan ( ) aut oi mmune) i sl etcel l s mal Hi st ol ogyof Los sof Nor bet a i sl et s

Gl ucos ei nt heur i ne Ur i nat i ngf r equent l y :Pol y ur i a Fr equent l yt hi r st y :Pol ydi ps i a I sl et sofLanger hansi nType1Di abet es Mel l i t us

Compl i cat i onsofDi abet esMel l i t us

CLS308-Pancr eas • Car di ov as cul ar – At her os c l er os i s :gangr eneof ext r emi t i es – Ar t er i ol os cl er os i s • Ki dney – Gl omer ul os cl er os i s – Py el onephr i t i s • Ey e( cl as si cf ors omeonew/Ty peI I Di abet es ) – Ret i nopat hy – Cat ar ac t s • Ner v ouss y s t em – Cer ebr ov as cul ardi sease – Per i pher al neur opat hy

Gangr ene amput at i onupt ot hek nee...