1. THE PANCREAS

2. General Features

3. .arising from foregut, transverse retro- peritoneal organ extending from “C” loop of duodenum to hilum of spleen
.20 cm long, 90 gm in men, & 85 gm in women
.divided into head, body, & tail
.duct of Wirsung most commonly drains into duodenum at papilla of Vater
.duct of Santorini drains into duodenum by separate minor papilla
.main pancreatic duct merges with the common bile duct>ampulla of Vater

4. Pancreatic ductal anatomy

5. pancreas has 2 components -exocrine, (85% of the gland), produces 2-2
.pancreas has 2 components -exocrine, (85% of the gland), produces L of bicarbonate-rich fluid -endocrine, (up to 2% of the gland), consists of 1 million clusters of islets of Langerhans, secrete insulin, glucagon, & somatostatin

6. Pancreatic acini (exocrine pancreas)

7. Congenital Anomalies

8. AGENESIS .very rare associated with wide-spread malformations, incompatible with life PANCREATIC DIVISUM .failure of fetal duct systems of dorsal & ventral pancreatic primordia to fuse> chronic pancreatitis

9. ANNULAR PANCREAS .band-like ring of pancreatic tissue encircling second part of duodenum> duodenal obstruction early in life ECTOPIC PANCREAS .sites (stomach, duodenum, jejunum, Meckel diverticulum, ileum) .forms a sessile mass (inflammation, bleeding) .complicated in 2% by islet cell tumors

10. CYSTIC FIBROSIS .an autosomal recessive disorder of ion transport in epithelial cells that affects fluid secretion (abnormally viscous> obstruction) in exocrine glands and epithelial lining of respiratory, alimentary, & reproductive systems .incidence is 1/2500 live births

11. .the primary defect is abnormal function of epithelial chloride channel protein heterozygous person has higher incidence of respiratory and pancreatic diseases than normal person .mild cases, accumulation of mucus in ducts>dilation of exocrine glands .severe cases, squamous metaplasia of ducts lining epithelium, atrophy of exocrine glands, & fibrosis

12. Pancreas, cystic fibrosis

13. .clinical features -meconium ileus -exocrine pancreatic insufficiency> malabsorption syndrome -idiopathic chronic pancreatitis -endocrine pancreatic insufficiency -cardiorespiratory complications (recurrent sinonasal polyps, pneumonia, COPD, corpulmonale) -biliary cirrhosis -male infertility

14. Inflammation

15. ACUTE PANCREATITIS. reversible process
ACUTE PANCREATITIS .reversible process .etiologic factors -metabolic (alcohol, hypercalcemia, drugs, hyperlipoproteinemia) -genetic -mechanical (gall stone, trauma, iatrogenic) -vascular (shock, atheroembolism, vasculitis) -infection (mumps)

16. Hereditary Pancreatitis
Hereditary Pancreatitis .about 10%-20% of idiopathic acute pancreatitis have genetic basis .characterized by recurrent attacks of severe pancreatitis usually beginning in childhood .mostly due to mutation in trypsinogen gene>trypsin formation less commonly due to gene mutation encoding trypsin inhibitor .both mutations>pancreatic enzymes activation

17. .pathogenesis -autodigestion of the pancreatic by inappropriately activated pancreatic enzymes secondary to inappropriate activation of trypsinogen

18. Pathogenesis of acute pancreatitis

19. .morphology -mild (inflammation, edema) -severe (parenchymal necrosis, hemorrhage)

20. Acute pancreatitis, hemorrhage & fat necrosis

21. Acute pancreatitis, fat & parenchymal necrosis

22. .clinical features -abdominal pain -DIC -respiratory distress syndrome -diffuse fat necrosis -shock, acute renal tubular necrosis .diagnosis -laboratory findings .elevated serum amylase in 24 hrs .rise of serum lipase in hrs .glycosuria, hypocalcemia -radiology

23. management -resting the pancreas plus supportive therapy
.management -resting the pancreas plus supportive therapy .complications -sterile pancreatic abscess -pancreatic pseudocyst -infected abscess

24. CHRONIC PANCREATITIS .irreversible process with inflammation & destruction of pancreas>fibrosis .etiology -chronic alcohol abuse (most common) -obstruction of pancreatic duct -tropical pancreatitis -hereditary pancreatic enzymes abnormalities -cystic fibrosis -idiopathic (40%)

25. .pathogenesis -ductal obstruction by concretions -direct toxic effects on acini (alcohol) -oxidative stress (free radicals-alcohol)

27. .morphology -parenchymal fibrosis -atrophy of acini -loss of the islets of Langerhans -variable dilation of pancreatic ducts

28. Chronic pancreatitis, interstitial fibrosis with glandular atrophy

29. Chronic pancreatitis, dilated duct with inspissated eosinophilic concretions

30. .clinical features -silent until pancreatic insufficiency & diabetes mellitus develop -repeated attacks of abdominal pain -recurrent attacks of jaundice or vague attacks of indigestion .diagnosis -high degree of suspicion -visualization of calcifications within the pancreas by CT scan & U/S .prognosis -long-term outlook is poor

31. Lymphoplasmacytic Sclerosing Pancreatitis
Lymphoplasmacytic Sclerosing Pancreatitis .autoimmune chronic pancreatitis characterized by -duct-centric inflammation -venulitis -IgG4-producing plasma cells -clinically mimic pancreatic cancer -responds to steroid therapy

32. Non-Neoplastic Cysts

33. CONGENITAL CYSTS. solitary, sporadic
CONGENITAL CYSTS .solitary, sporadic .coexist with cysts in kidney & liver in -polycystic kidney disease -von-Hippel-Lindau disease .cysts or neoplasms in liver & kidney .vascular neoplasms in retina & brain

34. PSEUDO-CYSTS .account for 75% of pancreatic cysts, secondary to acute or chronic pancreatitis, or abdominal injury .usually solitary, embedded in peri pancreatic tissue .resolve, secondarily infected or perforate into adjacent structures

35. Pancreatic pseudocyst

36. Pancreatic pseudocyst, lined by granulation tissue

37. Neoplasms

38. CYSTIC NEOPLASMS
Serous Cyst Adenomas
.female to male ratio is 2:1
.account for 25% of all cystic neoplasms of pancreas
.present at 7th decade as
-abdominal pain, or
-abdominal mass

39. Pancreatic serous cystadenoma

40. Pancreatic serous cystadenoma

41. Mucinous Cyst Neoplasms. almost always arise in women
Mucinous Cyst Neoplasms .almost always arise in women .present as painless, masses in body & tail of pancreas .1/3 of surgically resected neoplasms harbor invasive adenocarcinoma

42. Pancreatic mucinous cystadenoma

43. Pancreatic mucinous cystadenoma

44. PANCREATIC CARCINOMA .has one of highest mortality rates of all cancers, 5-year survival of less than 5% .progression from non-neoplastic epithelium>noninvasive lesions in small ducts & ductules>invasive carcinoma (pancreatic intraepithelial neoplasias PanINs), through multiple mutations

45. Progression model for development of pancreatic cancer

46. .epidemiology & pathogenesis a disease of elderly -contributing factors .cigarette smoking (strongest influence) .diet rich in fat .chronic pancreatitis (cause or effect) .diabetes mellitus (cause or effect) .genetic

47. .morphology -60% in head, 15% in body, & 5% in tail; in 20% diffusely involving gland -two characteristic features .highly invasive .presence of desmoplastic reaction -gross, hard, stellate, gray-white, illdefined mass -histology, ductal adenocarcinomas

48. Pancreatic carcinoma, normal pancreas on left side, carcinoma on right side

49. Pancreatic carcinoma, poorly formed glands

50. .clinical features -silent until local extension -obstructive jaundice -non-specific -migratory thrombophlebitis (Trousseau sign) .diagnosis -imaging techniques (endoscopic ultrasonography, CT) -percutaneous needle biopsy -serum markers for follow up (CEA, CA19-9)