Pathology of the
Exocrine Pancreas
Tyler Verdun, PGY3 General Pathology
University of British Columbia
November 5, 2013
Objectives
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Brief review of normal pancreatic anatomy
Overview of acute and chronic pancreatitis
Introduction to pancreatic adenocarcinoma
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This session will not cover:
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Endocrine pancreas pathology
Congenital abnormalities
Cystic lesions
Benign tumors (SPPT, cystadenomas, etc.)
Neuroendocrine tumors
The Normal Pancreas
Normal Pancreas
http://upload.wikimedia.org/wikipedia/commons/f/fc/Pancreas_4.jpg
Normal Pancreas
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Wait! There’s something wrong with this picture…
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No islets: this is actually parotid salivary gland
Sourced from http://www.youtube.com/watch?v=1Kavxv3jHzA
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Dr. John Minarcik’s excellent “Shotgun Histology” series
Normal Pancreas
Pancreatitis
Acute Pancreatitis
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1. The pancreas is (metaphorically) a box of
corrosive chemicals
2. Damage to the pancreas by some etiologic
factor releases these chemicals from cells
3. Digestion, saponification, and calcification of
neighboring healthy tissue
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On gross examination/autopsy – greasy, chalk-white
deposits
Acute Pancreatitis - Etiologies
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I – Idiopathic
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G – Gallstones
E – Ethanol abuse
T – Trauma: anything that compromises the blood supply
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 Important
S – Steroids
M – Microbiological (bacterial, viral, or parasitic infections)
A – Autoimmune diseases
S – Scorpion bite: Tityus trinitatis in Trinidad and Tobago  Impress your staff !
H – Hypercalcemia or hyperlipidemia
 Not so much
E – ERCP: endoscopic procedure; can cause pancreatitis
D – Drugs: too many to list…
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FYI: in a pinch, never doubt the “The Big 3”©
 Antibiotics, antiepileptics/antipsychotics, anti-inflammatories
Acute Pancreatitis – Diagnosis
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Clinical presentation:
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Imaging
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Moderate to severe epigastric pain radiating to back
Nausea and vomiting
Fever, ↑HR, ↑RR, ↓BP
Rarely: abdominal or flank bruising (Cullen & Grey-Turner)
CT scan and abdominal ultrasound showing inflammation or
cystic structures around pancreas
Labs
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Elevated amylase and lipase
Elevated glucose
May see elevated liver markers
Acute Pancreatitis – Radiologic
Findings
http://upload.wikimedia.org/wikipedia/commons/9/97/Pankreatitis_exsudativ_CT_axial.jpg
Acute Pancreatitis – Histology
Horror Show
Normal pancreas
Acute Pancreatitis – Histology
Hemorrhage
Necrosis
Background pancreas
Neutrophils
Acute Pancreatitis - Prognosis
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Mild
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Resolves with minimal supportive care within days
Severe
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Significant fluid depletion and electrolyte abnormalities
Systemic inflammatory response and disseminated
coagulation
Pseudocyst formation
Necrosis and hemorrhage
Abscess formation and sepsis
May require ICU and surgical management
Chronic Pancreatitis
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Consequence of long-standing inflammation
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Usually will have had recurring episodes of acute pancreatitis
~80% will have history of alcoholism
Clinical presentation
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Chronic epigastric pain
Persistent nausea and vomiting
Other common findings
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Weight loss
Fatty stools
Low or normal plasma amylase and lipase levels
Chronic Pancreatitis – Radiologic
Findings
http://upload.wikimedia.org/wikipedia/commons/7/7b/Chronische_Pankreatitis_mit_Verkalkungen_-_CT_axial.jpg
Chronic Pancreatitis – Histology
Residual pancreas
Fibrosis and lymphocytic
inflammation
Chronic Pancreatitis
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Functional pancreatic tissue is destroyed
1. Enzyme levels are decreased or misleadingly
normal
 2. Loss of enzymes  decreased food digestion and
nutrient absorption in small bowel
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Fatty stools
3. Weight loss
Pancreatic
Adenocarcinoma
Pancreatic Adenocarcinoma –
Diagnosis
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Risk factors
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Signs and symptoms:
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Painless jaundice
Pain that radiates to back
Weight loss
Physical exam
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Chronic pancreatitis
Smoking
Obesity
Sometimes no major findings
Ascites and hepatomegaly due to metastases
Abdominal and rectal nodules from metastases
Approximately 75% will present at an advanced stage
Pancreatic Adenocarcinoma –
Radiologic Findings
http://upload.wikimedia.org/wikipedia/commons/f/f6/MBq_cystic-carcinoma-pancreas.jpg
Pancreatic Adenocarcinoma –
Whipple Resection
Duodenum
(cut open)
Common bile duct
Head of pancreas
(cut open)
http://upload.wikimedia.org/wikipedia/commons/1/17/Macroscopic_image_of_pancreas_adenocarcinoma_removed_by_Whipple_procedure.jpg
Pancreatic Adenocarcinoma –
Histology
Cancerous glands with mucin production
Pancreatic Adenocarcinoma –
Histology
Residual pancreas
Tumor with mucin
Pancreatic Adenocarcinoma –
Histology
Pleomorphic (ugly) cells
Mitoses
Pancreatic Adenocarcinoma Prognosis
http://progressreport.cancer.gov/doc_detail.asp?pid=1&did=2009&chid=95&coid=927&mid
Pancreatic Adenocarcinoma Prognosis
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Why so poor?
Pancreatic anatomy
Anatomically isolated
 Lacks a capsule  contiguous with surrounding fat
 Rich vascular supply
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Cancer cells respond poorly to chemotherapy
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Thick connective tissue in tumor prevents diffusion
of chemo drugs?
Thank You