Pancreas and Biliary Tract Pathology Lecture Notes

Overview

• Focus on inflammation (acute and chronic) and pancreatic cancer.
• Emphasis on molecular mechanisms, particularly involving KS in pancreatic cancer.
• Biliary tract pathologies including gallstones.
• Symptoms and clinical presentations.

Acute Pancreatitis

• Common Causes: Excessive alcohol in adults, cystic fibrosis (CFTR chromosome 7 issues) in children.
• Symptoms: Epigastric pain radiating to the back, nausea, vomiting, low-grade fever, potential tachycardia.
• Enzymatic Activities:
  • Exocrine Pancreas Enzymes: Trypsin, carboxypeptidase, lipase (auto-digestion due to excessive enzyme release).
  • Important to differentiate exocrine from endocrine functions.
• Causes:
  • Alcohol: A major common cause.
  • Gallstones: Can travel and cause blockages and compression leading to pancreatitis.
  • Metabolic Issues: Hypercalcemia, hyperlipidemia (Type 1 hyperlipidemia lacks lipoprotein lipase leading to high triglycerides).
  • Drugs: Examples include ASA, pentamidine, hydrochlorothiazide.
  • Infections: Mumps, coxsackievirus, parasites.
  • Others: Blunt trauma, ischemia, vasculitis, embryologic issues like ductus divisum.

Chronic Pancreatitis

• Characterized by irreparable damage leading to pancreatic insufficiency.
• Development of pancreatic pseudocyst.

Differential Diagnosis

• Epigastric Pain:
  • Radiating to the back (pancreatitis).
  • Pain relieved by eating (duodenal peptic ulcer disease).
  • Pain worsening after eating (gastric peptic ulcer disease).

Diagnostic Techniques

• Lab Tests: Elevated amylase and lipase (lipase is more specific for pancreatitis).
• Imaging: Abdominal and chest x-ray to identify complications like atelectasis or ARDS.
• ERCP/MRCP:
  • ERCP: Diagnostic and sometimes therapeutic, but risk of causing pancreatic damage.
  • MRCP: Non-invasive, increasingly replacing ERCP.
• Ranson's Criteria: Important for determining severity and prognosis in acute pancreatitis.

Management of Acute Pancreatitis

• Supportive Care: Bowel rest, IV fluids, analgesia.
• Antibiotics: For necrotizing pancreatitis or suspected infection.
• Nutritional Support: Essential due to the role of the pancreas in digestion.
• ERCP: For duct disruption or stone removal but used cautiously.
• Surgery: For complications like abscess or pseudocyst.

Complications

• Local:
  • Phlegmon (fluid collection, often sterile).
  • Pancreatic pseudocyst (non-epithelial wall).
  • Pancreatic abscess.
  • Aneurysm of the splenic artery (hemosuccus pancreaticus).
• Systemic:
  • ARDS: Enzyme-related lung damage.
  • Acute renal failure.
  • Shock due to severe fluid loss.
  • Disseminated intravascular coagulation (DIC): Triggered by severe stress or systemic alterations.