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97 Cards in this Set

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What is the anatomical location of the Pancreas?
Retroperitoneal

**except the tail
80-85% of the glands in the Pancreas are __1__ cells organized into acini that drain into the __2__
1. Secretory

2. Duct of Wirsung = Main pancreatic duct
The Duct of Wirsung normally drains into the __1__ just proximal to the __2__, but may enter the duodenum directly
1. Common Bile Duct

2. Ampulla of Vater
What will a gallstone stuck at the Ampulla of Vater normally cause?
reflux of bile into the pancreatic duct
2 important enzymes that are detectable in the serum after Pancreatic damage
1. Lipase

2. Amylase
Stimulation of this nerve increases the Pancreatic excretion
Vagus nerve
What 2 things stimulate the release of Cholecystokinin?

What causes the release of Secretin?
Presence of Amino acids and pH < 3 -> Cholecystokinin -> stimulates pancreas to release digestive enyzmes from Acinar cells

Stomach distension -> Secretin -> stimulates pancreas to release Bicarbonate and Water from Ductal cells
What do most cancer of the Pancreas arise from?
Pancreatic Ducts (Ductal Adenocarcinoma)
Pancreatitis: __1__ inflammatory condition of the __2__ pancreas that results from cellular injury to __3__ cells
1. Reversible
2. Exocrine
3. acinar
Describe how a person would present with Acute/Chronic Pancreatitis
Severe, boring Mid-Epigastric and LUQ abdominal pain radiating to the back
What are the 2 most common causes of Acute Pancreatitis?
1. Alcohol (6 times more common in MEN)

2. Gallstones (3 times more common in women)
List 5 complications of Acute Inflammation of the Pancreas
1. Shock = pancreatic enzymes eating through the Splenic Artery
2. Peritonitis
3. Hypocalcemia = Ca+ soaps formed during fat necrosis
4. Malabsorption
5. Pseudocyst formation
What are the 2 elevated lab findings in Pancreatitis? Which one is elevated first? Which one is more specific for Pancreatitis?
Amylase and Lipase

First: Amylase

Specific: Lipase
What can Hypocalcemia result in?

What is the cause of Hypocalcemia?
Tetani and seizures

Saponification reaction (Ca+ reacting with Fatty acids) in Acute Hemorrhagic Pancreatitis Fat Necrosis
What is Chronic Pancreatitis associated with? (3)
Alcohol ingestion

Hemochromatosis

Cystic Fibrosis
What are 3 complications of Chronic Pancreatitis?
1. Pseudocyst formation

2. Malabsorption (Vitamin B12 deficiency)

3. Diabetes
Cystic Fibrosis:
-lack of __1__ secretion is linked to impaired secretion of __2__, resulting in unusually viscid secretions
-__3__ of the Pancreas ensues, with resultant __4__ and failure to thrive
-death is almost always due to __5__ complications
1. chloride
2. sodium and water
3. Atrophy
4. malabsorption
5. pulmonary
Islet cells that secrete Glucagon
Alpha cells
Islet cells that secrete Insulin
Beta cells
What groups of people is Type I Diabetes Mellitus most common in?

Races less common in
Northern Europeans

Asians, African-Americans, & Native Americans
When has Type I DM been noticed to increase in incidence in several studies?
Late fall and early winter
What HLA do 95% of Type I DM patients express?
DR3 or DR4

**compared to only 20% of the population expressing these HLAs
__1__ antibodies are detectable in most Type I diabetics, but likely represents a __2__ response to proteins released by destruction of beta cells by __3__
1. Beta cells
2. humoral
3. T lymphocytes
Seasonal variation of Type I DM in incidence suggests ______ as a possible cause of the abnormal immune response to beta cells
Viral infections
What are the 2 major risk factors for Type I DM?
1. immediate family member with Type 1 DM

2. Caucasians are at a greater risk than other ethnic groups
What is the pathology seen in Type I DM?
1. Insulitis = inflammation of the islet

2. Beta cell depletion

3. Diffuse fibrosis of the pancreas
Most of the pathology seen in Diabetes Type I is due to the __1__, which are thought to be related to the long-term deleterious effects of __2__
1. complications

2. Hyperglycemia
Normal Pancreas
-ducts are within fibrous septa
-Islets of Langerhans
What is this picture showing?
Normal Pancreas histology
-Acini of the Exocrine pancreas
What is this showing?
Isle of Langerhans
What is this showing?
Acute Edematous Pancreatitis
-edema and inflammatory infiltrate
What is this showing?
Pancreatic Pseudocyst from Acute Pancreatitis

Splenic Artery bleeding into the pseudocyst
What can be seen here?

What could cause it to pulsate?
Pancreatic Pseudocyst
What is seen here?
Hemorrhagic Pancreatitis
What can be seen here?
Hemorrhagic Pancreatitis
What is shown here?
Fat Necrosis with formation of calcium-fatty soaps
What is this showing?
Chronic Pancreatitis with punctate calcifications
What is shown here?
Chronic Pancreatitis
What is shown here?
Chronic Pancreatitis
What is shown here?
Chronic Pancreatitis

Absence of acinar structures & replacement by pink collagen = FIBROSIS
What is this showing? How do you know?
Cystic Fibrosis, P. aeruginosa, & Bronchiectasis
What are the 3 associations here?
Cystic Fibrosis in the Pancreas
-ducts are dilated, with fibrosis surrounding them
What is this showing?
Alpha cells = Glucagon

Beta cells = Insulin
What cells are on the left & what do they secrete?

What cells are on the right & what do they secrete?
Type I Diabetes Mellitus = Insulitis
What is shown here?
What are 7 risk factors for Type II Diabetes?
1. Obesity
2. Age (generally >30)
3. family history of diabetes
4. lack of regular exercise
5. high BP &/or high conc. of fats in blood
6. history of gestational diabetes or giving birth to a baby weighing > 9 lbs.
7. Blacks, Hispanic, N. Americans, & Asian-Americans
Describe the pathogenesis of Type II Diabetes (Non-Insulin Dependent)
-Genetically programmed failure of Beta cells to compensate for peripheral insulin resistance
-Multifactorial inheritance
-Altered Beta cell function
-Insulin resistance = may have increased amounts of Insulin, but decreased # receptors (or non-responsive)
Describe the pancreatic pathology of Type II Diabetes
-No reduction in Beta cells

- May have increased islet fibrosis or Amyloidosis
What is the stain for Amyloid?
Congo Red stain
Type II Diabetes with Amyloid infiltration of the Islet
What is shown here?
What are the treatments for Type II Diabetes?
1. Diet
2. Weight loss and exercise
3. Hypoglycemic drugs
4. Eventually Insulin
What is the mode of action for Metformin?
makes muscle cells and fat cells utilize glucose in the peripheral tissue
What is the mode of action for Sulfonylureas and Thiazolidinediones?
Stimulate pancreas to make more insulin
-
-
Describe the pathogenesis leading to the complications seen in Diabetes
Nonenzymatic protein glycosylation through the polyol pathway
Explain the accelerated atherosclerosis as a complication of diabetes
-
Nodular Glomerulosclerosis = Kimmelstiel-Wilson disease
-pink nodules

ACE inhibitors
What is shown here?

What can prevent this complication?
Papillary Necrosis = diabetes affects small vessels and end arteries

Papilla can slough off and occlude to ureter = hydroureter and kidney swelling
What is shown here? What is there risk of?
Describe the characteristics of Background Retinopathy
1. Hemorrhages
2. Microaneurysms
3. "cotton-wool" exudates
4. DOES NOT NORMALLY IMPAIR VISION!!
What is the pathogenic cause of Diabetic Retinopathy?
Osmotic damage
Background Retinopathy
-follow the vessels out
-vessels are thicker than normal and hemorrhaging can be seen
-Starburst cotton-wool spots are seen at 3 o'clock
What is shown here?
What is Proliferative Retinopathy?
Neo-vascular proliferation in the retina, which OBSCURES vision
What are common complications of Proliferative Retinopathy?
Retinal detachment and blindness
Proliferative Retinopathy
What is shown here?
Proliferative Retinopathy with Microaneurysms (due to Osmotic damage from increased Sorbitol)
What is seen here?
What is another name for Gallstones?
Cholelithiasis
What are the 10 F's that are associated risk factors for Cholesterol or Mixed Gallstones?
1. Fat = obese
2. Forty and above
3. Fertile = multiparous
4. Flatulent = intestinal disease or malabsorption
5. Female

with Fatty, Foul, Fetid, Floating Feces
What drugs can cause an increased risk for Cholesterol or Mixed Gallstones (Cholelithiasis)?
Cholesterol-lowering drugs
- Clofibrate
- Cholestryramine
When would a man be at an increased risk for developing Cholesterol Gallstones?
if he was on hormone therapy to treat Prostatic Carcinoma
What ethnicities are at increased risk for Cholesterol/Mixed Gallstones?
Pima & Navajo Indians

Scandinavian countries & Latin America
List 4 examples of GI tract disorders that could lead to Cholesterol/Mixed Gallstones
1. Malabsorptive disorder
2. Ileal resection for obesity
3. Cystic Fibrosis with Pancreatic insufficiency
4. Chronic Diarrheal states
What are the risk factors associated with Pigmented Gallstones?
1. Hemolytic anemias
2. Alcoholic Cirrhosis
3. Infected bile (E. coli)
4. Parasitic infections
Examples of Hemolytic Anemias or Hemoglobinopathies that can cause Pigmented stones
1. Malaria
2. Sickle Cell anemia
3. Polycythemia vera
What Parasitic infections can cause Pigmented (bilirubinate) stones?
Ascaris or Clonorchis sinensis
What is the most common type of Gallstone?
Mixed stone = composed primarily of cholesterol but also contain variable amounts of bilirubin and calcium salts
What clinical manifestation is characteristic of Cholelithiasis?
fatty food intolerance
What is the most common stone associated with Cholecystitis?
Mixed stone
What is the most common cause of both Acute and Chronic Cholecystitis?
Gallstones
-80% of acute
-90% of chronic
How do you diagnose Cholecystitis?
Murphy's sign = inspiratory arrest in response to palpation of the RUQ during deep inspiration
Acute Cholecystitis
-fibrinous exudates
-red, congested = inflammation
What is shown here?
Cholecystitis with stones (cholelithiasis)
What is seen here?
Cholecystitis with cholelithiasis
What is seen here?
Porecelain Gallbladder
-due to Dystrophic Calcification of the gallbladder
-late complication of Chronic Cholecystitis
What is seen here?
Porcelain Gallbladder
-consequence of transmural chronic inflammation
-extensive fibrosis during the repair phase with scarring and DYSTROPHIC CALCIFICATION
What is seen here?

Explain the pathogenesis
What 2 things are present in 75-90% of cases of Carcinoma of the gallbladder?
Chronic Cholecystitis

Cholelithiasis
What is a high-risk condition for Gallbladder Adenocarcinoma?
Porcelain gallbladder
Gallbladder Adenocarcinoma:
1. Gender preference
2. Age preference
3. Ethnic distribution
4. 5 year survival
1. Female:Male = 2:1
2. Average age = 65
3. Pima and Navajo indians
4. 1% five-year survival
Gallbladder Adenocarcinoma
-opened up, thicker than normal
-fibrotic area
What is seen here?
Gallbladder Adenocarcinoma
-Left: GB is thickened
-Right: glandular structures indicating Adenocarcinoma
What is shown here?
What is the difference b/w Acute Interstitial Pancreatitis & Acute Hemorrhagic Pancreatitis?
Interstitial = mild inflammation characterized by widening edema and widening of interstitial spaces that contain scattered inflammatory cells

Hemorrhagic = Pancreatic Acinar cell injury results in activation of pancreatic enzymes and enzymatic destruction of pancreatic parenchyma
What are the most common drugs associated with causing Acute Pancreatitis?
1. Azathiopurine
2. Mercaptopurine
3. Corticosteroids
4. high dose Estrogen
Pseudocyst:
-massive necrosis leads to __1__ necrosis of the pancreatic tissue, which becomes enclosed by __2__.
1. liquefactive

2. Granulation tissue
What are 5 systemic complications of Acute Hemorrhagic Pancreatitis?
1. Shock = due to increased vascular permeability caused by pancreatic enzymes

2. DIC = pancreatic enzymes in circulation leads to formation of platelet and fibrin thrombi in small vessels

3. ARDS = due to enzymatic injury of the alveolar-capillary units in the lung -> hyaline membranes

4. Renal failure = due to shock

5. Subcutaneous Fat Necrosis = due to lipase enzymes from pancreas
Explain Fat Necrosis and the Saponification reaction
Acute Hemorrhagic Pancreatitis causes release of Lipases which digest Fat, releasing Fatty acids which form Calcium soaps
Define Chronic Pancreatitis
Chronic inflammation with FIBROSIS leading to a progressive loss of pancreatic function
-reduction in size
-often shows calcifications
What do pigmented stones result from?
precipitation of excess insoluble unconjugated Bilirubin

Hemoglobin -> Heme -> Biliverdin -> Bilirubin
What is the most common primary tumor of the Gallbladder?
Adenocarcinoma of the Gallbladder
Type of Diabetes that may cause Ketoacidosis?
Type 1 Insulin Dependent Diabetes