16-Disorder of gallbladder and pancreas(6).ppt

Pathology

1. Disorder of gallbladderDisorder of gallbladder

2. Gall stonesGall stones
•Two types:Two types:
•Cholestrol stone and pigment stoneCholestrol stone and pigment stone
•Cholestrol stone:Cholestrol stone:
•Pathogenesis:Cholestrol is water insoluble Pathogenesis:Cholestrol is water insoluble
and render soluble by bile saltand render soluble by bile salt
•Increase cconcentration of cholestrol exceed Increase cconcentration of cholestrol exceed
the solubility effect of bilethe solubility effect of bile
•Gall bladder stasis play key factor for stone Gall bladder stasis play key factor for stone
formationformation

3. Risk factor of cholestrol stoneRisk factor of cholestrol stone
•Advanced age,Advanced age,
•female genderfemale gender
•,obesity,obesity
•,oral contraceptive,oral contraceptive
•,pregnancy,pregnancy
•,GB stasis,GB stasis
•,hyperlipidemia,hyperlipidemia

4. Pigment stonePigment stone
•Composed of bilirubin saltsComposed of bilirubin salts
•Increase concentration of indirect Increase concentration of indirect
bilirubinin bilebilirubinin bile
•Risk factors:Risk factors:
•Chronic hemolytic anaemiaChronic hemolytic anaemia
•Biliary infectionBiliary infection
•GIT disorders:Ileal disease,resection bypassGIT disorders:Ileal disease,resection bypass

5. MorphologyMorphology
•Chol stone:pale yellow,often Chol stone:pale yellow,often
multiple,faceted surface,radiolucentmultiple,faceted surface,radiolucent
•Pigment stone: black or brown Pigment stone: black or brown
incolor.may be single or incolor.may be single or
multiple,radioopaquemultiple,radioopaque

6. Clinical pictureClinical picture
•May be silentMay be silent
•Acute colicky painAcute colicky pain
•Obstruction and picture of cholestasisObstruction and picture of cholestasis
•Complication:empyema,perforation,infaComplication:empyema,perforation,infa
mmationmmation

7. CholecystitisCholecystitis
•Inflammation of GB may be acute or chronicInflammation of GB may be acute or chronic
•Acute cholecystitis:Acute cholecystitis:
•1- acute calculous cholecystitis:1- acute calculous cholecystitis:
•Associated with gall stoneAssociated with gall stone
•Sever upper abdominal painSever upper abdominal pain
•Fever,leucocytosis and tender subcostal Fever,leucocytosis and tender subcostal
regionregion

8. 2-Acute Acalculous 2-Acute Acalculous
cholecystitischolecystitis
•Not associated with stoneNot associated with stone
•Associated with:Associated with:
• surgical operationssurgical operations
•traumatrauma
•sever burnsever burn
•and sepsisand sepsis

9. MorphologyMorphology
•Acute :GB enlarged,tense.red,may be Acute :GB enlarged,tense.red,may be
black due to hge,lumen contain pus in black due to hge,lumen contain pus in
sever cases(Empyema)sever cases(Empyema)
•Chronic:may be contracted in Chronic:may be contracted in
size,stones are foundsize,stones are found

10. Chronic cholecystitisChronic cholecystitis
•Chronic inflammation of GBChronic inflammation of GB
•Associated with gall stoneAssociated with gall stone
•E coli can be cultured from bileE coli can be cultured from bile
•c/p is similar to acutec/p is similar to acute

11. CholangitisCholangitis
•Acute inflammation of bile duct wallAcute inflammation of bile duct wall
•Bacterial infection is commonBacterial infection is common
•Predisposing factors; Predisposing factors;
stones,operations,catheterstones,operations,catheter
•c/p: fever,rigor ,pain, jaundice c/p: fever,rigor ,pain, jaundice

12. TumoursTumours
•Risk factors: gall stones,infectionRisk factors: gall stones,infection
•Morphlogy: adenocarcinoma and Morphlogy: adenocarcinoma and
invade the liverinvade the liver
•c/p: pain and cholestasisc/p: pain and cholestasis

13. Acute pancreatitisAcute pancreatitis
•Inflammation of the pancrease,associated Inflammation of the pancrease,associated
with acinar cell injurywith acinar cell injury
•Risk factors:4 istems:Risk factors:4 istems:
•1-Metabolic;Alcohol,increase lipid,increase 1-Metabolic;Alcohol,increase lipid,increase
Ca,drugs(thiazide)Ca,drugs(thiazide)
•2-Mechanical:gall stones,trauma2-Mechanical:gall stones,trauma
•3- Vascular:embolism or shock3- Vascular:embolism or shock
•4-Infections; mumps ,coxsackie virus4-Infections; mumps ,coxsackie virus

14. PathogenesisPathogenesis
•Two fundemental events;Two fundemental events;
•1- autodigestion of pancreatic tissue by 1- autodigestion of pancreatic tissue by
inappropriately activated pancreatic inappropriately activated pancreatic
enzymeenzyme
•2-Cellular injury response mediated by 2-Cellular injury response mediated by
proinflammatory cytokinesproinflammatory cytokines

15. MorphologyMorphology
•Four basic features:Four basic features:
•1-: proteolytic destruction of pancreatic 1-: proteolytic destruction of pancreatic
substance substance
•2-necrosis of blood vesseles2-necrosis of blood vesseles
•3-fat necrosis3-fat necrosis
•4- inflammatory reaction4- inflammatory reaction

16. Clinical pictureClinical picture
•Sever abdominal pain in epigastrium Sever abdominal pain in epigastrium
radiating to to back.radiating to to back.
•Shock due hge or release of vasodilators as Shock due hge or release of vasodilators as
PGPG
•Lab findings;Lab findings;
•Increase S amylase (onset 12h ,remain for Increase S amylase (onset 12h ,remain for
48h-72h).However it may be elevated in 48h-72h).However it may be elevated in
other conditions as perforated peptic other conditions as perforated peptic
ulcer.peritonits and intestinal obstructionsulcer.peritonits and intestinal obstructions

17. Lab findingsLab findings
•Increase S lipase:onset 24h and remain Increase S lipase:onset 24h and remain
for 7-10 daysfor 7-10 days
•Hypocalcemia(Ca bind to Fa released Hypocalcemia(Ca bind to Fa released
from hydrolysed fat)from hydrolysed fat)
•Jaundice,hypoglycemia and glycosuriaJaundice,hypoglycemia and glycosuria

18. Chronic pancreatitisChronic pancreatitis
•Repeated attack of mild pancreatic Repeated attack of mild pancreatic
inflammationinflammation
•Risk factors:alcohol,hyperlipidemiaRisk factors:alcohol,hyperlipidemia
•Pathogenesis:is obscured and blurredPathogenesis:is obscured and blurred
•Morphology ; loss of parenchymal with Morphology ; loss of parenchymal with
replacement by fibrous tissuereplacement by fibrous tissue
•c/p:repeated attack of abdominal pain (mild c/p:repeated attack of abdominal pain (mild
to sever)to sever)
•Later on diabetes mellitus developLater on diabetes mellitus develop

19. Diagnosis of chronic pancreatitisDiagnosis of chronic pancreatitis
•Mild elevation of s amylase and lipaseMild elevation of s amylase and lipase
•CT scan and ultrasonographyCT scan and ultrasonography

20. Cancer pancreasCancer pancreas
•60-70% in head60-70% in head
•15% in body15% in body
•15% in tail15% in tail
•Morphology;Usuallly invade ampullary Morphology;Usuallly invade ampullary
region(head),while body and tail do not region(head),while body and tail do not
•Clinical picture:Clinical picture:
• abdominal painabdominal pain
•Cholestasis(Common in cancer head due to Cholestasis(Common in cancer head due to
biliary obstruction)biliary obstruction)
•Diagnosis : CT scan ,ultrasonography and biopsyDiagnosis : CT scan ,ultrasonography and biopsy

21. Islet Cell TumorsIslet Cell Tumors
•HyperinsulinemiasHyperinsulinemias
•Gastrinomas (Zollinger - Ellison's Gastrinomas (Zollinger - Ellison's
Syndrome)Syndrome)
•Multiple Endocrine Neoplasia (MEN)Multiple Endocrine Neoplasia (MEN)

22. Insulinoma (Beta Cell Insulinoma (Beta Cell
Tumors)Tumors)
Clinical Clinical
•Paroxysmal Paroxysmal
Hypoglycemia Hypoglycemia
( ( Glucose: Glucose: Insulin) Insulin)
•CNS - Confusion, CNS - Confusion,
UnconsciousnessUnconsciousness
•Relief with Glucose Relief with Glucose
AdministrationAdministration
Pathologic FindingsPathologic Findings
•70% Single Adenomas70% Single Adenomas
•Usually confined to Usually confined to
pancreas only.pancreas only.
•10% Multiple 10% Multiple
AdenomasAdenomas
•10% carcinoma and 10% carcinoma and
metastasis locally.metastasis locally.
•10% Hyperplasia10% Hyperplasia

23. Gastrinoma Gastrinoma
(Zollinger-Ellison Syndrome)(Zollinger-Ellison Syndrome)
•Marked hypersecretion of gastrin.Marked hypersecretion of gastrin.
•Duodenal ulcer is common than Duodenal ulcer is common than
peptic ulcerpeptic ulcer
•Diarrhea in 30% of cases.Diarrhea in 30% of cases.
•40% Adenomas,arises not only in 40% Adenomas,arises not only in
pancres but also in peripancreatic pancres but also in peripancreatic
tissues and duodenum.tissues and duodenum.
•60% Carcinomas and give metastasis60% Carcinomas and give metastasis

24. Multiple Endocrine Multiple Endocrine
Neoplasia MEN SyndromeNeoplasia MEN Syndrome
Group of Familial Diseases (AGroup of Familial Diseases (A
DD
) Associated with ) Associated with
Neoplasms and/or Hyperplasia of Various Neoplasms and/or Hyperplasia of Various
OrgansOrgans
MEN I - (Wermer's) - 11 q 13MEN I - (Wermer's) - 11 q 13
Parathyroid AdenomaParathyroid Adenoma
Pancreatic Adenoma/CaPancreatic Adenoma/Ca
Z-E SyndromeZ-E Syndrome
InsulinomasInsulinomas
Pituitary AdenomasPituitary Adenomas

25. Multiple Endocrine Multiple Endocrine
Neoplasia MEN SyndromeNeoplasia MEN Syndrome
Group of Familial Diseases (AGroup of Familial Diseases (A
DD
) Associated ) Associated
with Neoplasms and/or Hyperplasia of with Neoplasms and/or Hyperplasia of
Various OrgansVarious Organs
MEN IIB or MEN III - 10 q 11.2 (RET)MEN IIB or MEN III - 10 q 11.2 (RET)
PheochromocytomaPheochromocytoma
Medullary Ca of ThyroidMedullary Ca of Thyroid
PLUSPLUS
Neuromas/GanglioneuromaNeuromas/Ganglioneuroma