Chronic Pancreatitis

 Pancreatic adenocarcinoma and CP may coexist






Microscopic




• Fibrosis and chronic inflammation
image Variable extent and distribution of fibrosis

image Irregular atrophy and obliteration of pancreatic acini and ducts

image Retention of normal lobular pancreatic architecture

– Lobular architecture aids histologic distinction from pancreatic adenocarcinoma

• Pancreatic duct alterations related to fibrosis and destruction
image Duct epithelium may show atrophy, reactive, or hyperplastic changes

image Squamous, mucinous, or pyloric metaplasia

• Islets of Langerhans usually preserved, may show pseudohyperplasia

image
Fibrosis and Chronic Inflammation
The main features of chronic pancreatitis are fibrosis and chronic inflammation. Note the marked loss of acinar parenchyma. Residual islet cells and ductules are visible within the rounded contour of the lobule.


image
Preserved Lobular Architecture
In chronic pancreatitis, the normal lobular architecture is typically retained, and the rounded configuration of the lobule image is apparent at low power. Note the fibrosis and loss of acinar parenchyma. Rare islets are still visible image .

image
Atrophic Lobule With Acinar Loss
Atrophic lobules in chronic pancreatitis are characterized by lobular arrangements of small ducts image, fibrous tissue, and residual islet cells image. No residual acini are seen.

image
Islet Cell Pseudohyperplasia
Islet cell pseudohyperplasia, or proliferation and formation of cords and small clusters, is a common finding in chronic pancreatitis. Note the surrounding marked fibrosis and chronic inflammation. There is essentially no residual acinar parenchyma.


TERMINOLOGY


Abbreviations




• Chronic pancreatitis (CP)


Definitions




• Progressive inflammatory disorder of pancreas resulting in scarring, gland destruction, and functional impairment


ETIOLOGY/PATHOGENESIS


Alcohol




• By far most common cause of CP in developed countries


Anatomic




• Duct obstruction
image Stones or tumors involving head of pancreas lead to proximal duct dilatation, gland atrophy, and scarring

• Paraduodenal or “groove” pancreatitis


Metabolic




• Hypercalcemia

• Hyperlipidemia


Hereditary




• Autosomal dominant form
• Several associated gene mutations described

image Trypsinogen gene ( PRSS1 ) accounts for 60-80% of hereditary CP cases

image Cystic fibrosis transmembrane conductance regulator gene ( CFTR )

image Serine protease inhibitor Kazal type 1 gene ( SPINK1 )

image Chymotrypsin C ( CTRC )

• Presents during childhood with recurrent attacks of acute pancreatitis

• Complications similar to those seen in alcohol-related CP but at younger age


Eosinophilic




• Rare form of chronic pancreatitis with prominent eosinophilic infiltrate
• May present as mass-forming process or with biliary obstruction

• Often systemic process with peripheral eosinophilia and eosinophilias in other organs

• May occur as primary disease or with other processes

image Parasitic infection

image Allergic process or hypersensitivity reaction

image Associated with pancreatic carcinoma or inflammatory myofibroblastic tumor

image Pancreatic allograft rejection


Tropical




• Aggressive form of juvenile pancreatitis occurring in tropical developing countries

• May be related to malnutrition, toxin exposure, &/or genetic predisposition


Other




• Also related to trauma, radiation injury, smoking, or medications

• Up to 25% of cases are idiopathic


CLINICAL ISSUES


Epidemiology




• Age
image Alcohol-related CP usually affects adults > 40 years of age

image Hereditary and tropical forms of CP present during childhood

• Sex
image Alcohol-related CP more common in males than in females


Presentation




• Abdominal pain
image Most common presenting symptom

• Steatorrhea
image Associated with malabsorption due to impaired pancreatic enzyme secretion

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Apr 20, 2017 | Posted by in PATHOLOGY & LABORATORY MEDICINE | Comments Off on Chronic Pancreatitis
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