1. PATHOLOGY 2B PANCREAS ROBERTO D. PADUA JR.,MD,DPSP DEPARTMENT OF PATHOLOGY FATIMA COLLEGE OF MEDICINE

5. Normal pancreatic anatomy

28. Trypsin Trypsinogen Activate other proenzymes Phospholipase Proelastase Disintegration of fat cells Damage elastic fibers of b.v. Acute Pancreatitis Prekallikrein  Kallikrein Kinin system Hageman factor Clotting system Complement system Inflammation Small vessel thromboses

35. SEQUELAE OF ACUTE PANCREATITIS

51. SEQUELAE OF CHRONIC PANCREATITIS

78. A cross-section through the head of the pancreas and adjacent CBD showing both an ill-defined mass in the pancreatic substance and the green discoloration of the duct resulting from total obstruction to bile flow.

82. Poorly formed glands are present in densely fibrotic stroma within the pancreatic substance with presence of some inflammatory cells.

90. American Joint Committee for Cancer Staging for Carcinoma of the Pancreas TNM classification criteria T1 No direct extension of the primary beyond the pancreas T2 Limited direct extension to the duodenum, bile duct, or stomach T3 Advanced direct extension incompatible with surgical resection TX Direct extension not assessed N0 Regional nodes not involved N1 Regional nodes involved NX Regional LN not assessed

91. American Joint Committee for Cancer Staging for Carcinoma of the Pancreas TNM classification criteria M0 No distant metastasis M1 Distant metastasis present MX Distant metastasis not assessed TNM Stages Stage I T1-2, N0, M0 Stage II T3, N0, M0 Stage III T1-T3, N1, M0 Stage IV Any T or N, M1

97. ENDOCRINE PANCREAS ROBERTO D. PADUA JR.,MD,DPSP DEPARTMENT OF PATHOLOGY FATIMA COLLEGE OF MEDICINE

103. What is glucose? Glucose is an essential nutrient that provides energy for the proper functioning of the body cells. MAN needs glucose to work CAR needs fuel to move FUEL

104. Blood Glycogenolysis (-) GLUCAGON (+) INSULIN Fed State Pyruvate/Lactate Amino acids Glycerol / FFA Glycogenesis X X *All cells

105. Blood Glycogenolysis (+) GLUCAGON (-) INSULIN Postabsorptive / Fasting State Pyruvate/Lactate Amino acids Glycerol / FFA Glycogenesis *6-8hrs after a meal First 24-48hrs Preferentially used by brain, & other non-insulin dependent tissues X

106. Blood Glycogenolysis (+) GLUCAGON EPINEPHRINE CORTISOL GROWTH HORMONE (-) INSULIN Postabsorptive / Fasting State Glycogenesis After 48hrs of fast Lipolysis Proteolysis Ketogenesis Ketones for brain Pyruvate/Lactate Amino acids Glycerol / FFA

112. Classification of Glucose Transport According to Their Tissue Distribution and Functional Regulation Glucose Organ Transporter HK Coupler Classification Brain GLUT 1 HK-I Insulin independent Erythrocyte GLUT 1 HK-I Insulin independent Adipocyte GLUT 4 HK-II Insulin dependent Muscle GLUT 4 HK-II Insulin dependent Liver GLUT 2 HK-IVL Glucose sensor GK  -cell GLUT 2 HK-IVB Glucose sensor (Glucokinase) Gut GLUT 3-symporter - Sodium dependent Kidney GLUT 3-symporter - Sodium dependent

116. Early Insulin Secretion Helps Control Post-meal Glucose Levels & DM

117. Immediate Tissue Membrane transport of glucose Muscle, adipose, liver Intermediate Carbohydrate metabolism  Glycogen synthesis Muscle, liver  Glycogenolysis Muscle, Liver  Gluconeogenesis Liver Lipid metabolism  Lipogenesis Liver, adipose  Lipolysis Adipose  Cholesterol synthesis Liver  Ketogenesis Liver Protein metabolism  Protein synthesis Liver, muscle, adipose INSULIN ACTION

121. Cell = Powerplant Keyhole = Insulin Receptor G G G G G G G Key = Insulin Glucose

122. Keyhole = Insulin Receptor G G G G G Key = Insulin CELL = POWERPLANT

123. G G G G G CELL = POWERPLANT Energy G G G G G G

124. DIABETES Greek MELLITUS Latin Sweet as honey To pass water like a siphon

125. G G G G G Type 1 DM insulin (key) absent G G G G G Type 2 DM defective insulin receptor (keyhole) with insufficient insulin Insufficient production of insulin or the inability of cells to use insulin (insulin resistance). What causes it?

126. “ Sweet Urine” Diabetes Mellitus group of metabolic disorders characterized by high blood sugar levels Hyperglycemia can lead to spillage of glucose into the urine (> 180 renal threshold)

128. SYMPTOMS OF DIABETES Polyuria Polydipsia Polyphagia

129. SYMPTOMS OF DIABETES Poor Wound Healing Weight Loss Weakness and Fatigue Blurring of Vision

130. SYMPTOMS OF DIABETES Many have no symptoms. They are noted to have high blood sugar on testing.

131. RISK FACTORS FOR DIABETES Heredity Old Age Obesity Mothers of large babies

132. Criteria for diagnosis of DM ADA 2004 Note: criteria should be confirmed by repeat testing on a different day.

133. CRITERIA FOR DIAGNOSIS OF DIABETES MELLITUS “ prediabetics” – risk for developing type 2 DM (40% risk over 5yrs) & CV disease Level of glycemia at which diabetic chronic complications occur American Diabetes Association 8 hr Fasting Blood Sugar 2 hours after 75g glucose (OGTT) NORMAL < 100 mg/dL < 140 mg/dL IMPAIRED FASTING GLYCEMIA (IFG)  100 and < 126 mg/dL --- IMPAIRED GLUCOSE TOLERANCE (IGT) ---  140 and < 200 mg/dL DIABETES MELLITUS  126 mg/dL  200 mg/dL Symptoms of diabetes and Random Blood Sugar of  200 mg/dL

135. Etiologic Classification of DM exocrine I. II. III. IV. Based on pathologic process that leads to hyperglycemia

138. Etiologic Classification of DM I. II. III. IV. Genetic predisposition Immunologic trigger No DM with DM Beta cell mass (%) 100 50 20 0 Time (years) Overt DM

142. Three Pathophysiologic Mechanisms of Type 2 Diabetes Glucose (G) Insulin (I) I I I I I I I G G G G G G G G I G G G I G Fasting hyperglycemia Postprandial hyperglycemia Carbohydrate Impaired insulin secretion Excessive fatty acid release Reduced peripheral glucose Uptake and usage Excess liver glucose output (gluconeogenesis) Resistance to the action of insulin

144. Natural history of type 2 diabetes: a progressive disease Post-prandial glucose Abnormal glucose tolerance Insulin resistance Increased insulin resistance Fasting glucose Hyperglycemia Insulin secretion Hyperinsulinemia, then  -cell failure Adapted from International Diabetes Center (IDC), Minneapolis, Minnesota. Normal IGT Type 2 diabetes

156. Glycemic goals 1 American Diabetes Association. Diabetes Care 2004; 27:S15–S35. 2 American Diabetes Association. Diabetes Care 2002; 25:S35–S49. 3 American Association of Clinical Endocrinologists. Endocrine Pract 2002; 8 (Suppl. 1):40–82. 4 European Diabetes Policy Group. Diabet Med 1999; 16:716–730. Fasting/pre-prandial plasma glucose < 140 < 180 Postprandial plasma glucose < 110 90–130 Biochemical index AACE 3 ADA 1,2 mg/dl mmol/l mg/dl mmol/l 5.0–7.2 < 10.0 < 6.5 < 7 HbA 1c (%) < 6.0 < 7.8

159. It cannot be cured. But it can be controlled by keeping blood sugar level within normal range. Diabetes Mellitus

160. Why do I need to control Diabetes?

162. COMPLICATIONS OF UNCONTROLLED DIABETES

170. Normal retina Diabetic retinopathy Preproliferative Proliferative Vitreous Hemorrhage BLINDNESS

171. Diabetic Neuropathy Peripheral Neuropathy Autonomic Neuropathy Erectile difficulty Constipation

180. HOW DO I PREVENT COMPLICATIONS?

181. Checking Your Blood Sugar

183. What is a good self-testing blood glucose goal? Your doctor will set the appropriate goal for you. The self-testing blood glucose goals for most people with diabetes are as follows: Premeals 80-120mg/dL At bedtime 100-140mg/dL

184. Guarding Your Heart

186. Guarding Your Kidneys

189. Caring for Your Eyes

191. Caring for Your SKIN

196. Caring for Your FEET

203. Do not wade in floodwaters without boots Footcare

205. Caring for Your TEETH

206. Caring for Your TEETH A film of bacteria, saliva and food particles (dental plaque) constantly forms on the teeth. Bacteria feed on sugars and starches in foods and produce acids that damage teeth enamel.

207. Caring for Your TEETH High blood sugar gives bacteria more food supply producing more acid, damaging the enamel leading to tooth decay.

208. Caring for Your TEETH If plaques are not removed with brushing and flossing, it hardens under the gumline into “tartar”. Tartar irritates the gums causing gum inflammation (gingivitis).

209. Brush your teeth at least twice a day especially after each meal and snack. Use soft-bristled brush. Floss daily . Caring for Your TEETH

210. See your dentist at least 2x a year. Consult your diabetes doctor prior to any dental extraction. Caring for Your TEETH

211. LIVING WITH DIABETES EDUCATION DIET EXERCISE MEDICINES

212. EDUCATION

214. BALANCED DIET wellnessbread.com Eat more of the foods at the bottom. Eat less of the foods at the top.

221. Diabetes Pills Insulin Medicines

234. INSULIN If your pancreas no longer makes enough insulin, you need to take insulin. You inject the insulin just under the skin with a small, short needle.

235. TYPES OF INSULIN

236. Hyperglycemia and Hypoglycemia “ When controlling diabetes, blood sugar may become too high or too low. This should be taken seriously.”

237. Hyperglycemia Guide

238. Hyperglycemia Hyper (Latin) – more Glycemia (Latin) – sugar in blood +

242. Hypoglycemia Guide

243. Hypoglycemia Hypo (Latin) – low Glycemia (Latin) – sugar in blood +

245. B LOOD G L U C O S E mg/dL Hypoglycemia: Symptoms & Signs LETHARGY COMA CONVULSIONS Sweating Tremor Palpitations Irritablity PERMANENT DAMAGE DEATH HEADACHE 90 - 80 - 70 - 60 - 50 - 40 - 30 - 20 - 10 -

248. Sick-Day Guide

251. Patient education is the key to success in diabetes management

263. THANK YOU!