MEDizzy - A 63-year-old man who had worsening congestive heart failure

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The Pancreas

A 63-year-old man who had worsening congestive heart failure with cardiac dysrhythmias for the past year of his life died of pneumonia. At autopsy, his pancreas is grossly small and densely fibrotic. Microscopic examination shows extensive atrophy of the acini with residual chronic inflammation, fibrosis, and inspissated protein plugs in small, obstructed pancreatic ducts. Some of the protein plugs show calcification. The islets of Langerhans appear normal. The heart weighs 500 g, and all four chambers are dilated. Which of the following conditions is most likely to account for his findings?

ExplanationThis patient has chronic pancreatitis. Alcohol promotes intracellular proenzyme activation that leads to acinar cell injury. Although the exact mechanism for development of pancreatitis with alcoholism is unknown, the production of a protein-rich pancreatic secretion that forms inspissated plugs that cause ductal obstruction is observed in many cases. Ductal obstruction predisposes to acinar injury, and the ongoing or repeated injury leads to chronic pancreatitis. Patients with a history of alcohol abuse may have bouts of chronic pancreatitis that go unnoticed, only to have a superimposed case of clinically apparent acute pancreatitis. Alcohol, drugs, traumatic injury, and viral agents may have a direct injurious effect on pancreatic exocrine acinar cells. A dilated cardiomyopathy also can occur in chronic alcoholism, as in this case. A deficiency of α1-antitrypsin can produce liver disease with chronic hepatitis or cirrhosis, or both. Blunt abdominal trauma can produce hemorrhage, sometimes with a component of acute pancreatitis