Download Pancreas Part 1

Holdorf
ULTRASOUND OF THE ABDOMEN
PART 1
LECTURE 4
PANCREAS PART 1
PANCREAS Outline
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Normal anatomy
Spatial relationships of pancreatic anatomy
Acute pancreatitis
Chronic Pancreatitis
Pancreatic cysts
Cystic fibrosis
Pancreatic Pseudocysts
Pancreas divisum
Annular pancreas
pancreatic adenocarcinoma
Serous cystadenoma
Mucinous cystic neoplasms
Islet Cell Tumors (Endocrine Tumors)
Multiple Endocrine Neoplasia (MEN)
Laboratory Values
Summary of Anatomical spatial relationships
Normal Anatomy
 The
pancrease is a nonencapsulated,
retroperitoneal structure that lies between
the duodenal loop and the splenic hilum. The
pancreas is divided into the head, uncinate
process, neck, body, and tail.
 The EXOCRINE function of the pancreas is to
secrete trypsin, lipase and amylase through
the ductal system.
Netter diagram of the Pancreas
Endocrine vs. Exocrine
 Exocrine glands have ducts to carry their
secretions
to specific locations. In the
pancreas, the pancreatic duct carries
pancreatic fluid to the duodenum.
 Endocrine glands are glands of internal
secretion, whose secretions are usually
spread directly into the blood. Most
hormones are secreted in this manner.
 The endocrine function (non-ductal) of the
pancreas is to secrete insulin via the islets of
Langerhans.
 On Cross-sectional images, the normal
pancreas should measure < 3 cm.
 The posterior wall of the stomach overlies the
anterior border of the pancreatic body and
tail.
 To better visualize the pancreas (specifically
the pancreatic tail), a technique is used in
which the patient in left lateral decubitus
position, drinks water to fill the stomach.
 While scanning the pancreas, the patient is
then turned to the supine or right lateral
decubitus position. Water in the stomach and
duodenum is used as an acoustic window.
Spatial Relationships of
Pancreatic Anatomy
 Head of the pancreas is anterior to the IVC.
 Head of the pancreas is medial to the
duodenum.
 CBD is posterior / lateral to the pancreatic
head.
 Gastroduodenal artery is anterior / lateral to
the pancreatic head.
Spatial Relationships of the
pancreatic anatomy GDA-CBD
Spatial Relationships of Pancreatic
Anatomy SMV-SMA-IVC
Cartoon-GDA, CBD
Pancreas - longitudinal
Blood supply to the pancreas
Spatial Relationships Aorta
Cartoon- Celiac Axis
 Superior mesenteric artery and vein are
posterior to the neck of the pancreas.
 Superior mesenteric artery and vein are
anterior to the uncinate process.
 Aorta is posterior to the body of the
pancreas.
 Celiac axis arises from the aorta at the
superior border of the pancreas
 Superior mesenteric artery arises from the
aorta at the inferior border of the pancreas.
 The celiac axis gives off the left gastric artery and
then divides into the common hepatic artery and
the splenic artery.
 The splenic artery follows a tortuous course
along the superior border of the body and tail of
the pancreas.
 The common hepatic artery divides into the
proper hepatic and the Gastroduodenal arteries.
 The proper hepatic artery travels superiorly
toward the liver anterior to the portal vein and
left of the bile duct.
 The right gastric artery is a branch of proper
hepatic artery.
 The gastroduodenal artery (GDA) travels
posterior to the first portion of the duodenum
than anterior to the head of the pancreas.
 The GDA then divides into the:
 Right gastroepiploic artery
 Superior pancreaticoduodenal artery
 The superior mesenteric artery is located:
 Inferior to the pancreas
 Anterior to the uncinate process
 Anterior to the 3rd portion of the duodenum
 The splenic vein is located on the posterior
aspect of the pancreas.
 The splenic vein joins the superior mesenteric
vein to create the main portal vein.
 The superior mesenteric vein is located:
 To the right of the superior mesenteric artery
 Anterior to the 3rd portion of the duodenum
 Anterior to the uncinate process.
Spatial relationships GDA
Spatial Relationships-Splenic vein
Cartoon-Main portal vein
 The Common bile duct travels posterior to the 1st
portion of the duodenum and the head of the
pancreas to lie to the right of the main
pancreatic duct.
 The common bile duct and the duct of Wirsung
(main pancreatic duct) join to become the
hepaticpancreatic ampulla (ampulla of Vater)
which opens into the 2nd portion of the
duodenum at the major papilla.
 The accessory pancreatic duct (duct of Santorini)
opens into the 2nd portion of the duodenum at
the minor papilla.
 50% of the population has complete regression
of the duct of Santorini.
Spatial relationships
Spatial Relationships Duct of Wirsung
Duct of Santorini
Duct of Santorini
Pancreas cartoon
 The duodenum is divided into 4 portions:
 1st and 3rd portions are transverse.
 2nd and 4th portions are longitudinal.
 The normal pancreatic duct may be imaged.
 The pancreatic duct is considered abnormal if
it is >2.0 mm.
 Pancreatic duct dilation is typically due to
stones within Wirsung’s duct from chronic
pancreatitis or a stone in the ampulla of
Vater.
Cartoon- Duodenum
Dilated pancreatic duct
Acute Pancreatitis
 Inflammatory disease producing temporary
pancreatic changes.
 Diagnosis is usually based on clinical and
laboratory findings.
 The most common causes of acute
pancreatitis are:
 Biliary tract disease
 Chronic alcohol abuse.
Acute pancreatitis
 Sonographic findings:
 Enlarged hypoechoic gland
 Acute Pancreatitis can take several
directions:
 Resolution
 Pseudocyst formation
 Chronic pancreatitis
Acute pancreatitis
 Complications of acute pancreatitis include:
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Pseudocyst formation
Abscess
Pancreatic necrosis
Hemorrhage
Venous thrombosis
Pseudoaneurysm formation
 Pancreatic phlegmon (focal pancreatitis)
 An inflammatory mass formed by edema and leakage
of pancreatic enzymes. It forms as a complication of
acute pancreatitis.
 Definition of a Phlegmon
 A spreading diffuse inflammatory reaction to an infection
which forms a isolated lesion.
Acute Pancreatitis
Chronic pancreatitis
 Irreversible destruction by repeated bouts of
pancreatic inflammation.
 Patient presents with intermittent attacks of
severe pain.
 Causes of chronic pancreatitis include:
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Alcoholism (most common)
Cystic fibrosis
Hereditary pancreatitis
Congenital abnormalities (Pancreas divisum)
Blunt abdominal trauma
Idiopathic chronic pancreatitis
 Elevation of serum amylase and lipase are
found only during acute attacks of
pancreatitis.
 Sonographic findings include:
 Small and echogenic gland
 Calcifications
 Pancreatic duct dilatation
 Pseudocyst formation
 Bile duct dilatation
 Portal vein thrombosis
Chronic Pancreatitis