Download Dilatation of the main pancreatic duct

Dilatation of the main pancreatic duct: what to think and
flowchart to aid in the differential diagnosis.
Poster No.:
C-0577
Congress:
ECR 2014
Type:
Educational Exhibit
Authors:
T. C. Rodrigues , S. B. Bergamaschi , R. Steinwandter , C. F. R.
1
2
1
1 1
1
2
B. Milito , D. Sjzenfeld ; São Paulo, SP/BR, São Paulo/BR
Keywords:
Abdomen, Biliary Tract / Gallbladder, Pancreas, CT, MR,
Diagnostic procedure, Cancer, Inflammation
DOI:
10.1594/ecr2014/C-0577
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Learning objectives
Dilatation of the main pancreatic duct is a common finding in abdominal imaging, and
can be a sign of very serious diseases, like pancreatic adenocarcinoma. So, this finding
should always be taken into account, and with the aid of some ancillary findings, the
differential diagnosis can be made in the majority of the pacients.
Background
The main pancreatic duct is considered dilated when wider then 3 mm in the head, and
2 mm in the tail of the pancreas. Common bile duct dilatation is an important finding in
this context, and is considered when wider than 6 mm in no colecistectomized pacients
and 10 mm in colecistectomized pacients.
There are several causes of pancreatic duct dilatation, the most commons are pancreatic
adenocarcinoma, chronic pancreatitis, IPNM, cholangiocarcinoma and idiopathic..
Imaging techniques: Computerized tomography (CT) with and without contrast of the
abdomen and Magnetic Resonance Cholangiopancreatography (MRC).
Findings and procedure details
Single Duct Dilatation
1. Chronic Pancreatitis
Inflamatory condition caracterized by irreversible morphologic alterations, that generaly
lead to chronic pain and pancreatic insuficiency. The leading cause is alcohol.
It leads to single duct dilation in the majority of the cases, and additional findings are
pancreactic atrophy and calcifications
2. IPMN
Intraductal Papillary Mucinous Neoplasms (IPNMs) are tumors that grow in the pancreatic
ducts, and produce large quantities of mucin. It can presents as segmentar or difuse
pancreatic duct dilatation, and secondary duct dilatation.
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3. Idiopathic
When no adjacent cause of obstruction nor any sign of pancreatic disease is found, the
duct dilatation is considered idiopathic, and is the second most common cause of single
duct obstruction.
Doble Duct Dilatation
1. Pancreatic Adenocarcinoma
Most common pancreatic neoplasm, very agressive and with a bad prognosis. Generally
affects the pancreatic head, therefore leading to dilatation of the common bile duct and
the main pacreactic duct. It presents as a hipovascular solid mass, generally invasive
and with poorly defined contours.
2. Cholangiocarinoma
Rare neoplasm originated from the bile duct epithelia, predominantly in older pacients.
When distal, generally presents as an hipovascular mass in the periampullar region, and
lead to double duct obstruction.
Images for this section:
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Fig. 1: Flowchart
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Fig. 2: Patient, 78 year old, with chronic pancreatitis and dilatation of the main pancreatic
duct, parenchymal atrophy and calcifications
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Fig. 3: Patient, 78 year old, with chronic pancreatitis and dilatation of the main pancreatic
duct, parenchymal atrophy and calcifications
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Fig. 4: Intraductal Papillary Mucinous Neoplasms (IPNMs): difuse pancreatic duct
dilatation
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Fig. 5: Intraductal Papillary Mucinous Neoplasms (IPNMs): difuse pancreatic duct
dilatation
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Fig. 6: Intraductal Papillary Mucinous Neoplasms (IPNMs): patient 65 years old with
combined type IPMN showing dilatation of the main duct and multiple secondary ducts.
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Fig. 7: Patient 67 year old with adenocarcinoma of the pancreatic head, showing
dilatation of the main pancreatic duct , with distal parenchymal atrophy. Hypoattenuating
mass in the head region.
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Fig. 8: Patient 67 year old with adenocarcinoma of the pancreatic head, showing
dilatation of the main pancreatic duct , with distal parenchymal atrophy. Hypoattenuating
mass in the head region.
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Fig. 9: Patient, 55 year old, with pancreatic adenocarcinoma, showing dilatation of
the main pancreatic duct, with distal parenchymal atrophy. In this case, there was no
dilatation of bile ducts.
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Fig. 10: Patient, 55 year old, with pancreatic adenocarcinoma, showing dilatation of
the main pancreatic duct, with distal parenchymal atrophy. In this case, there was no
dilatation of bile ducts.
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Fig. 11: Patient, 56 years old, with pancreatic adenocarcinoma with dilation of the main
pancreatic duct and atrophy of distal parenchyma. Patient with liver metastases
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Fig. 12: Patient, 56 years old, with pancreatic adenocarcinoma with dilation of the main
pancreatic duct and atrophy of distal parenchyma. Patient with liver metastases
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Fig. 13: Patient, 64 year old, with distal cholangiocarcinoma. It is noted dilatation of the
main pancreatic duct with significant parenchymal atrophy, caused by mass periampular
region.
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Fig. 14: Patient, 64 year old, with distal cholangiocarcinoma. It is noted dilatation of the
main pancreatic duct with significant parenchymal atrophy, caused by mass periampular
region.
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Conclusion
With a sistematic approach, the abdominal CT and MRC can bring a lot of information,
helping make the differential diagnosis and guide the conduct of patients with main
pancreatic duct dilatation.
Personal information
References
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the pancreas and bile duct system: value of curved planar reformations. AJR Am J
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