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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 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myESR.org Page 1 of 18 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. Page 2 of 18 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: Page 3 of 18 Fig. 1: Flowchart Page 4 of 18 Fig. 2: Patient, 78 year old, with chronic pancreatitis and dilatation of the main pancreatic duct, parenchymal atrophy and calcifications Page 5 of 18 Fig. 3: Patient, 78 year old, with chronic pancreatitis and dilatation of the main pancreatic duct, parenchymal atrophy and calcifications Page 6 of 18 Fig. 4: Intraductal Papillary Mucinous Neoplasms (IPNMs): difuse pancreatic duct dilatation Page 7 of 18 Fig. 5: Intraductal Papillary Mucinous Neoplasms (IPNMs): difuse pancreatic duct dilatation Page 8 of 18 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. Page 9 of 18 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. Page 10 of 18 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. Page 11 of 18 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. Page 12 of 18 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. Page 13 of 18 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 Page 14 of 18 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 Page 15 of 18 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. Page 16 of 18 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. Page 17 of 18 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 1. Mark D Edge, Maarouf Hoteit, Amil P Patel, Xiaoping Wang, Deborah A Baumgarten, Qiang Cai. Clinical signifi cance of main pancreatic duct dilation on computed tomography: Single and double duct dilation. World J Gastroenterol 2007 March 21;13(11): 1701-1705 2. Sarner M. Pancreatitis definitions and classification. In: 2nd ed. Go VLW, DiMagno EP, Gardner JD, Lebenthal E, Reber HA, Scheele GA editor. The pancreas: pathobiology and disease. New York: Raven; 1993;p. 575-580 3. Nino-Murcia M, Jeffrey RB Jr, Beaulieu CF, Li KC, Rubin GD. Multidetector CT of the pancreas and bile duct system: value of curved planar reformations. AJR Am J Roentgenol. 2001 Mar;176(3):689-93 4. Luetmer PH, Stephens DH, Ward EM. Chronic pancreatitis: reassessment with current CT. Radiology. 1989 May;171(2):353-7. 5. Tanaka S, Nakao M, Ioka T, et al. Slight dilatation of the main pancreatic duct and presence of pancreatic cysts as predictive signs of pancreatic cancer: a prospective study. Radiology 2010;254(3):965-972. Page 18 of 18