Part 1 Lecture 4 Pancreas Part 1 Holdorf PANCREAS Outline Normal anatomy Spatial relationships of pancreatic anatomy Acute pancreatitis Chronic Pancreatitis Pancreatic cysts Cystic fibrosis ID: 908709
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Slide1
Ultrasound of the abdomen Part 1Lecture 4Pancreas Part 1
Holdorf
Slide2PANCREAS OutlineNormal anatomySpatial relationships of pancreatic anatomyAcute pancreatitisChronic 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
Slide3Normal AnatomyThe 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.
Slide4Slide5Netter diagram of the Pancreas
Slide6Endocrine vs. ExocrineExocrine 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.
Slide7The 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.
Slide8To 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.
Slide9Spatial Relationships of Pancreatic AnatomyHead 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
.
Slide10Spatial Relationships of the pancreatic anatomy GDA-CBD
Slide11Spatial Relationships of Pancreatic Anatomy SMV-SMA-IVC
Slide12Cartoon-GDA, CBD
Slide13Pancreas - longitudinal
Slide14Blood supply to the pancreas
Slide15Spatial Relationships Aorta
Slide16Cartoon- Celiac Axis
Slide17Superior 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
.
Slide18The 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.
Slide19The 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 arterySuperior pancreaticoduodenal artery
The superior mesenteric artery is located:
Inferior to the pancreas
Anterior to the uncinate process
Anterior to the 3
rd
portion of the duodenum
Slide20The 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 3
rd
portion of the duodenum
Anterior to the uncinate process.
Slide21Spatial relationships GDA
Slide22Spatial Relationships-Splenic vein
Slide23Cartoon-Main portal vein
Slide24The 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 2
nd
portion of the duodenum at the major papilla.
The accessory pancreatic duct (
duct of Santorini
) opens into the 2
nd
portion of the duodenum at the minor papilla.
50% of the population has complete regression of the duct of Santorini.
Slide25Spatial relationships
Slide26Spatial Relationships Duct of Wirsung
Slide27Duct of Santorini
Slide28Duct of Santorini
Slide29Pancreas cartoon
Slide30The duodenum is divided into 4 portions:1st and 3rd portions are transverse.2
nd
and 4
th
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.
Slide31Cartoon- Duodenum
Slide32Dilated pancreatic duct
Slide33Acute PancreatitisInflammatory 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.
Slide34Acute pancreatitisSonographic findings:Enlarged hypoechoic glandAcute Pancreatitis can take several directions:Resolution
Pseudocyst formation
Chronic pancreatitis
Slide35Acute pancreatitis
Slide36Complications of acute pancreatitis include:Pseudocyst formationAbscessPancreatic necrosisHemorrhageVenous 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.
Slide37Acute Pancreatitis
Slide38Chronic pancreatitisIrreversible destruction by repeated bouts of pancreatic inflammation.Patient presents with intermittent attacks of severe pain.Causes of chronic pancreatitis include:
Alcoholism (most common)
Cystic fibrosis
Hereditary pancreatitis
Congenital abnormalities (Pancreas divisum)
Blunt abdominal trauma
Idiopathic chronic pancreatitis
Slide39Elevation of serum amylase and lipase are found only during acute attacks of pancreatitis.Sonographic findings include:Small and echogenic glandCalcificationsPancreatic duct dilatationPseudocyst formation
Bile duct dilatation
Portal vein thrombosis
Slide40Chronic Pancreatitis