Ultrasound of the abdomen - PowerPoint Presentation

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Ultrasound of the abdomen Part 1Lecture 4Pancreas Part 1

Holdorf

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PANCREAS 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

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Normal 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.

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Netter diagram of the Pancreas

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Endocrine 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.

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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.

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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.

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Spatial 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

.

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Spatial Relationships of the pancreatic anatomy GDA-CBD

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Spatial Relationships of Pancreatic Anatomy SMV-SMA-IVC

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Cartoon-GDA, CBD

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Pancreas - longitudinal

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Blood supply to the pancreas

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Spatial Relationships Aorta

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Cartoon- Celiac Axis

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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

.

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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.

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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 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

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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 3

rd

portion of the duodenum

Anterior to the uncinate process.

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Spatial relationships GDA

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Spatial Relationships-Splenic vein

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Cartoon-Main portal vein

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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 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.

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Spatial relationships

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Spatial Relationships Duct of Wirsung

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Duct of Santorini

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Duct of Santorini

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Pancreas cartoon

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The 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.

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Cartoon- Duodenum

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Dilated pancreatic duct

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Acute 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.

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Acute pancreatitisSonographic findings:Enlarged hypoechoic glandAcute Pancreatitis can take several directions:Resolution

Pseudocyst formation

Chronic pancreatitis

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Acute pancreatitis

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Complications 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.

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Acute Pancreatitis

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Chronic 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

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Elevation 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

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Chronic Pancreatitis