Pancreas Flashcards
what is this?
age group?
Assocaitions
pancreaticoblastoma
- rare primary pancreatic neoplasm of child hood
- Usually pts between 1-8 yo
- reported in neonates and adults
- A congenital form is A/w Beckwith widemann syndrome
- Slow growing
- uaully large at presentation
- large well defined multilobulated masses with enhancing septa by ct
- mixed echotexture seen on US
- The tumours are soft and gelatenous and if arising in the pancreatic head, do not usually produce obstructive symptoms.
Radiology Findings of Autoimmune Pancreatitis
- US
- Focal hypoechoic diffuse enlargement of gland
- gland may be normal in appearance
- CBD may be dilated
- CT
- diffuse enlargement of the pancreas
- loss of normal surface indentations
- tail retracted from splenic hilum
- capsule-like rim enhancement around gland
- peripancreatic adenopathy
- no calcificaiton
- vascular encasement of CBD dilatation
- Can have typical linea ‘cut off’ from normally enhancing pancreas to more distal hypoenhancing pancreas
Single phase CT scan (multiphase scans not performed due to age of patient) demonstrates a diffusely enlarged pancreas with a “halo” like rim of hypoattenuating tissue which is smoothly marginated. Minimal peripancreatic fat stranding.
Associated splenic vein thrombosis, splenomegaly and cavernous transformation of the portal vein.
what is this tumour?
who does it occur in?
- Solid pseudopapillary neoplasm
- AKA
- Frantz tumour
- solid and cystic acinar tumour
- Papillary epithelial neoplasm
- solid and papillary epithelial neoplasm
- DAUGHTER TUMOUR
- Large lesions of epithelial tissue that are slightly more common in body/tail
- well-demarcated mixed solid and cystic hemorrhagic mass
- solid components with enhacment
- may contain calcificaitons
- good prognosis after resection
- women <50yo
- Solid pseudopapillary tumours of the pancreas are rare (usually benign) pancreatic tumours.
Terminology
The tumour has been referred to with multiple different names, including:
solid pseudopapillary tumour (SPT) of the pancreas
solid pseudopapillary neoplasm (SPN)
solid pseudopapillary epithelial neoplasm (SPEN)
papillary cystic neoplasm of the pancreas
Hamoudi tumour
Gruber-Frantz tumour (or just Frantz tumour)
Epidemiology
They are rare and thought to account for 1-2% of exocrine pancreatic tumours. They tend to present in young non-Caucasian females around the 2nd and 3rd decades of life (the ‘daughter’ tumour) 10.
Associations
pancreatic dorsal agenesis: possible association 5
Clinical presentation
Most patients are asymptomatic at diagnosis. They may occasionally present with a gradually enlarging abdominal mass or vague abdominal pain.
Pathology
The tumours frequently contain varying amounts of necrosis, haemorrhage, and cystic change. Lesions can be large at time of diagnosis (median size ~8 cm) 2.
Location
There is a greater predilection to occur at pancreatic tail.
Imaging features of Chronic Pancreatitis
- Size
- commonly small, uniformly atrophic pancreas
- focal enlargement from normal or inflamed pancreas bay be coexistent 40%
- Tissue
- fatty replacement
- fibrosis
- parenchymal calcificaitons
- intraductal calculi
- Ducts
- Irregular dilation of PD
- Side branches may have clubbed appearance
- MRI study shows dilated beaded main pancreatic duct measures about 7 mm with associated thinned out pancreatic parenchyma, smooth pancreatic surface, and loss of normal lobulation. Dilated side branches of the pancreatic duct giving a “chain of lakes sign”. Multiple filling defects are seen within the proximal main pancreatic duct best seen on DWI and coronal T2 space as low signal intensities suggestive of intraductal calculi
Multiple variable size GB stones are also noted.
- https://radiopaedia.org/cases/chronic-pancreatitis-chain-of-lakes-sign-1
Intraductal Papillary Mucinous Neoplasms of the pancreas
Types 2
associations 3
- Types
- side branch
- Main duct lesions
- Associations
- Adenocarcinoma (25%)
- Hyperplasia (25%)
- Dysplasia (50%)
Complications of Chronic Pancreatitis
- Pseudocysts 30%
- Obstructed CBD 1-%
- Venous Thrombosis
- splenic
- portal
- mesenteric veins
- Increased Risk of Cancer
- Malabsorption/steatorrhea 50%
Generalised atrophy of body and tail of the pancreas. Diffuse parenchymal calcification with main pancreatic duct dilated throughout its course with a beaded appearance reaching up to 10mm in diameter. Multiple intraductal calculi are present, the largest measuring 10 mm in the pancreatic head. This stone is obstructing the main pancreatic duct resulting in ductal dilatation. No hypoenhancing pancreatic parenchymal lesions. No peripancreatic fat stranding or localised collections. No radio-opaque stones in the gallbladder, cystic duct, or common bile duct. No intrahepatic biliary duct dilatation.
Case Discussion
When presenting with an episode of abdominal pain, this patient underwent an ultrasound of the abdomen which revealed features of chronic calcific pancreatitis. However, due to the suboptimal acoustic window, a CT scan was recommended to rule out any pancreatic inflammation or neoplasm. The chronic inflammatory changes result in reduction in volume of pancreatic parenchyma with only a ghost of the gland remaining in the latter stages. These patients are more prone for neoplasms and have to be watched closely.
https://radiopaedia.org/cases/chronic-calcific-pancreatitis-with-obstructing-stone
what is this?
Increased risk of what
Tropical Pancreatitis
- Variant of Chronic pancreatitis
- young age at onset
- usually no alcohol abuse
- a/w malnutrition
- regional predisposition in tropical countries
- rapidly progressive course with severe pancreatitis
- presence of large intraductal calculi
- increased risk of adenocarcinoma
What is this sign and condition?
- Colon cut off sign
- The colon cut-off sign describes gaseous distension seen in the proximal colon associated with abrupt termination of gas within the colon usually at the level of the splenic flexure and decompression of the more distal part of the colon. Though originally described in abdominal radiographs, this sign has also been demonstrated on contrast enemas and computed tomography 1.
Replaced right hepatic artery (RHA) arising from the superior mesenteric artery (SMA).
Case Discussion
The right hepatic artery arises from the superior mesenteric artery (SMA), also referred to as “replaced to the SMA”, in 9 to 15% of the population. It is the most common variant in hepatic arterial anatomy.
Core tip: Appreciation and study of hepatic arterial anatomical variability is essential to the successful performance of complex pancreaticobiliary procedures. An aberrant right hepatic artery (aRHA) represents the vascular anomaly encountered most frequently during pancreatoduodenectomy (PD) and, because of its course, is most susceptible to intraoperative damage and tumor involvement. When an aRHA is present, the challenge in peripancreatic malignant disease is to balance its preservation and the need to achieve oncological clearance. In this study, we analyzed the incidence of aRHA and its relationship with the operative complexity, occurrence of complications and oncological clearance in a large cohort of patients undergoing PD.
An aRHA represents the vascular anomaly encountered most frequently during PD. It may have a suprapancreatic, intrapancreatic or rarely transpancreatic course, and, because of its course, it is most susceptible to intraoperative damage and tumor involvement[4,5]. The incidence of an aRHA identified in patients undergoing PD varies from 11%-26.5%[1,6]. When an aRHA is present, the challenge in peripancreatic malignant disease is to balance between its preservation and the need to achieve oncological clearance, which represents the only chance for prolonged survival[1,5,7]. The presence of an aRHA leads not only to an alteration in the surgical approach, but may also adversely affect the outcomes of the surgical procedure[5,8]. In this study, we analyzed the incidence of aRHA and its relationship with the operative complexity, occurrence of complications and oncological clearance in a large cohort of patients undergoing PD.
Where does the duct of Wirsung enter into?
what is the upper size limit of the PD
- The duct of wirsung enters into the major papilla with the CBD
- The duct of santorini empties into the minor papilla
- Both pancreatic ducts communicate with each other near the neck of the pancreas, forming a single remaining duct that runs through the center of the body and tail of the pancreas
- The upper size limit of the main duct in young adults is 3mm, older adults 5mm
- mucinous cystic neoplasm of the pancreas
- MCN
- large peripheral tumours surrounded by thick fibrous capsule.
- the cyst cavity is filled with muycinous material
- Unlike Intraductal papillary mucinous tymours (IPMT) there is no connection to the pancreatic duct
- AKA
- mucinous macrocytic neoplasm
- Mucinous Cystadenoma
- Mucinous Cystadenocarcinoma
- Macrocystic adenoma
Mucinous cystadenomas (MCN) of the pancreas are a type of mucinous cystic neoplasm of the pancreas.
Epidemiology
Previously believed to occur exclusively in middle age females 5, it has occasionally been described in males 6,7.
Pathology
It is a large uni/multilocular cystic pancreatic neoplasm lined by columnar mucinous epithelium. While mucinous cystadenomas very infrequently communicate with the pancreatic duct 13, they can cause partial pancreatic ductal obstruction 11. They are considered premalignant or malignant lesions with usually elevated CEA and CA 19-9 serum levels.
Location
Largely (~80%) occur in the body or tail of the pancreas, and less commonly in the head of the pancreas (~20%) 11.
Radiographic features
CT
the tumour contour tends to be rounded or ovoid although this is not an absolutely specific feature 2
associated calcification when present tends to be more peripheral 1,11
contents of the lesion may be heterogenous in attenuation 2
internal septations may be present and tend to be linear or curvilinear 2
Differential diagnosis
On ultrasound or CT consider:
mucinous cystadenocarcinoma of the pancreas: at times almost impossible to differentiate on ultrasound or CT from a mucinous cystadenoma 8
pancreatic pseudocyst
oligocystic variant of serous cystadenoma of the pancreas
pancreatic hydatid cyst 14
Findings: A well-defined rounded exophytic cystic lesion measuring 6.3 x 7 x 7 cm is seen originating from the tail of the pancreas. It has an average density of 8 HU and shows mild peripheral enhancement on post contrast study. A few thin septations and a tiny mural calcification are seen in it. No solid component is seen in it. Morphology of the remaining pancreas is unremarkable.
Impression: Well-defined rounded exophytic cystic lesion originating from the tail of the pancreas, which is likely, a mucinous cystadenoma of the pancreas (mucinous cystic neoplasm of the pancreas) with possible differential diagnosis of pancreatic pseudocyst (if there is a past history of pancreatitis). Another possible differential can be a hydatid cyst which is however, very unlikely.
https://radiopaedia.org/cases/mucinous-cystadenoma-of-the-pancreas-4
Infected fluid collections
- Any of the following can be infected
- walled off necrosis
- pseudocyst
- acute peripancreatic fluid collections
- air in a fluid collections suggests infection by a gas forming bacterium
- pitfulls of calling infection by presence of air:
- fistulization to bowel
- or previous manipulation
Islet cell Neoplasm
AKA
Which cells do they arise from?
Types?
Classification
Islet cell Neoplasm/AKA neuroendocrine Tumours
- arise from multipotential stem cells.
- pancreatic endocrine tumours have commonly been referred to as “islet cell tumours”, referring to the islets of Langerhans, from which they were thought to derive.
- It has since been shown that these tumours derive from ductal pluripotent stem cells, and “endocrine tumour” is now preferred.
- APUD
- amine
- precursor
- uptake and
- decarboxylation
- systme
- Classification
- functional 85%, secretion of one or more hormones
- Insulinoma (most common functional tumour)
- Gastrinoma (2nd most common)
- Glucagonoma
- VIPoma
- Somatostatinoma
- non functional (3rd most common)
- functional 85%, secretion of one or more hormones
What are the Cystic neoplasms of the pancreas?
- Mucin producing tumours
- Intraductal Papillary Mucinous Neoplasm/tumour (IPMN)
- Mucinous Cystic Neoplasm (MCN)
- Serous Cystadenoma
What is this?
Fatty infiltration of the pancreas
- Common
- normal findings with increasing age.
- Also seen in DM and other endocrine dysfunction
- Fatty distribution is often uniform
- Focal sparing around CBD is common
- Lobulated external contour
diagnosis?
A/w which disease?
- Pancreatic Cystosis
- Pancreatic cystosis (PC) is an uncommon manifestation of pancreas involvement in cystic fibrosis (CF), characterized by the presence of multiple macrocysts partially or completely replacing pancreas. Only few reports are available from literature and management (surgery vs follow up) is commonly based on the presence of symptoms or complications due to local mass effect, although evidence-based recommendations are still not available.
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7021641/
Imaging features of IPMN
- Locaiton
- head, uncinate 55%
- body tail 10%
- Diffuse/multifocal 35%
- Ductal abnormalities
- Combined main/side branch duct type 70%
- Isolated side branch duct type 30%
- ductal dilatation 97%
- “masses of mucin”
- Clusters of small cysts from 1-2cm in diameter
Acinar cell carcinoma
- Older men
- Less desmoplastic and often larger than pancreatic adenocarcinoma.
- May be encapsulated
- invades rather than encases vessels
- metastatic fat necrosis
Case Discussion
Ultrasound-guided biopsy of the spleen was performed leading to the rare diagnosis of pancreas acinar cell carcinoma.
Pancreas acinar cell carcinoma highlights:
very rare <1%
exocrine tumour
larger size at diagnosis and often better prognosis than adenocarcinoma
some have paraneoplastic syndrome with hypersecretion of lipase (as in this case), which can lead to fat necrosis of subcutaneous nodules and polyarthralgia
On physical exam, this patient did have subcutaneous nodules in the lower extremities which would be clinically consistent with fat necrosis related to hyperlipasaemia.
which nuclear imaging studies can be useful in looking for insulinomas and why?
Ga-68 DOTATATE PET-CT
About 80% of insulinomas express the somatostatin receptors 2, and the Ga-68 DOTATATE scans have a high affinity for these receptors and, therefore, have high sensitivity in the detection of these tumours, particularly for low-grade and well-differentiated ones 8-10. The sensitivity of this study has been reported in up to 90% 8, when assessing insulinomas specifically, and ranging between 90-100% for pancreatic neuroendocrine tumours as whole 9.
PET-CT is also useful in excluding additional pancreatic neuroendocrine tumours eventually not detected on CT or MRI, particularly, in inherited syndromes such as MEN1 8.
F-18 FDG PET-CT
Neuroendocrine tumours are slow-growing tumours that usually have slow metabolic activity in their initial stages and, therefore, are not notably avid on F-18 FDG PET-CT 9. Tumours with a higher grade or poorly differentiated tend to show marked uptake 8-10.
Acute peripancreatic fluid collections
APFC
- Fluid collections/Phlegmon
- occur in the setting of intersitial edematous pancreatitis
- ie normal pancreatitis
- < 4 weeks after the onset of pancreatitis
- Can either be infected or not
- occur in the setting of intersitial edematous pancreatitis
- Acute peripancreatic fluid collections (APFC) are an early complication of acute pancreatitis that usually develop in the first four weeks. After four weeks, the term pseudocysts is used. The absence of necrosis differentiates APFCs from acute necrotic collections (ANC), that is, APFCs occur in interstitial oedematous pancreatitis, not in necrotising pancreatitis.
- Pathology
APFCs result from pancreatic/peripancreatic inflammation and/or rupture of one of the small pancreatic side ducts 1.
describe a whipples proceedure
- resection of the
- pancreatic head
- duodenum
- gastric antrum
- GB
- a jejunal loop is brought up to the RUQ for gastrojejunal, choledochojenumal or hepatic jejunal and pancreaticojejunal anastomosis
- Some surgeons prefer to perform pancreatoduodectomy to preserve the pylorus when possible
- The pylous preserving pancreatoduodenectomy, the stomach is left intact and the proximal duodenum is used for duodenojejunal anastomosis
What is this?
Ectopic/Heteropic pancreatic tissue
- Present in 1-10% of the population
- Sites
- Stomach (antrum)
- Duodenum
- Smooth submucosal mass often with central umbilication (remnant of PD)
definition of this condition.
Chronic pancreatitis
progressive, irreversible destruction of pancreatic parenchyma by repeated episodes of mild or subclinical pancreatitis
Thick punctate pancreatic calcifications with dilatation of duct of Wirsung. Distended gallbladder. Decreased liver attenuation coefficient, probably due to fat infiltration.
No focal hepatic lesions are observed. Normal adrenal glands and kidneys. No ascites or retroperitoneal lymphadenopathy are observed.
Case Discussion
This case shows typical findings of chronic pancreatitis with calcification and main duct dilatation. This is most commonly associated with chronic alcohol abuse as was the case for this patient.
https://radiopaedia.org/cases/chronic-pancreatitis-5
Imaging features of Groove Pancreatitis/paraduodenal pancreatitis
- CT
- soft tissue in the pancreaticoduodenal groove with delayed enhancement
- small cystic lesions along the medial wall of the duodenum
- MRI
- Sheet like mass in pancreaticoduodenal groove hypointense to pancreas on TI and isointense to slightly hyperintense to pancreas on T2
- delayed enhancement
- cystic lesions in the medial wall of duodenum seen in cystic dystrophy
The walls of the second part of the duodenum are thickened with a small volume of free fluid; there are recognizable ectopic pancreatic islands with a similar degree of enhancement to the rest of the pancreas. The adjacent fat tissue is hyperdense due to inflammation. There are multiple foci of calcification in the pancreas. Normal biliary tree.
Case Discussion
Paraduodenal pancreatitis is characterised by a history of excess alcohol and tobacco use in male patients, and a painful symptomatology. Histology analysis demonstrates granulomatous tissue, stromal proliferation, and ectopic pancreatic tissue within the duodenal wall. The epicentre of the inflammation is typically located between the duodenum, common bile duct and pancreas. The presence of cysts inside the inflamed duodenal wall allows distinguishing between a “cystic” (75%) and a “solid” variant of paraduodenal pancreatitis.
https://radiopaedia.org/cases/paraduodenal-pancreatitis-3
what is the inheritance pattern?
what is the genetic mutation?
what are the imaging features similar to?
What are these patients at risk of?
- hereditary pancreatitis
- AD
- mutation of the cationic trypsinogen gene
- acute attacks begin in childhood
- imaging features resemble those of tropical pancreatitis
- 50-70 fold increased risk of pancreatic adenocarcinoma
- Hereditary pancreatitis in an 18-year-old man with recurrent episodes of idiopathic acute pancreatitis. Axial (a) and coronal (b) unenhanced CT scans reveal multiple focal areas of punctate calcifications throughout the pancreatic parenchyma (arrows in a, arrowheads in b), findings that are nonspecific and suggest chronic calcific pancreatitis. However, the young age of the patient, the absence of any known predisposing factors, and the family history of pancreatitis favor a diagnosis of hereditary pancreatitis.
- https://www.researchgate.net/figure/Hereditary-pancreatitis-in-an-18-year-old-man-with-recurrent-episodes-of-idiopathic-acute_fig3_26674084
- A Clinical and Radiologic Review of Uncommon Types and Causes of Pancreatitis
- https://www.researchgate.net/publication/26674084_A_Clinical_and_Radiologic_Review_of_Uncommon_Types_and_Causes_of_Pancreatitis
What is Cystic Fibrosis?
Inheritance pattern
Which gene?
GIT manifestations?
- CF is an Autosomal recessive disease
- secondary to mutation of a gene encoding chloride channel
- GIT manifestations
- preceded pulmonary manifestations
- exocrine pancreatic insufficiency 90%
- CF is the most common cause of pancreatic insufficiency in young patients
- Genetics
Cystic fibrosis is due to a homozygous defect of the CFTR gene located on chromosome 7q31.2. This gene encodes for a transmembrane protein known as cystic fibrosis transmembrane regulator (CFTR) which is responsible for regulating chloride passage across cell membranes. There are at least 6 classes of mutations, the commonest being ∂F508 (66-70%) 6.
Epidemiology
Cystic fibrosis is the most common genetic disease affecting European population with an incidence of approximately 1:2000-3500 live births
https://radiopaedia.org/cases/distal-intestinal-obstruction-syndrome-and-cirrhosis
The liver has nodular surface and atrophic, in keeping with cirrhosis. Dilated paraumbilical vein and large number of varices around the distal oesophagus, splenorenal, as well as splenic hilum, features of portal hypertension. Splenomegaly is also seen.
The small bowel loops are distended, with small bowel faeces signs seen in the distal ileum, leading to a transition point, from there the distal and terminal ileum are collapsed. No enhancing mass can be seen. No abnormal bowel wall thickening or hyperenhancement seen.
The pancreas is atrophic with fatty replacement, in keeping with the known history of cystic fibrosis.
Portal vein as well as splenic and SMV appear patent.
Minimal ascetic free fluid.
Interpretation
acute small bowel obstruction, with transition point in the distal ileum (distal intestinal obstruction syndrome)
features of cirrhosis and portal hypertension
Case Discussion
CT of the abdomen of a 25-year-old patient with known cystic fibrosis (CF) presents with distal intestinal obstruction syndrome.
The liver is markedly nodular in contour in keeping with advanced cirrhosis and extensive dilated portosystemic collaterals are seen, consistent with portal hypertension. The spleen is also markedly enlarged. Also, note the complete fatty atrophy of the pancreas - a feature of cystic fibrosis.
The small bowel is dilated and fluid-filled bowel all the way to the distal ileum.
Causes of Pancreatitis
What is this?
- Common 70%
- etoh
- cholelithiasis
- less common 30%
- post op/ERCP/trauma
- hyperlipidemia, hypercalcaemia
- Drugs
- azathioprine, thiazides, sulfonamides
- inflammation
- PUD
- hyperparathyroidism
- Pregnancy
- The pancreas is diffusely enlarged mainly in its corporeocaudal region with indistinct margins. It shows a homogeneous increase signal on T2WI with no areas of parenchymal necrosis.
Peripancreatic and left anterior pararenal fluid collections are noted (the largest measures 33 x 14 mm).
The gallbladder is anechoic with normal size and wall thickness. The Intra-and extrahepatic biliary ducts are not dilated. No CBD stone was seen.
Case Discussion
Case showing acute pancreatitis with peripancreatic fluid collections, without pancreatic necrosis in a pregnant patient at 25 weeks gestation with a history of systemic lupus erythematosus (SLE).
Acute pancreatitis is considered as one of the gastrointestinal manifestations of the systemic lupus erythematosus as in this case.
Imaging features of PDAC
- Mass effect
- HOP 65% (5% curable)
- Tail and body 35% (incurable)
- Only part of the pancreas is enlarged
- global enlargement from associated pancreatitis is uncommon (15%)
- Compression of duodenum
- Some small pancreatic tumours are better resulved by US than by CT b/c of texture changes
- Alterations of density
- subtly hypodense on NCCT and CECT bc of edema and necrosis
- Calcifications are VERY UNCOMMON
- c/f cystic and islet cell tumours where they are more common
- Ductal obstruction
- PD +/- CBD obstruction
- double duct sign
- tumours in the uncinate may not cause ductal obstruction
- extrapancreactic extension
- usually retropancreatic with obliteration of fat around the CMA or SMA (one sign of incurability)
- Portahepatis extension
- Direct invasion of stomach or SB
- Vascular involvement
- Need to rule out REPLACED RIGHT Hepatic artery prior to Whipples
- Criteria for unresectability
- SMA encased
- PV or proximal SMV obstructed/encased
- tumours are still resectable if small branches are encased
- Dilation of smaller venous branches >5mm is an indirect sign of venous encasement
- Mets
- Liver
- LNS
- peritoneal/serosal
- Lung
A large heterogeneous mass arising from the head of the pancreas is present which abuts the superior mesenteric artery over more than 180 degrees and results in narrowing. The upper aspect of the superior mesenteric vein and origin of the main portal vein are also stenosed.
A biliary stent is in situ with associated pneumobilia. The main pancreatic duct is markedly dilated and pancreatic parenchyma is atrophic. Numerous enlarged retroperitoneal nodes are present.
Case Discussion
This case illustrates T4 pancreatic cancer. The vascular criteria for unresectability vary from country to country and surgeon to surgeon, but generally it is accepted that SMA with tumour encasement >180 degrees circumference (which this case has, with associated narrowing) is unresectable. A coronal would probably be better to demonstrate it. The portal vein at the origin is very narrow… combined with the SMA involvement would make it unresectable.
https://radiopaedia.org/cases/pancreatic-cancer-t4-uncinate-process
What is this?
What are the complications?
Annular pancreas
- Results from abnormal migration of the ventral pancreas
- the pancreas surrounds and obstructs the duodenum
- appears as annular constriction of the second portion of the duodenum
- ERCP is the imaging study of choice
- the Pancreatic duct encircles the duodenum
- Increased incidence of pancreatitis and PUD
Types of Pancreatic Trauma
- Simple superficial contusion with minimal parenchumal hemorrhage
- deep laceration or performation without duct injury
- Laceration with duct transection (picture 1 and 2)
- Neck of pancreas transection. Surgically confirmed neck of pancreas transection. Duodenal tear. Vascular pedicle disrupted. Massive haemoperitoneum. case 1
- The pancreatic body was transected with injury to the main pancreatic duct. Case 2
- Necrotising Pancreatitis
- accuracy of CECT for detection of pancreatiti necrosis:
- 80-90%
- presence and extent of cludi a/w fat necrosis cannot be accurately determined by CT attenuation numbers
- Prognosis
- 30% necrosis = 8% mortality
- 50% necrosis = 24% mortality
- >90% necrosis = 50% mortality
- accuracy of CECT for detection of pancreatiti necrosis:
- Acute necrotic collections (ANC) can be either parenchymal, peripancreatic or a combination of both.
- collections can be sterile or infected.
The double duct sign refers to the presence of simultaneous dilatation of the common bile and pancreatic ducts. Being an anatomical sign it can be seen on all modalities that can visualise the region, including: MRI, CT, ultrasound and endoscopic retrograde cholangiopancreatography (ERCP).
The two most common causes of the double duct sign are carcinoma of the head of the pancreas and ampullary tumours (e.g. carcinoma of the ampulla of Vater), although occasionally an impacted gallstone in the distal duct, with associated oedema, can also result in obstruction of the pancreatic duct.
Describe Pancreatic ductal Adenocarcinoma
- AKA PDAC
- Poor prognosis
- 1 year mean survival rate 8%
- 65% are over 60 years
- Clinical findings
- jaundice
- weight loss
- Courvoisier sign
- enlarged nontender GB 25%
- Distended gall bladder and biliary tree down to the distal end where there is a small (3 cm) pancreatic head mass. Note also pancreatic duct enlargement.
Case Discussion
Courvoisier sign states that in the presence of an enlarged gallbladder which is non-tender and accompanied by jaundice, the cause is unlikely to be gallstones and suspicious for pancreatic/periampullary malignant mass obstructing distal CBD. Here we have the CT and US correlates.
It is usually used to describe the physical examination finding of a painless right-upper quadrant mass in the abdomen in a jaundiced patient.
Hemorrage and pancreatitis
when and why does it occur?
- usually occurs as a late consequence of vascular injury
- Aeitiology
- may result from rupture of pseudoaneurysm
- erosion into splenic or pancreaticoduodenal artery
- rupture of psudocyst
- Haemorrhagic pancreatitis
Last revised by Dr Jeremy Jones◉ on 20 Sep 2021
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Citation, DOI and article data
Haemorrhagic pancreatitis is characterised by bleeding within or around the pancreas, and is usually considered a late sequela of acute pancreatitis.
Pathology
Haemorrhage can occur in patients with severe necrotising pancreatitis or as a result of pancreatic pseudoaneurysm rupture when it constitutes a life-threatening emergency.
Aetiology
According to one study, the usual causes of haemorrhage were 2:
bleeding pancreatic pseudoaneurysm or peripancreatic pseudoaneurysm: ~60%
diffuse bleeding with pancreatic necrosis: ~20%
haemorrhagic pancreatic pseudocysts: ~20%
Radiographic features
CT
Acute haemorrhage typically has high attenuation on unenhanced CT scans. The attenuation value then decreases as the haematoma ages through time 5.
MRI
Haemorrhagic fluid collections are more evident on MRI than CT due to the following reasons 1:
T1: high-signal intensity methaemoglobin
T2: low-signal intensity haemosiderin rim
Signal abnormalities due to haemorrhage remain visible longer on MRI than on CT.
Unenhanced MRI of abdomen demonstrates high T1/ low T2 signal in the body of pancreas, as well as within a large peripancreatic collection.
T1FS demonstrates markedly high signal in body/tail of pancreas from haemorrhage, with decreased signal in remaining head and distal tail.
T2FS demonstrates oedema in head and tail of pancreas as well as retroperitoneum, with decreased T2 signal corresponding to the haemorrhagic area.
Axe and Cor T2 demonstrates oedema in head and tail of pancreas as well as retroperitoneum, with decreased T2 signal corresponding to the haemorrhagic area. Large collection displaces stomach anteriorly.
Delayed complications of Pancreatic Trauma
what is this?
- Pancreatic fistula 10-20% (gastropancreatic fistula in picture)
- Abscess 10-20%
- Pancreatitis
- Pseudocyst
What is the definition of this process?
- Fulid collection >4 weeks after necrotizing pancreatitis
- collections can be sterile or infected
Walled-off pancreatic necrosis
Last revised by Dr Jeremy Jones◉ on 20 Sep 2021
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Citation, DOI and article data
Walled-off pancreatic necrosis (WOPN) is a late complication of acute pancreatitis, although it can occur in chronic pancreatitis or as a result of pancreatic trauma. Differentiation of WOPN from pancreatic pseudocyst is essential because management differs. WOPN may need aggressive treatment to avoid complications.
WOPN usually occurs four weeks after the episode of acute pancreatitis. Before this time, it is referred to as an acute necrotic collection (ANC).
Terminology
The following are the latest terms according to the updated Atlanta classification to describe fluid collections associated with acute pancreatitis 10,11:
fluid collections associated with interstitial oedematous pancreatitis (i.e. minimal or no necrosis)
acute peripancreatic fluid collections (APFC): in the first 4 weeks: non-encapsulated peripancreatic fluid collections
pseudocysts: develop after 4 weeks; encapsulated peripancreatic or remote fluid collections
fluid collections associated with necrotising pancreatitis
acute necrotic collections (ANCs): in the first 4 weeks; non-encapsulated heterogeneous non-liquefied material
walled-off necrosis (WON or WOPN): develop after 4 weeks; encapsulated heterogeneous non-liquefied material
Clinical presentation
The walled-off collection may cause mass effect (e.g. against the biliary system, causing upstream dilatation). It may also become infected.
Pathology
WOPN consists of necrosis and subsequent liquefaction of pancreatic and/or peripancreatic tissue. It may be intrapancreatic or parapancreatic.
Radiographic features
A history of pancreatitis is necessary to exclude a complex cystic neoplasm. One should remember that an obstructing adenocarcinoma can cause pancreatitis, and if this is a concern, follow-up imaging (3-6 months) after the resolution of pancreatitis would be useful to exclude a mass.
CT
cystic lesion within or around the pancreas with an area of heterogeneous attenuation non-enhancing (necrotic) tissue, surrounded by a wall 3
remember to look for other sequelae of pancreatitis (e.g. pseudoaneurysm)
MRI
MRI is superior to CT in differentiating WOPN from pseudocyst, given its ability to depict the internal necrotic debris that favours the WOPN.
Treatment and prognosis
The mortality rate with WOPN is high but less than infected pancreatic necrosis. Management depends on the patient’s symptoms and the location of the WOPN. Since 40% of walled-off pancreatic fluid collections (including pseudocysts) resolve spontaneously 4, and ~10% of patients develop complications, conservative treatment may appropriate in some asymptomatic patients 5.
Symptomatic patients should have WOPNs drained. Percutaneous catheter drainage and endoscopic retrograde cholangiopancreatography (ERCP) drainage (+/- necrosectomy) have been used to treat the walled-off necrosis. These techniques are replacing surgical drainage 1,2.
Because of the necrotic debris, WOPN usually requires a wide-bore drainage catheter as compared to the small calibre catheters that can be used to drain a pseudocyst 3.
History and etymology
The term “walled-off pancreatic necrosis” was used by Connor et al. in 2005 2.
What are the percutaneous therapies for Pancreatitis?
- Needle aspiration
- may be performed on any fluid collection, necrotic tissue or hemorrhage to determine if infected
- psuedocysts <5cm should be monitored rather than aspirated bc pseudocusts commonly resolve spontaenous
- aspiration risks superinfection 10%
- Percut drainage
- fluid collections are amenable to drainage if there is clinical suspicious of infection.
- success rate 70%
- pseudocysts >5cm are good candidates for drainage
- Pecutaenous and endoscopically placed catheters are now more routinely being used to drain ANC and walled off necrosis
- Surgery is still preferred for infected pancreatic necrosis
- If the pt is not stable enough for surgery percut drainage is an option.
Heterotopic Pancreas
Heterotopic Pancreas
- Abnormally located pancreatic tissue with its own ductal system and no vascular, neural or anatomic contact with the normal pancreas
- Most common heterotopia in the GIT
- Usually asymptomatic
- Most common locations
- duodenum 30%
- Stomach 25%
- usually submucosal in location
- prepyloric region along greater curvature in 90%
- Jejunum 15%
- less common locations
- Meckel
- ileum
- GB
- Fallopian tubes
- umbilicus
- esophagus
- spleen
- mediatmediastinumum
Clinical Findings of Acute Pancreatitis
- Mild
- pain
- vomiting
- tenderness
- severe
- shock
- pulmonary insufficiency
- renal failure
- GIT hemorrhage
- metabolic abnormalities
- flank ecchymosis
- grey turner sign
- periumbiliacl ecchymosisi
- cullen sign
- the severity of acute pancratitis can be assessed using Ranson or PACHE II critteria
Classifications of Pancreatitis
- Classificaiotn
- Acute pancreatitis
- mild
- interstitial edema
- Severe
- necrosis
- fluid collections
- Groove pancreatitis
- inflammation localized to groove between the duodenum and pancreatic head
- mild
- Chronic Pancreatitis
- Acute pancreatitis
what is this?
- Glucagonoma
- 4 D syndrome
- Diahorra
- Diabetes
- Depression
- Dermatitis
- DVT
- Glossitis
- necrolytic eythema migrans
- 4 D syndrome
- 80% malignant potential
Glucagonomas are pancreatic endocrine tumours that secrete glucagon. Most lesions are malignant.
Epidemiology
They are very rare with an incidence of ~0.000005% or less than 1 case per 20 million. Equal incidence in middle-aged men and women.
Accounts for 1% of all the neuroendocrine tumours and less than 5% of all primary pancreatic malignancies 2.
Clinical presentation
Most patients present with a necrolytic migratory rash and various other elements of the 4D syndrome which includes:
- dermatitis / necrotising migratory erythema
- diabetes mellitus
- deep vein thrombosis
- depression
Stomatitis, diarrhoea, anaemia, and weight loss may also occur.
Plasma level of glucagon is elevated (>500 pg/mL).
Radiographic features
Tumour size is variable, but most are large (>5 cm) and have metastasised at the time of diagnosis. Most are located in the distal pancreas and tend to demostrate significant hypervascularity.
Tumours may be solid or contain central low-attenuation areas on CT.
The MR features of these lesions have not yet been reported.
Treatment and prognosis
Standard treatment is surgical resection, depending on its location the approach can be divided into local resection, pancreactic body and tail resection and pancreatoduodenectomy.
Approximately 50% of patients survive for at least 5 years post-diagnosis.
What is an Insulinoma?
which cells do they arise from?
- Most common Functional Pancreatic endocrine tumour
- single 70%
- Multiple 10%
- diffuse hyperplasia/extrapancreatic 10%
- Malignant transformation 10%
- <2cm (90%)
- Hypervascular 70%
- Symptoms
- hypoglycaemia
- Pathology
They develop from ductal pluripotent cells into unregulated cells secreting insulin. The beta cells of the islets of Langerhans normally secrete insulin. Approximately 10% of insulinomas are multiple and 10% malignant.
- Clinical presentation
Typically insulinomas present with Whipple’s triad consisting of:
fasting hypoglycaemia (<50 mg/dL)
symptoms of hypoglycaemia (due to subsequent catecholamine release)
immediate relief of symptoms after the administration of IV glucose
As with other endocrine tumours of the pancreas, there is an association with multiple endocrine neoplasia type I (MEN I).
Imaging features of CF and the pancreas
- Pancreatic tissue largely nonexistent
- often total fatty replacement is seen
- endstage disease: pancreatic insufficiency
- Imaging features
- US
- increased echogenicity (fatty replacement)
- small cysts are rarely visulaised although that are very common (1-3mm)
- large cysts (<5mm) have been reported but are uncommon
- CT
- pancreatic tissue totally missing. May see duct
- SB may be dilated with fecal appearing contents
- Fibrosing colonopathy. Wall thickening is the predominant proximal colon complications of enzyme replacement tx.
- US
What is a secretin stimulation test?
What is it used for?
- Secretin is given IV and the pancreatic and CBD sizes are measures before and every minute after administration for 15minutes. Secretin increases the volume and bicarbonate contentof secreated pancreatic juice
- Changes in duct diameter in normal volunteers
- baseline duct size 1.9mm (1-3mm)
- 70-100% increase in duct size is normal.
- Return to baseline duct size within 10 minutes
- Chronic Pancreatitis
- No significant change in PD size
- Functional ductal obstruction
- PD remains dilated 10 min after administration of secretin.
What is a somatostinoma?
- Suppression of insulin
- Thyroid stimulating hormone
- Growth Hormone secretion (hyperglycaemia
- 90% malignant transformation
- The presentation can be variable. Patients with functional somatostatinoma may present with an “inhibitory syndrome” which is a triad of mild diabetes mellitus, cholelithiasis, and diarrhoea/steatorrhoea. Other lesions can present with obstructive pancreatitis.
History and Physical
Non-functional tumors are frequently asymptomatic. Later in the course of the disease, they may present with abdominal pain, vomiting, jaundice, and steatorrhea due to the mechanical effects of the tumor on the biliary and pancreatic drainage.[11] Functional tumors present with the inhibitory effects of somatostatin on the neuroendocrine system. Cholelithiasis is present in almost 70%, and diabetes mellitus in 60% of symptomatic cases.[4] Rarely, they manifest as a triad of diabetes mellitus, cholelithiasis, and steatorrhea, referred to as inhibitory syndrome due to the suppression of insulin, cholecystokinin, and pancreatic exocrine enzymes, respectively.[5][6] The physical examination might reveal icterus in the patients presenting with obstructive jaundice, abdominal tenderness in acute cholecystitis, and neurocutaneous markers such as cafe au lait spots, neurofibromas, and axillary freckling in patients with concomitant NF1.
Go to:
https://www.researchgate.net/figure/Somatostatinoma-in-a-39-year-old-man-with-abdominal-pain-and-cholelithiasis-a-Axial_fig4_47755312
Somatostatinoma in a 39-year-old man with abdominal pain and cholelithiasis. (a) Axial contrast-enhanced CT image shows a well-defined mass in the pancreatic tail that demonstrates heterogeneous hyperenhancement. (b) Axial T1-weighted MR image shows the homogeneous mass, which demonstrates low signal intensity relative to the normal high signal intensity of the pancreas. (c) Axial T2-weighted fat-suppressed MR image shows the pancreatic mass, which demonstrates characteristic high signal intensity. (d) Axial contrast-enhanced T1-weighted fat-suppressed MR image obtained in the arterial phase shows the mass, which demonstrates heterogeneous hyperenhancement.
Somatostatinomas are a rare type of neuroendocrine tumour.
Epidemiology
They form up to ~1% of all gastroenteropancreatic endocrine neoplasms.
Associations
multiple endocrine neoplasia type I 2
von Hippel Lindau syndrome 2
duodenal somatostatinoma: neurofibromatosis type I 1
Clinical presentation
The presentation can be variable. Patients with functional somatostatinoma may present with an “inhibitory syndrome” which is a triad of mild diabetes mellitus, cholelithiasis, and diarrhoea/steatorrhoea. Other lesions can present with obstructive pancreatitis.
Pathology
They typically occur in the pancreas but can also manifest in extrapancreatic organs (e.g. duodenum and ampulla of Vater) and can result in chronic obstructive pancreatitis.
Biochemistry
They may be functional (i.e patients have high fasting somatostatin levels) or non-functional. Functional somatostatinomas can release excessive amounts of somatostatin 2.
Radiographic features
As they share the radiographic features of other pancreatic endocrine tumours, please refer to this parenting article for a detailed discussion regarding these features.
What is a VIPoma?
- Vasoactive intestinal Peptide
- WDHA syndrome
- 60% malignant trasformation
CT of the abdomen and pelvis without contrast was significant for multiple ill-defined, hypodense liver lesions. There was also a hypodense, cystic lesion in the tail of the pancreas measuring 1.0 cm.
On arterial phase imaging, again seen are multiple, non-specific, hypodense liver lesions. The lesion in the tail of the pancreas shows subtle peripheral enhancement.
Venous phase imaging again demonstrates the hypodense lesion in the pancreatic tail, now with peripheral enhancement.
Case Discussion
Initial workup was negative for viral, bacterial, parasitic, inflammatory, osmotic, and malabsorptive aetiologies of diarrhoea.
Patient’s laboratory workup was significant for electrolyte disturbances including hypokalaemia, hyponatraemia (K 2.6, Na 127) and Vasoactive Intestinal Peptide (VIP) of 1930 (normal 0-60).
The patient underwent an ultrasound guided liver biopsy of a liver lesion seen on CT. Pathology results from patient’s liver biopsy showed metastatic neuroendocrine cells in the liver representing a tumour arising from the endocrine pancreas (VIPoma).
VIPomas are a very rare type of pancreatic endocrine tumours that secrete, and get their name from, vasoactive intestinal peptide (VIP). The clinical syndrome resulting from these tumours is commonly known as WDHA syndrome, as an acronym of the cardinal symptoms of watery diarrhoea, hypokalaemia, and achlorhydria.
Epidemiology
VIPomas represent <2% of pancreatic endocrine tumours 2. There are two epidemiological peaks in the diagnosis of these tumours, one peak in middle-age adults and another peak in children aged between two and four years 1.
Clinical presentation
Patients present with the classic clinical triad of 1:
watery diarrhoea that persists with fasting
hypokalaemia
achlorhydria or hypochlorhydria
https://radiopaedia.org/cases/vipoma
Describe a Pancreatic Transplant
what are the complications?
- pancreas attached to bladder or jejunum by duodenal interposition
- stent may be in place
- Complications
- rejection 35%
- pancreatitis 35%
- peripancreatic abscess 35%
- perpancreatic hemorrhage 35%
- vascular thrombosis 20%
- Pancreas transplantation aims to restore physiologic normoglycemia in diabetic patients with glomerulopathy and avoid or delay the onset of diabetic retinopathy and arteriopathy. Simultaneous pancreas-kidney transplant is the most common approach, using a cadaveric pancreas donation in conjunction with either cadaveric or live donor renal transplant. Alternative techniques include pancreas after kidney transplant, in which the pancreas transplant is performed some years after renal transplant. Pancreas transplant alone is utilized rarely in diabetic patients with compensated renal function. Pancreas grafts have vascular and enteric connections that vary in their anatomic approach, and understanding of this is critical for imaging with ultrasonography, computed tomography, or magnetic resonance imaging. Imaging techniques are directed to display the pancreatic transplant arterial and venous vasculature, parenchyma, and intestinal drainage pathway. Critical vascular information includes venous thrombosis (partial or complete), arterial occlusion, or aneurysm. Parenchymal abnormalities are nonspecific and occur in pancreatitis, graft rejection, and subsequent graft ischemia. Peripancreatic fluid collections include hematoma/seroma, pseudocyst, and abscess. The latter two are related to pancreatitis, duct disruption, or leak from the duodenojejunostomy. An understanding of transplant anatomy and complications will lead to appropriate use of imaging techniques to diagnose or exclude important complications.
What are the 2 forms of this?
- groove pancreatitis
- Pancreatitis involving the pancareatic groove which is a potential space between head of pancreas, duodenum and the CBD
- Two forms
- segmental
- involves the pancreatic head with development of scar tissue in the groove
- Pure form
- affects groove only sparing pancreatic head
- segmental
Case Discussion
This uncommon form of chronic pancreatitis can mimic pancreatic carcinoma. The potential space between the pancreatic head, the common bile duct and the duodenum is referred to as the pancreaticoduodenal groove.
In this case, the overall impression was that of improving paraduodenal pancreatitis. On follow-up CT there was no evidence of a mass, but the pancreatic head remained heterogenous in appearance.
https://radiopaedia.org/cases/paraduodenal-pancreatitis
What are the complicaitons of a pancreatoduodenectomy?
- Delayed gastric emptying
- persistent need for an NG tube for longer than 10 days and is seen in 11-29% of pts
- Pancreatic Fistula
- surgical drain output of amylase rich fluid >5ml/day or beyond 7-10 days
- wound infection
- hemorrhage
- can occur if replaced right HA is severed
- Pancreatitis
- Abscess formation
- Biliary complications
- Biloma
causes of this condition?
- progressive, irreversible destruction of pancreatic parenchyma by repeated episodes of mild or subclinical pancreatitis
- Causes
- etoh
- hyperparathyroidism
- hyperlipidaemia
- hereditary
CT features of Pancreatic trauma
- CT
- fragmentation of the gland
- pancreatic hematoma
- non-enhancing regions
- peripancreatic stranding
- exudate
- Intraoperative pancreatography
- should be performed to evaluate integrity of PD. Injury to the duct requires different surgery
- Picture:
- pancreatic Avulsion
Diagnosis?
- Pseudocyst
- encapsulated collection of pancraetic fluid which is typically round or oval
- The capsule is usually indistinguishable but may occasionally be identified.
- caused by micro-perforation of the PD such a communication can be identified by ERCP in 50% of patients
- Defined by the presence of fluid collection > 4 weeks after an episode of interstitial edematous pancreatitis
- can either be sterile or infected
- The only definitive criteria on imaging for infection is the presence of air
- occurs in 40% of pts with Acute pancreatitis and 30% of pts with chronic pancreatitis
- Prognosis
- 50% resolve spontaneously and are not clinically significant
- 20% are stable and
- 30% cause complications
- dissection into adjacent organs: liver spleen, kidney, stomach
- hemorrhage (erosion into vessel, thrombosis, pseudoaneurysm)
- Peritonitis: rupture into the peritoneal cavity
- Obsteciton of duodenum, bile ducts (jaundice, cholangitis)
- infeciton
Clinical manifestations of Groove pancreatitis
- Clinical manifestations related to duodenal and bniliary obstrcuition
- biliary strictures in 50%
- Factors related to development of Groove pancreatitis
- PUD
- gastric resection
- true duodenal wall cysts
- pancreatic heterotopia
- distrubance in flow of main pancreatic duct
Describe the variants of Pancreas duct anatomy
- Type 1: Normal anatomy 85%
- Type 2: separate duodenal openings for PD and CBD (5%)
- Type 3: Pancreatic divism. Lack of fusion of the dorsal and ventral PD. Occurs in 10% of the population. The main pancreatic drainage is thru the minor papilla. Up to 25% of pts with recurrent idiopathic pancreatitis have divism.
- orifice of the duct of. santorini is relatively too small to handle secreations.
- ERCP: cannulisation of the major pailla only allows visulasion of the ventral duct.
what are non-functioning islet cell tumours?
- Most common in the pancreatic head
- 80-90% malignant transformation
- 5ys 45%
- Usually large >5cm and cause symptoms via mass effect
- jaundice
- palpable
- Calcification 20%
- hypervascular at angiography
- Liver mets enhance brightly on CT
- less aggressive than adenocarcinoma
- BEtter response to chemo
What are the imaging features of this disease?
increased risk of what?
Tropical Pancreatitis
- Large pancreatic calculi within dilated PD
- up to 5cm in size
- may extend into side branches
- incontrast, calcuili in alcoholic related chronic pancreatitis are small and speckled
- parenchymal atrophy
- 15-25 fold increased risk of pancreatic adenocarcinoma
