Pancreas

Question 1

Which is the most typical finding of serous cystadenoma of the pancreas?

A. Numerous sub centimetre cysts forming a homogenous pattern

B. Multiple cysts < 2cm separated by a fibrous septa coalescing into a central scar

C. A few large cysts > 2cm with septae in the head of the pancreas

D. Multicystictumour larger than 10cm

E. Hypervascular solid tumour

Answer 1

B. Multiple cysts < 2cm separated by a fibrous septa coalescing into a central scar

In serous cystadenoma of the pancreas, the polycystic pattern with cysts < 2cm represents 70% of cases.

The honeycomb pattern occurs in 20% and macro/oligocytic type in 10%.

Giant subcutaneous serous cystic change with intraluminal haemorrhage and solid serous cystadenoma are atypical manifestations.

Question 2

A 40-year-old with a Multiple Endocrine Neoplasia (MEN) syndrome has parathyroid hyperplasia with hyperparathyroidism recently diagnosed. Which of the following is a feature of MEN II rather than MEN I?

A. Pancreatic islet cell tumour

B. Pituitary gland tumour

C. Adenocortical adenoma

D. Carcinoid tumour

E. Phaeochromocytoma

Answer 2

E. Phaeochromocytoma

Features of MEN2A include parathyroid hyperplasia, medullary T cell carcinoma of the thyroid, and phaeochromocytoma. MEN2A may also be associated with carcinoid and Cushing’s.

Question 3

@# Which is the most likely source of a metastatic deposit to the pancreas?

A. Bronchogenic carcinoma

B. Breast cancer

C. Renal Cell Carcinoma (RCC)

D. Soft tissue sarcoma

E. Colon carcinoma

Answer 3

C. Renal Cell Carcinoma (RCC)

The most likely primary tumor leading to a metastatic deposit to the pancreas is renal cell carcinoma. These metastases are usually solitary and heterogeneously enhancing masses with increased attenuation relative to the pancreas.

Question 4

Which of the following favour a diagnosis of glucagonoma rather than somatostatinoma?

A. Arrange size > 4cm

B. Hypervascular

C. Duodenal obstruction

D. Predilection for body/tail of pancreas

E. Association with Neurofibromatosis Type 1 (NFI)

Answer 4

D. Predilection for body/tail of pancreas

Glucagonomas are predominantly in pancreatic body/tail, mean size 6.4 cm and hypervascular. Somatostatinomas are predominantly in pancreatic head/duodenum of ampulla of Vater.

Question 5

A 35-year-old woman presents with severe watery diarrhoea. She is hypokalaemic. A neuroendocrine tumour is diagnosed in the pancreatic body measuring 5cm. This is mildly hypervascular. Which of the following is the most likely diagnosis?

A. Somatostatinoma

B. Non functional islet cell tumour

C. Glucagonoma

D. VIPoma (Verner Morrison Syndrome)

E. Gastrinoma

Answer 5

D. VIPoma (Verner Morrison Syndrome)

VIPOMA are usually in the pancreatic body/tail (75%).

Extrapancreatic locations include retroperitoneal ganglioblastoma, phaeochromocytoma, lung, neuroblastoma (in children).

50-80% of VIPOMAs undergo malignant transformation.

Question 6

Which of the following most favours a diagnosis of an infected rather than a sterile post-necrotic fluid collection, following acute pancreatitis?

A. Presence of gas bubbles

B. Size of collection > 5cm

C. Association with extrapancreatic necrosis

D. Association with organised pancreatic necrosis

E. Association with central gland necrosis

Answer 6

A. Presence of gas bubbles

The only reliable feature on imaging indicating an infected collection is the presence of gas bubbles.

All three types of pancreatic necrosis, organised central gland and extrapancreatic are associated with post-necrotic fluid collection.

Necrotic pancreatitis becomes infected in 40-70%, most often with gram negative enteric bacteria.

Question 7

Regarding intraductal papillary mucinous tumours (IPMT):

A. Is more common in females than mucinous cystic tumours

B. Has a higher incidence of malignancy in branch than main ducts

C. Focal wall thickening indicates malignancy with very high sensitivity and specificity

D. Parietal nodules indicate malignancy with very high sensitivity and specificity

E. Can range from hypoplasia to invasive carcinoma

Answer 7

E. Can range from hypoplasia to invasive carcinoma

Parietal nodules and focal wall thickening are useful indicators in detecting malignant branch IPMT but there is a high incidence of false positive errors. IPMT has a slightly higher incidence in males.

Question 8

1. A 65-year-old woman undergoes CT of the abdomen. An incidental finding of a well-defined 5 cm mass in the head of the pancreas is noted. It has a mean attenuation value of 5 HU, and contains multiple tiny cysts with a central nidus of calcification. There is no pancreatic duct dilatation. What is the most likely diagnosis?

A. mucinous cystadenoma

B. main duct intraductal papillary mucinous tumour

C. serous cystadenoma

D. pancreatic pseudocyst

E. pancreatic insulinoma

Answer 8

C. serous cystadenoma

Serous cystadenomas are benign neoplasia of the pancreas most commonly seen in older women and are frequently asymptomatic.

Typical appearances are of a cystic lesion measuring up to 20 cm in size, containing innumerable small cysts, though these may be difficult to discriminate, giving the appearance of a solid mass.

They may occur in any part of the pancreas but are slightly more common in the pancreatic head and neck.

Characteristic features include a central stellate scar containing dystrophic calcification.

Mucinous cystadenomas usually occur in the pancreatic tail (90%) and, when multilocular, contain larger cysts of >2 cm in diameter.

Pancreatic pseudocysts are usually unilocular and occur following a history of pancreatitis.

Intraductal papillary mucinous tumours of the main duct are typically associated with dilatation of the main pancreatic duct.

Insulinomas are usually small (<2 cm) solid tumours that produce symptoms early due to recurrent hypoglycaemia.

Question 9

2. A 50-year-old woman presents with recurrent episodes of hypoglycaemia. Biochemistry confirms endogenous insulin hypersecretion, and she undergoes multiphasic CT of the abdomen. Which of the following is the most likely finding in the pancreas?

A. 1.5 cm arterially enhancing, solid mass in the head

B. 5 cm arterially enhancing, cystic mass in the tail

C. 1.5 cm arterially enhancing, cystic mass in the body

D. 1.5 cm non-enhancing, solid mass in the tail

E. 5 cm non-enhancing, cystic mass in the body

Answer 9

A. 1.5 cm arterially enhancing, solid mass in the head

Insulinomas are rare tumours of the islet cells of the pancreas, which present at an early stage with hypoglycaemic episodes.

Diagnosis is made biochemically, by demonstrating fasting hyperinsulinaemia, and the main purpose of imaging is to detect and localize accurately the tumours, which tend to be small (<2 cm) at presentation.

Tumours may occur anywhere in the pancreas, with 2–5% in an ectopic location.

CT is considered the first-line investigation, but newer techniques such as MR and functional imaging are being increasingly used.

On CT, insulinomas are typically solid and highly vascular, and are best visualized on arterial-phase imaging, when they demonstrate marked enhancement.

Question 10

@# 3. A 64-year-old woman presents to the dermatologist with erythematous maculopapular lesions on her legs, buttocks and face, and is diagnosed with necrolytic migratory erythema. Which initial imaging investigation is most appropriate?

A. no imaging

B. mammography

C. CT of the brain

D. chest radiograph

E. CT of the abdomen

Answer 10

E. CT of the abdomen

Necrolytic migratory erythema is a rare dermatological condition with a strong association with glucagonoma, an islet-cell tumour of the pancreas derived from alpha cells. Over 70% of patients with glucagonoma demonstrate the condition, and they may also complain of weight loss, diarrhoea and diabetes. The association is considered strong enough to warrant thorough investigation for pancreatic malignancy. Glucagonomas typically occur in the pancreatic body or tail, and are large (2.5– 25 cm) Hypervascular tumours with solid and necrotic components. They have a high rate of malignant transformation, and around 50% of patients have liver metastases at the time of diagnosis

Question 11

4. A 58-year-old man with recurrent episodes of upper abdominal pain undergoes MRCP, which demonstrates pancreatic atrophy and marked dilatation of the main pancreatic duct, which contains high T2-signal material. A low T2-signal nodular filling defect is also identified within the dilated duct. ERCP demonstrates thick mucus protruding from a bulging papilla. What is the most likely diagnosis?

A. intraductal papillary mucinous tumour

B. chronic pancreatitis

C. mucinous cystadenoma

D. pancreatic pseudocyst

E. acute pancreatitis

Answer 11

A. intraductal papillary mucinous tumour

Intraductal papillary mucinous tumour (IPMT) of the pancreas is characterized by a mucin-producing tumour with dilatation of the main or branch ducts of the pancreas due to copious secretions. They may arise in the main duct or branch duct. Main duct tumours typically cause dilatation of all or part of the duct, which is filled with mucinous secretions, appearing hyperintense on T2W images. A T2-hypointense intraductal filling defect may be identified, which may represent the tumour or concretions of mucin. Chronic pancreatitis may result in parenchymal atrophy and duct dilatation, with intraductal filling defects due to calculi or debris, but a bulging papilla at ERCP makes IPMT more likely. The branch duct type usually consists of conglomerated communicating cysts or a unilocular cyst in the uncinate process; these appearances may be mimicked by mucinous cystadenoma and pancreatic pseudocyst.

Question 12

5. A 67-year-old man undergoes Whipple’s procedure for adenocarcinoma of the head of the pancreas. Which finding is of most concern on CT of the abdomen performed 4 days postoperatively for persistent pyrexia?

A. free intraperitoneal gas

B. aerobilia in the left intrahepatic ducts

C. oral contrast within the afferent jejunal loop

D. small thin-walled fluid collection in Morison’s pouch

E. gas-containing fluid collection in the pancreatic bed

Answer 12

E. gas-containing fluid collection in the pancreatic bed

The two main indications for Whipple’s procedure (radical pancreaticoduodenectomy) are tumour in the periampullary region, and chronic pancreatitis involving the head and uncinate process of the pancreas.

Surgery is complex and involves gastrojejunostomy, pancreaticoenterostomy and choledochojejunostomy.

Common post-operative findings include retroperitoneal fat stranding and transient, thin-walled fluid collections, which may be in the pancreatic bed, perianastomotic or in Morison’s pouch.

Free gas is common and aerobilia is seen in around 70% of cases, more commonly in the left intrahepatic ducts.

Filling of the afferent jejunal loop with contrast is normal and occurs in up to 44% of patients.

The commonest complications are delayed gastric emptying, pancreaticojejunal leak and sepsis.

Anastomotic failure can occur at any of the sites, but the pancreaticoenterostomy is most important because of the risk of leakage of pancreatic secretions.

Anastomotic leak is associated with increased free gas, perianastomotic fluid and ascites.

Focal septic collections can occur anywhere, and complex or gas-containing areas are considered suspicious. Other early complications include vascular injury and thrombosis, Clostridium difficile colitis and pancreatitis of the pancreatic remnant.

Question 13

A 42-year-old man presents with severe central abdominal pain and a raised serum amylase. 4 days later, extremely ill, the patient undergoes a CT of the abdomen which demonstrates that only the head and uncinate process of the pancreas are enhancing and there is extensive free fluid in the peri-pancreatic tissues. How you interpret these findings?

(a) Acute pancreatitis

(b) Acute pancreatitis with necrosis

(c) Acute pancreatitis infected necrosis

(d) Acute pancreatitis with abscess

(e) Acute pancreatitis with pseudocyst formation

Answer 13

(b) Acute pancreatitis with necrosis

The clinical scenario and imaging features clearly indicate acute pancreatitis. Areas of non-enhancement >3 cm, or > 30% of the pancreatic volume are considered reliable CT signs for necrosis. Imaging too early in clinical course will reduce the sensitivity of CT for evaluating pancreatic necrosis. Sepsis tends to complicate severe pancreatitis after first 1-2 weeks, peaking at 3 weeks, and is a common cause of mortality in these patients. A discrete abscess is less common but is suggested by the development of air within a collection. Pseudocysts are common sequelae of acute pancreatitis but take at least 4 weeks to form.

Question 14

An 18-year-old male patient with known von Hippel Lindau disease is referred for abdominal imaging. Which of the following conditions would you not expect to see in association with this disease?

(a) Pheochromocytoma

(b) Serous cystadenoma of the pancreas

(c) Neuroendocrine pancreatic tumour

(d) Pancreatic cysts

(e) Adrenocortical carcinoma

Answer 14

(e) Adrenocortical carcinoma

There are a number of abdominal manifestations in addition to these including renal cysts and renal cell carcinoma. Epidydimal papillary cystadenoma may be seen on scrotal US in male patients.

Question 15

A 46-year-old man presents with abdominal pain, fever and vomiting 5 weeks after am episode of acute pancreatitis. A CT study shows a well-circumscribed collection adjacent to the pancreas with an enhancing rim. What is the most likely diagnosis?

(a) Pseudo cyst

(b) Pancreatic abscess

(c) infective necrosis

(d) Acute pancreatitis

(e) Chronic pancreatitis

Answer 15

(b) Pancreatic abscess

A pancreatic abscess complicates 3%of cases of acute pancreatitis and is due to infection within a fluid collection such as a pseudocyst. Such abscesses may be found anywhere within the abdomen or pelvis and require percutaneous drainage. .

Question 16

Which of the following is true of insulinomas?

(a) Men are affected twice as often as women

(b) Multiple lesions are seen in 25% cases

(c) They account for 25% Of pancreatic endocrine tumours

(d) They are associated with MEN-I syndrome

(e) Approximately 25% cases are malignant

Answer 16

(d) They are associated with MEN-I syndrome

Endocrine tumours account for 1 -2% Of all pancreatic tumours and insulinoma is the most common of these, representing 60% of cases. Approximately 5-10% are malignant; these tend to be the larger lesions (>5 cm). However, most lesions are less than 1.5 cm at presentation and only 5-10% cases have multiple lesions.

Question 17

@# A patient with a 4-month history of severe upper abdominal pain undergoes an endoscopic US. This reports a combination of echogenic and echo-poor foci throughout the pancreas, an irregular contour of the pancreatic duct and thickening of the duct wall with some side duct dilatation. What is the most likely diagnosis?

(a) Autoimmune pancreatitis

(b) Pancreatic adenocarcinoma

(c) Intraductal papillary mucinous tumour

(d) von Hippel Linda u syndrome

(e) Chronic pancreatitis

Answer 17

(e) Chronic pancreatitis

These are the typical findings of chronic pancreatitis at endoscopic ultrasound.

Question 18

@# Which of the following is associated with an increased risk of developing pancreatic adenocarcinoma?

(a) Hereditary pancreatitis

(b) High alcohol consumption

(c) High coffee consumption

(d) Low fiber diet

(e) Type-I diabetes mellitus

Answer 18

(a) Hereditary pancreatitis

There is a 70-foId increase in pancreatic adenocarcinoma in this condition. Dietary factors play no role, but cigarette smoking is associated. Diabetes mellitus may be a presenting feature, but is not associated with an increased risk Of malignancy.

Question 18

A 58-year-old lady undergoes a CT of the abdomen and pelvis identifies a 4 cm cyst within the pancreas. Endoscopic US-FNA shows a unilocular cyst and yields fluid with high amylase and lipase but low CEA antigen levels. What is the diagnosis?

(a) Serous cystadenoma

(b) Mucinous cystadenoma

(c) Intraductal papillary mucinous neoplasm

(d) Mucinous cystadenocarcinoma

(e) Pseudocyst

Answer 18

(e) Pseudocyst

These are typical findings; there may or may not be a clear history of pancreatitis. An elevated CEA > 200 ng/ml is an indicator of malignancy.

Question 19

A 51-year-old lady with recurrent episodes of central abdominal pain undergoes a CT study. This is reported to diffuse enlargement of the pancreas with a peripancreatic ‘halo’. What is the most likely diagnosis?

(a) Intraductal papillary mucinous neoplasm

(b) Autoimmune pancreatitis

(c) Chronic pancreatitis

(d) Primary pancreatic lymphoma

(e) Acute pancreatitis

Answer 19

(b) Autoimmune pancreatitis

This is a typical clinical presentation and characteristic imaging finding. The diagnosis needs to be confirmed histopathologically and then treated with corticosteroids, unlike other forms of pancreatitis. Relapse is well documented. Patients may progress to develop biliary complications, atrophy and chronic symptoms.

Question 20

39 A 28-year-old patient is referred to the radiology department for abdominal imaging following extensive neck surgery to remove a medullary thyroid cancer and hyperplastic parathyroid glands. What, in particular, would you look for in this patient?

(a) Pancreatic islet cell tumour

(b) Gastrointestinal stromal tumour

(c) Adrenal cortical tumour

(d) Gastrointestinal ganglioneuroma

(e) Adrenal medullary tumour

Answer 20

(e) Adrenal medullary tumour

The patient has 2/3 components of MEN Type IIA adrenal medullary tumour being the 3rd component. NEN Type I comprises parathyroid adenoma/hyperplasia, pancreatic islet cell tumours and pituitary adenoma. NEN Type IIB comprises medullary thyroid carcinoma, adrenal medullary tumour and a variety of mucosal and cutaneous neurogenic lesions.

Question 21

A 42-year-old mam undergoes a CT of the abdomen which demonstrates the presence of a 4 cm diameter cystic lesion in the pancreas. Further evaluation with endoscopic US demonstrated that the lesion comprises innumerable small cysts each less than 1.5 cm in diameter. What is the most likely diagnosis?

(a) Serous cystadenoma

(b) Pseudo cyst

(c) Intraductal papillary mucinous neoplasm

(d) Mucinous cystadenoma

(e) Mucinous cystadenocarcinoma

Answer 21

(a) Serous cystadenoma

This is the typical appearance of this benign cystic lesion, formerly referred to as a microcystic tumour. Mucinous tumours tend to produce larger cysts and IPMN may extend along the main or side pancreatic ducts. A pseudocyst is often unilocular but may contain debris.

Question 22

A 45-year-old female patient undergoes simultaneous pancreas and kidney transplantation. A Doppler US of the pancreatic graft 1 week later shows a normal systolic low but complete reversal of diastolic blood flow in the artery. What is the most likely diagnosis?

(a) Arterial thrombosis

(b) Acute rejection

(c) Acute pancreatitis

(d) Venous thrombosis

(e) Arterio-venous shunt

Answer 22

(d) Venous thrombosis

This is the effect of the entire blood supply to the graft passing back and forth through the artery and is well recognised in pancreatic renal transplantation. This requires prompt intervention and may in graft loss.

Question 23

A 45-year-old man is referred for abdominal imaging with a history of watery diarrhoea, hypokalaemia and achlorhydria. CT imaging demonstrates a 4 cm diameter lesion within the pancreas which demonstrates uptake of 111In-pentetreotide at scintigraphy. What is the most likely diagnosis?

(a) Insulinoma

(b) Gastrinoa

(c) Glucagonoa

(d) VIPoma

(e) Soatostatinoma

Answer 23

(d) VIPoma

These are the characteristic clinical features (Verner-Morrison syndrome) associated with these uncommon tumours. 90% of tumours are intrapancreatic and they measure 2-7 cm at diagnosis. Extrapancreatic lesions are usually benign, but 50% of pancreatic lesions are malignant. Lesions also take up.

Question 24

1. A 48 year old woman with upper abdominal pain is found to have a 4 cm hypervascular lesion in the head of the pancreas on contrast-enhanced CT. She subsequently has an MR scan; the lesion is of low intensity on fat-saturated T1-weighted and high intensity on T2-weighted imaging. Which of the following is the most likely diagnosis?

a. Pancreatic adenocarcinoma

b. Gastrinoma

c. Insulinoma

d. Macrocystic adenoma

e. Pancreatic pseudocyst

Answer 24

b. Gastrinoma

Pancreatic adenocarcinoma is a hypovascular lesion. Macrocystic adenoma is also hypovascular, and is only rarely found in the head of the pancreas, with a predilection for the tail. The differential therefore lies between insulinoma and gastrinoma. Although both CT and MR imaging characteristics are similar, the majority of insulinomas are less than 1 cm in size, whereas gastrinomas tend to be larger at presentation with an average size of approximately 3 cm. Gastrinoma is associated with peptic ulceration and Zollinger–Ellison syndrome.

Question 25

2. A 56 year old woman is diagnosed with pancreatic adenocarcinoma. Which one of the following features on the pancreatic MR contraindicates curative surgery?

a. Splenic vein invasion

b. Tumour size of 2 cm

c. Portal vein invasion

d. Hepatic artery invasion

e. Invasion of the second part of the duodenum

Answer 25

d. Hepatic artery invasion

The only widely recognised absolute contraindication to curative surgical resection of the options listed is invasion of the hepatic artery. Invasion of the splenic and portal veins are relative contraindications as long as the veins are not completely occluded. Invasion of the second part of the duodenum is not a contraindication as it is resected at surgery. Other features that make the tumour unsuitable for curative resection are distant metastases, ascites, distant organ invasion, SMA/ coeliac/ aortic invasion and involved lymph nodes outside the boundaries of the resection.

Question 26

3. A 72 year old woman has a pancreatic MR to investigate recurrent episodes of pancreatitis. There is generalised pancreatic atrophy with dilatation of the main pancreatic duct and branch ducts, particularly in the tail. No focal lesion or intraductal calculi are present. Which one of the following diagnoses is most likely?

a. Microcystic cystadenoma

b. Intraductal papillary mucinous tumour of the pancreas

c. Cystic metastases

d. Cystic islet cell tumour

e. Pancreatic lipomatosis

Answer 26

b. Intraductal papillary mucinous tumour of the pancreas

Intraductal papillary mucinous tumour (IPMT) of the pancreas is a rare tumour. It tends to present in the elderly population and can be a cause of recurrent pancreatitis. Two recognised types include main duct IPMT, in which the main pancreatic duct is dilated, and branch duct IPMT, in which the main duct is usually uninvolved. It is a risk factor for mucinous carcinoma of the pancreas. Pancreatic atrophy is often present. Imaging characteristics are often similar to those seen in ch pancreatitis, although calcification is not a feature of IPMT

Question 27

4. A 58 year old male has a CT staging scan following a diagnosis of adenocarcinoma of the body of the pancreas. The tumour is 3 cm in size and extends beyond the boundaries of the pancreas but does not invade any vessels or adjacent organs. Two 1 cm lymph nodes lie adjacent to the tumour. No other nodes, or metastatic disease in the chest, abdomen or pelvis, are identified. The tumour is best staged as which one of the following?

a. T1N0M0

b. T1N1M0

c. T2N0M0

d. T3N0M0

e. T3N1M0

Answer 27

e. T3N1M0

T1 tumour is disease confined to the pancreas and less than 2 cm in diameter. T2 tumour is also confined to the pancreas but greater than 2 cm in diameter. As the tumour extends beyond the boundary of the pancreas, it is at least T3. Invasion of the coeliac or superior mesenteric arteries would make this a T4 tumour, but as these features are not present it is T3. The presence of regional nodes make it N1 rather than N0 (no nodes involved), and there is no metastatic disease so it is M0. Therefore the correct radiological stage is T3N1M0.

Question 28

5. A 68 year old female has a pancreatic MR for characterisation of an isolated lesion within the pancreas seen initially on CT performed for unexplained weight loss. The lesion is 3 cm in diameter, isointense on T1, isointense on T2 STIR and hypointense to pancreatic parenchyma during the arterial phase of gadolinium enhancement. It remains hypointense on the venous and delayed phases of contrast enhancement. Which one of the following is the most likely diagnosis?

a. Ductal adenocarcinoma

b. Insulinoma

c. Simple pancreatic cyst

d. Gastrinoma

e. Glucagonoma

Answer 28

a. Ductal adenocarcinoma

Insulinoma tends to be hyperintense on contrast-enhanced images. Gastrinoma is usually hyperintense on STIR imaging and on contrast-enhanced sequences. In a series of 25 patients, an article by Chandaranaet al. showed that pancreatic adenocarcinomas were either iso- or hypointense on T1-weighted imaging and iso- or hyperintense on T2 or STIR. All adenocarcinomas were hypointense to pancreatic parenchyma during the arterial phase of gadolinium enhancement on MR, 80% remained hypointense in the venous phase of enhancement and 68% remained hypointense in the delayed phase.

Question 29

6. A 58 year old male with unexplained elevated alkaline phosphatase has an MRCP and the ‘double-duct’ sign is observed. Which one of the following diagnoses is most likely to cause this finding?

a. Acute pancreatitis

b. Annular pancreas

c. Pancreas divisum

d. Periampullary tumour

e. Duodenal perforation

Answer 29

d. Periampullary tumour

The ‘double-duct’ sign is dilatation of the main pancreatic duct and the common bile duct as seen at ERCP and MRCP, and less commonly with CT and ultrasound. It occurs due to an obstructing lesion at the ampulla, most commonly a carcinoma of the head of the pancreas (in up to 77% of cases) or a carcinoma of the ampulla of Vater (in up to 52% of cases). The sign may be absent if there is an accessory pancreatic duct or when the main pancreatic duct drains into the minor papilla.

Question 30

A 53-year-old woman is seen in the general surgical outpatient clinic. She attended her GP with a 1-month history of upper abdominal pain and was found to have a palpable, firm mass in the epigastrium. An upper gastrointestinal (GI) endoscopy is normal and the surgical team request a contrast-enhanced CT of the abdomen. This demonstrates a multicystic mass in the pancreas. Which findings would make a mucinous cystic tumour more likely than a serous cystadenoma?

A Central stellate calcification is present within the lesion.

B The mass contains 12 separate cysts.

C The smallest cystic component measures 28 mm in diameter.

D The patient has a known diagnosis of von Hippel-Lindau disease.

E The tumour is located in the head of the pancreas.

Answer 30

C The smallest cystic component measures 28 mm in diameter.

Mucinous cystic pancreatic tumours (cystadenomas and cystadenocarcinomas) typically contain a few large cysts, each measuring more than 20 mm diameter.

Question 31

QUESTION 8
A 26-year-old man presents to the Emergency Department with acute epigastric pain and vomiting. The serum amylase is found to be markedly elevated and the patient is treated for acute pancreatitis. A contrast enhanced CT of the abdomen is subsequently performed and demonstrates calcification throughout the pancreas. Bilateral renal calculi are also noted. What is the most likely underlying diagnosis?

A Hereditary’ pancreatitis

B Hyperparathyroidism

C Hypoparathyroidism

D Mucinous cystadenocarcinoma

E Multiple pancreatic pseudocysts

Answer 31

B Hyperparathyroidism

A significant minority of patients with hyperparathyroidism will develop acutepancreatitis and around 30% of these patients develop pancreatic calcification. Hypoparathyroidism is associated with calcification in the soft tissues but pancreatic calcification is not a recognised feature. Hereditary pancreatitis is anautosomal dominant condition with 60% of patients demonstrating round, coarse calcification of the pancreas.

Question 32

QUESTION 19
A 42-year-old man has type 1 diabetes mellitus. Despite intensive medical management, the patient’s glycacmic control remains problematic and he receives a cadaveric pancreatic transplant with the pancreatic graft anastomosed to the right common iliac artery. Four days following surgery, the clinical team are concerned about the pancreatic graft function and request radiological assessment for post-transplant complications. Which one of the following statements is true regarding pancreatic transplant imaging?

A In acute rejection, the pancreatic graft is small and hyperechoic on ultrasound.

B Pancreatic exocrine secretions often drain into the urinary bladder.

C Radionuclide imaging with Tc-99m-pertechnetate is the most sensitive way of detecting acute pancreatic rejection.

D Surgical complications are more common following renal transplantation than pancreatic transplantation.

E Transplant pancreatitis is very rare in the first 48 hours post surgery.

Answer 32

B Pancreatic exocrine secretions often drain into the urinary bladder.

Formation of a cystoduodenostomy drains the exocrine pancreatic secretions into a duodenal loop, anastomosed directly with the urinary bladder. Enteric drainage into small bowel can also be performed depending on surgical technique

Question 33

@#e QUESTION 41
A 68-year-old man presents to his GP with weight loss and jaundice. Liver function tests demonstrate obstructive jaundice and an abdominal ultrasound shows mild intrahepatic biliary dilatation with a common bile duct measuring 12 mm in diameter. In the pancreatic head, a 3-cm hypoechoic mass is present. An ERCP is performed with insertion of a plastic stent and brushings confirm a pancreatic ductal adenocarcinoma. A triple-phase (precontrast, arterial and portal venous) multidetector CT of the pancreas is performed. Which finding would indicate a non resectable pancreatic tumour?

A Enhancing pancreatic parenchyma between the tumour and superior mesenteric vein

B The pancreatic duct dilated to 6 mm

C The presence of a 5-mm coeliac axis lymph node

D The tumour has invaded the duodenum

E The tumour in contact with 75% of the superior mesenteric artery

Answer 33

E The tumour in contact with 75% of the superior mesenteric artery

If the tumour is in contact with more than half of the vessel circumference, it is very unlikely to be resectable.

Question 34

QUESTION 48
A 42-year-old man has a history of alcohol excess and a previous duodenal ulcer. He presents to the Emergency Department with a 1-day history of epigastric pain and vomiting. Initial laboratory investigations are remarkable for a grossly elevated serum amylase and the patient is treated with intravenous fluids and analgesia. Six days later, his condition deteriorates and he develops a temperature of 39°C. A contrast-enhanced CT of the pancreas is performed. Which one would be most indicative of infected pancreatic necrosis?

A An area of non-enhancement in the pancreatic body containing a locule of gas

B Diffuse enlargement of the pancreas with peripancreatic fat stranding

C Focal enlargement of the pancreatic head with reduced enhancement

D Splenic artery pseudoaneurysm formation adjacent to the pancreatic tail

E Splenic vein thrombosis extending to the superior mesenteric vein

Answer 34

A An area of non-enhancement in the pancreatic body containing a locule of gas

Necrotic pancreatic tissue will demonstrate reduced or absent enhancement on contrast-enhanced CT. It may not be possible to differentiate sterile from infected necrosis, but the presence of gas is a strong predictor of infection. Local vascular complications are well recognised to occur in severe acute pancreatitis but may occur without pancreatic necrosis.

Question 35

QUESTION 75
An 81-year-old man presents with a 3-month history of weight loss and upper abdominal pain. Serum amylase is normal but CA 19-9 is elevated and liver function tests are abnormal. An abdominal ultrasound demonstrates mild intrahepatic biliary dilatation with common bile duct measuring 16 mm in diameter. The pancreatic head is obscured by bowel gas and a contrast enhanced CT of the abdomen is performed. What is the most likely finding in the pancreas?

A A 1-cm intensely enhancing mass in the pancreatic body

B A 6-cm septated cyst in the pancreatic tail

C Diffusely enlarged pancreas with peripancreatic fluid collection

D Hypovascular mass in the pancreatic head

E Pancreatic ductal calcification and atrophy

Answer 35

D Hypovascular mass in the pancreatic head

The history of elevated CA 19—9 and obstructive jaundice is highly suggestive of a pancreatic ductal adenocarcinoma. The classic CT appearance of pancreatic ductal adenocarcinoma is a hypovascular mass with pancreatic and or bile duct dilatation. Using a pancreatic mass protocol, these typical CT findings have a high positive predictive value and can help to differentiate ductal adenocarcinoma from other pancreatic masses (focal pancreatitis, neuroendocrine tumours, etc).

Question 36

QUESTION 79
A 27-year-old woman is admitted to hospital with an episode of mild acute pancreatitis. An abdominal ultrasound demonstrates no gallstones or biliary dilatation and the pancreas appears normal. She is managed conservatively and discharged after 7 days. Three months later, she is seen in the outpatient clinic and complains of worsening upper abdominal pain. A contrast-enhanced CT demonstrates a 6-cm cystic mass in the pancreatic body with a thin enhancing wall. Which statement is true regarding this cystic pancreatic mass?

A Forty to 60% will resolve spontaneously.

B Eighty to 90% occur within 7 days of acute pancreatitis.

C Gas within the lesion would be pathognomonic of an enteric fistula.

D Surgical drainage will be required to confirm the diagnosis.

E The cyst fluid is likely to have low amylase content.

Answer 36

A Forty to 60% will resolve spontaneously.

The majority of symptomatic pancreatic cysts are pseudocysts; approximately half of pancreatic pseudocysts resolve spontaneously.

Question 37

@#e QUESTION 90
A 41-year-old man has a 3-month history of weight loss and recurrent central abdominal pain. The pain is intermittent and radiates from the epigastrium through to his back. His past medical history includes excessive alcohol consumption and two previous admissions to hospital for acute pancreatitis. A contrast-enhanced CT of the abdomen is performed with precontrast, arterial and portal venous phase images of the upper abdomen. Which CT finding would be more suggestive of chronic pancreatitis than ductal pancreatic adenocarcinoma?

A Common bile duct dilatation

B Focal enlargement of the pancreatic head

C Intraductal pancreatic calcification

D Peripancreatic fat stranding and ascites

E Reduced enhancement of body of pancreas

Answer 37

C Intraductal pancreatic calcification

Intraductal calcification may be focal or diffuse and is not seen in all patients with chronic pancreatitis. When it is present, however, it is a highly reliable sign of chronic pancreatitis.

Question 38

QUESTION 92
A 56-year-old woman is found to have a 2.5-cm renal cell carcinoma in the upper pole of the right kidney. A contrast-enhanced CT of the chest and abdomen is performed and shows no evidence of local lymphadenopathy or distant metastases. The reporting radiologist notes a 2-cm cystic lesion in the pancreatic body. When assessing this cystic pancreatic lesion, which one of the following statements is true?

A Eighty to 90% of symptomatic cystic lesions are pseudocysts.

B Ninety to 95% of serous cystadenomas (microcystadenomas) contain calcification.

C An asymptomatic solitary 8-mm simple cyst requires mandatory follow up.

D In a mucinous cystadenoma (macrocystadenoma), multiple small cysts typically measure up to 20 mm each.

E The majority of mucinous cystadenomas occur in the pancreatic head.

Answer 38

A Eighty to 90% of symptomatic cystic lesions are pseudocysts.

The majority of symptomatic cystic pancreatic lesions are pseudocysts and many will resolve spontaneously. Serous cystadenomas can occur anywhere in the pancreas and contain multiple small cysts measuring up to 20 mm each while up to one-third contain calcification. Ninety per cent of mucinous (macrocystic) cystadenomas occur in the pancreatic body and tail and the cysts typically measure greater than 20 mm. Long-term follow-up of cystic pancreatic lesions indicates that an asymptomatic simple cyst measuring less than 20 mm is unlikely to become clinically significant.

Question 39

A patient with a history of alcohol abuse presents to A&E with epigastric pain. His haemoglobin is 8 g/dl on admission. An oesophago-gastroduodenoscopy (OGD) and ultrasound of abdomen are requested. The ultrasound of abdomen shows multiple hyperechoic lesions in the liver. There is no evidence of gallstones. Prior to the OGD the patient becomes acutely unwell and a CT scan is requested. This shows evidence of air and fluid in the subhepatic space. It also reveals a focal enhancing lesion causing prominence of the head of the pancreas. What is the most likely diagnosis?

A. Pancreatitis with associated peripancreatic abcscess.

B. Pancreatic carcinoma and liver metastases.

C. Pancreatitis and peptic ulcer perforation in an alcoholic patient.

D. Islet cell tumour with liver metastases.

E. Cholangiocarcinoma with liver metastases.

Answer 39

D. Islet cell tumour with liver metastases.

Whilst this tumour is rare, the CT findings indicate a focal mass lesion in the head of the pancreas. Hyperechoic metastases in the liver are suggestive of islet cell tumour, rather than pancreatic carcinoma metastases, even though pancreatic carcinoma is more common. The islet cell tumour could be a gastrinoma, which is most commonly found in the head of the pancreasand is malignant in 60%. It is also associated with peptic ulcer disease and the finding of air and fluid in the subhepatic space suggests a perforated duodenal ulcer.

Question 40

A 45-year-old male patient presents to A&E with an 8-hour history of epigastric pain. There is no history of alcohol intake. On examination he is tender in the epigastrium. The initial blood tests reveal that his amylase is 1024. His WCC is slightly elevated at 15. His glucose, calcium, PaO2, liver function tests (LFTs), lactate dehydrogenase (LDH) and serum electrolytesare all normal. Following an erect CXR, what is the next most appropriate radiological investigation?

A. Urgent CT scan to assess the pancreas.

B. CT within 24 hours.

C. Ultrasound scan within 24 hours.

D. Endoscopic retrograde cholangiopancreatography (ERCP) to look for ductal calculi.

E. MRCP on this admission to assess for ductal stones.

Answer 40

C. Ultrasound scan within 24 hours.

CT is only indicated as an investigation in cases of pancreatitis with severe prognostic indicators. This patient’s Ranson score is 1, which indicates a mild episode of pancreatitis and therefore CT is not indicated. ERCP was formerly contraindicated in pancreatitis, but is now recognized as a treatment for obstructing stones in the ampulla that are causing the pancreatitis. Ultimately further investigations can be directed based on the ultrasound findings.

Question 41

A patient is being worked up for a pancreatic neoplasm to assess potential resectability. Which one of the following does not rule out surgery?
A. Extension of the tumour beyond the margins of the pancreas into duodenum.

B. Tumour involvement of adjacent organs.

C. Enlarged peripancreatic lymph nodes (>15 mm).

D. Encasement or obstruction of superior mesenteric vessels.

E. Peritoneal carcinomatosis

Answer 41

C. Enlarged peripancreatic lymph nodes (>15mm).

Enlarged regional nodes are a sign of unresectability, but nodes adjacent to the pancreas are resected as part of Whipple’s procedure. The other factors all indicate that a pancreatic lesion is unresectable. Other features of unresectable pancreatic carcinoma are liver metastases. Only10–15% of pancreatic neoplasms are resectable at presentation.

Question 42

A 50-year-old female patient is referred for an outpatient CT after an ultrasound carried out to look for gallstones revealed a cystic lesion within the pancreas. The CT shows a number of large cysts of over 2 cm in diameter, containing fluid measuring 3 HU in the head and body of the pancreas. These cysts have thin enhancing walls. The pancreatic duct is not significantly distended. On further questioning the patient denies a history of previous pancreatitis. An MRI does not extend the diagnostic process. An FNA reveals fluid low in amylase, but with high carcino-embryonic antigen (CEA) content. What is the most likely diagnosis?

A. Pancreatic pseudocyst.

B. Mucinous cystic neoplasm.

C. Microcystic pancreatic tumour.

D. Intraductal papillary mucinous tumour (main duct type).

E. Lymphangioma.

Answer 42

B. Mucinous cystic neoplasm.

Mucin is detected in FNA fluid in these lesions. Pseudocysts are uncommon without a history of pancreatitis and the aspirated fluid is high in amylase. The cysts in microcystic lesions are usually smaller than 1cm, except in the oligocystic variant. They are also known as serous cystadenomas. Intraductal papillary mucinous tumours cause dilatation of the main pancreatic duct, side branch ducts or both. FNA, either percutaneous or via endoscopic ultrasound, has been described as alow-risk procedure for differentiating pancreatic cystic lesions.

Question 43

A 63-year-old male patient is admitted with acute pancreatitis. During his admission survey he is noted to have a Ranson score of 7 and he is transferred to the ICU. A CT scan is carried out prior to ICU admission and shows a homogeneously enhancing enlarged pancreas with a fluid collection in the tail. There are gallstones in the gallbladder, with a dilated duct. A further CT is carried out on day 3 and this shows two further fluid collections in the tail of the pancreas, with an area of poorly enhancing pancreas that involves over half of the gland. There is no evidence of abscess. Which of the following options is most useful in detecting the severity of this patient’s pancreatitis?

A. Ranson score to indicate severity of pancreatitis. CT is of value in detecting complications.

B. CT within 24 hours to show presence of gland swelling and/or necrosis.

C. CT scan within 24 hours to indicate absence of complications and evidence that causative factor has passed.

D. CT after 3 days showing necrosis and fluid collections.

E. CT scan after 3 days showing absence of abscess formation.

Answer 43

D. CT scan after 3 days showing necrosis and fluid collections.

The Balthazar CT staging system grades pancreatitis based on the presence of gland enlargement and/or fluid collections, as well as the presence of necrosis involving <30%, 30–50% or >50% of the gland. This has been shown to be a more accurate predictor of severity of pancreatitis and morbidity than the Ranson or Acute Physiology and Chronic Health Evaluation II (APACHE II) criteria. This staging system is, however, most accurate when carried out after 48 hours, as the degree of pancreatic necrosis may not be apparent before this.

Question 44

A 30-year-old man undergoes CT of the abdomen following a high-velocity collision during an RTA. The scan reveals peripancreatic fat stranding and a superficial laceration in the tail of the pancreas, which extends to less than 50% of the pancreatic thickness. What is the next most appropriate step?

A. Laparotomy.

B. ERCP.

C. Supportive therapy.

D. Ultrasound to assess the pancreatic duct.

E. Diagnostic peritoneal lavage.

Answer 44

C. Supportive therapy.

Injury to the pancreas is relatively uncommon, occurring in less than 2% of blunt abdominal trauma patients. Direct signs of pancreatic injury at CT include laceration, transection, enlargement, and inhomogenous enhancement. Secondary signs include peripancreatic fat stranding and fluid collections, haemorrhage, and thickening of the anterior pararenal fascia.The management of pancreatic trauma depends on the integrity of the pancreatic duct. If it is intact, the treatment is supportive and expectant. If the duct is disrupted, surgery or stenting at ERCP is required. Although CT may not always directly demonstrate the pancreatic duct, thelikelihood of ductal injury may be inferred from secondary signs. Wong et al. have devised a CT grading scheme, which is similar to the surgical classification of Moore.
Grade A injuries comprise pancreatitis or superficial laceration (<50% pancreatic thickness)
Grade B1 is deep laceration (>50% pancreatic thickness)
Grade B2 is transection of the pancreatic tail
Grade C1 is deep laceration of the pancreatic head
Grade C2 is transection of the pancreatic head.
Grade A injuries spare the duct and are usually seen with an intact duct by surgical grading. Grade B and C injuries correlate with duct disruption. MR pancreatography is an alternative to ERCP to assess the integrity of the pancreatic duct. The duct integrity cannot be reliably assessed by ultrasound, particularly in the context of recent trauma.

Question 45

A 58-year-old man with a history of alcohol abuse and diabetes presents with painless jaundice. Liver function tests reveal an obstructive picture and he undergoes an ultrasound of abdomen, which reveals dilatation of the CBD and a hypoechoic region in the head of the pancreas. He has a history of iodine allergy and undergoes MRI with dynamic gadolinium enhancement, as an alternative to contrast-enhanced CT. Which finding in the pancreatic head is most in keeping with the diagnosis of pancreatic adenocarcinoma?

A. Hypointensity on T1WI.

B. Hyperintensity on T2WI.

C. Hyperintensity on a STIR sequence.

D. Hypointensity during arterial phase enhancement.

E. Hypointensity during portal venous phase enhancement

Answer 45

D. Hypointensity during arterial phase enhancement.

Pancreatic adenocarcinoma is generally a hypovascular tumour at CT as well as MRI. Dynamic contrast-enhanced CT has been the gold standard for the diagnosis of pancreatic adenocarcinoma, but MRI is of value in those with renal failure or sensitivity to iodine-based contrast media. Care should be taken in patients with a very low GFR (typically less than 30ml/min) because of the risk of nephrogenic systemic fibrosis. Contrast-enhanced MRI may have a lower false negative rate than CT, as approximately 10% of pancreatic adenocarcinomas have been shown to be iso- rather than hypoattenuating, on both the pancreatic and portal venous phases. Chandarana et al. have reported that 25 of 25 neoplasms showed hypointensity during arterial phase enhancement (and 20 remained hypointense in venous phase), whereas only 12 of 25 were hypointense on unenhanced T1WI, and only 11 of 25 were hyperintense on STIR/T2WI.

Question 46

A 42-year-old man is referred for a CT scan by an upper GI surgeon. He has a long history of recurrent upper abdominal pain, with more recent episodic vomiting. CT shows excess soft-tissue thickening between the head of pancreas and duodenum. Small cystic lesions are seen along the medial wall of the duodenum. There is also mild dilatation of the common bile duct and distension of the stomach and proximal duodenum. What is the most likelydiagnosis?

A. Autoimmune pancreatitis.

B. Groove pancreatitis.

C. Pancreatitis related to ectopic or heterotopic pancreatic tissue.

D. Hereditary pancreatitis.

E. Pancreas divisum associated pancreatitis.

Answer 46

B. Groove pancreatitis.

This is a rare form of chronic pancreatitis. It occurs due to inflammation in the pancreaticoduodenal groove, the potential space between the pancreas, duodenum, and common bile duct. The clinical manifestations are primarily due to duodenal and biliary obstruction. The small cystic lesions in the duodenal wall refer to cystic dystrophy of the duodenum, which can be associated with groove pancreatitis.
Autoimmune pancreatitis generally shows a diffusely enlarged gland with loss of lobular architecture, a ‘sausage’ shape, and a peripheral ‘rind’ of hypoattenuation. There is usually a non-dilated or diffusely narrowed pancreatic duct and a distal biliary stricture.
Hereditary pancreatitis has a young age of onset of typical features of pancreatitis, with at least two acute attacks without an underlying cause.
Pancreas divisum associated pancreatitis is seen in young or middle-aged patients with recurrent acute pancreatitis or chronic relapsing pancreatitis. MRCP or ERCP are optimal for the diagnosis of the lack of communication between the ventral and dorsal pancreatic ducts. Although ectopic pancreatic tissue is a proposed cause of groove pancreatitis, ectopic orheterotopic tissue is # seen in relation to the gastric wall.

Question 47

A 39-year-old finale alcoholic represented to the Emergency Department feeling generally unwell three weeks after an initial diagnosis of acute pancreatitis. He self-discharged himself from hospital after 10 days of treatment. His original CT at diagnosis showed inflammation of the whole gland and a repeat CT on his representation showed a well-demarcated 4cm x 3 cm fluid collection directly anterior to the body of the pancreas which contained a small bleb of gas. What is the most likely diagnosis?

a Acute pseudocyst

b Enteric fistula

c Gland necrosis

d Pancreatic abscess

e Pancreatic phlegmon

Answer 47

Answer D: Pancreatic abscess

Pancreatic abscesses usually occur two to four weeks after onset of severe acute pancreatitis. It is seen as a fluid collection close to the pancreas itself, the most common organism is E. coli and 30- 50% contain gas. Patients are usually generally unwell and have symptoms and signs of sepsis with raised inflammatory markers. Pseudocysts take over four weeks to develop and rarely contain gas.

Question 48

CT is more sensitive than MRI for the detection of calcifications associated with chronic pancreatitis but MRI is a useful tool in assessing duct and parenchymal abnormalities in cases of chronic pancreatitis. Which abnormality is most likely to lead to a false negative on MRI?

a Demonstrating dilated duct upstream from an obstruction

b Demonstrating gland atrophy

C Demonstrating intraductal stones

d Evaluating duct strictures

e Demonstrating intraductal stones not surrounded by fluid

Answer 48

Answer E: Demonstrating intraductal stones not surrounded by fluid

Visualising intraductal stones not surrounded by fluid can be difficult with MRI as there is no fluid contrast to outline the filling defect.

Question 49

A pancreatic transplant patient had an ultrasound three weeks after their transplant procedure. It was difficult to delineate the margins of the gland and there was acoustic inhomogeneity and a dilated pancreatic duct. What is the correct interpretation of these features?

a Acute rejection

b Graft vessel thrombosis

C Pancreatitic abscess

d Pancreatitis

e Normal post-procedural appearances

Answer 49

Answer A: Acute rejection

These are classic features of acute rejection. Clinically, the patient may have focal tenderness over the transplant

Question 50

A young boy presented after hitting the handlebars of his push bike. Imaging demonstrated pancreatic parenchymal damage that did not involve the main pancreatic duct. What is the most likely site of injury?

a Pancreatic head

b Uncinate process

C Pancreatic tail

d junction of head and neck

e junction of body and tail

Answer 50

Answer E: Junction of body and tail

Question 51

A 58-year-old man presented with upper abdominal pain, haematemesis and diarrhoea. He had been treated with a proton pump inhibitor for epigastric pain for a year with little effect. Oesophagogastroduodenoscopy (OGD) revealed multiple erosions but no varices and an ultrasound showed a hypoechoic mass in the body of the pancreas. What is the most likely cause of the pancreatic abnormality?

a Adenocarcinoma

b Gastrinoma

C Metastasis

d Pseudocyst

e VIPoma

Answer 51

Answer B: Gastrinoma

Gastrinoma associated with peptic ulceration (Zollinger-Ellison syndrome) is the second most common functioning islet cell tumour. VIPoma is rare and not associated with peptic ulceration. Other functioning islet cell tumours include: insulinoma (commonest functional tumour), somatostatinoma and glucagonoma

Question 52

A 46-year-old male presented with a one-year history of vague epigastric pain. He had a history of ischaemic heart disease and hypercholesterolaemia. On examination there was mild hepatomegaly. Inflammatory markers, amylase and liver function tests were within normal limits. An abdominal ultrasound showed multiple hyperechoic focal deposits in the liver but obscuration of central structures by bowel gas. A CT was performed which showed two small (1-cm) lesions within the body of the pancreas that enhanced avidly in arterial phase. The liver lesions were also hypervascular. What is the most likely diagnosis?

a Hepatocellular carcinoma

b Lymphoma

C Pancreatic acinar cell carcinoma

d Pancreatic ductal adenocarcinoma

e Pancreatic islet cell tumour

Answer 52

Answer E: Pancreatic islet cell tumour

Pancreatic islet cell tumours are often small (<2 cm) and multiple and can often be difficult to detect. They are usually iso-attenuating on unenhanced CT but show avid enhancement in arterial phase. Metastases to the liver occur in 60-90% of cases with or without lymph node involvement and are often hypervascular. The average time from onset of symptoms to diagnosis is 2.7 years.

Question 53

A patient who was spiking temperatures on their fifth post-operative day underwent an abdominal CT. This showed reordered anatomy with a gastrojejunostomy, choledochojejunostomy and pancreaticojejunostomy. There was a small amount of free fluid and free air and more marked pneumobilia. What surgical procedure has been performed?

a Roux-en-Y choledochojejunostomy

b Roux-en-Y with post-operative complications

C Roux-en-Y normal with normal post-operative appearances

d Whipple’s procedure with post-operative complications

e Whipple’s procedure with normal post-operative appearances

Answer 53

Answer E: Whipple’s procedure with normal post-operative appearances

A standard Whipple’s procedure is a pancreaticoduodenectomy. There are three main anastomoses: a gastrojejunostomy, a choledochojejunostomy and a pancreaticojejunostomy

Question 54

A 16-year-old boy was involved in a road traffic accident and a multi-trauma CT was performed. He had a history of several previous admissions for acute abdominal pain that had remained undiagnosed and his father had died aged 36 of pancreatic carcinoma. The CT showed a sterna fracture, lung contusions and a femoral fracture. Additionally, there were several large spherical calcifications within the pancreas and a 4-cm pseudocyst with relative preservation of the gland volume. He made a good recovery from his acute injuries but follow-up was considered for his pancreatic findings. What is the most likely diagnosis?

a Cystic fibrosis

b Hereditary pancreatitis

C Pancreas divisum

d Post-mumps pancreatitis
q
e Trauma

Answer 54

Answer B: Hereditary pancreatitis

Hereditary pancreatitis is inherited in an autosomal dominant fashion. It is the most common cause of large spherical pancreatitic calcifications in childhood and causes repeat episodes of pancreatitis. Twenty to forty per cent develop pancreatitic carcinoma and pseudocyst formation is seen in 50%.

Question 55

A patient on the ITU was recovering from multi-organ failure after a severe episode of acute pancreatitis when his haemoglobin dropped by 3 g/dL over two days. Intra-abdominal haemorrhage was suspected and CT angiography demonstrated a contrast blush adjacent to an apparently aneurysmal vessel very near the pancreas itself. Which vessel is most likely to be involved?

a Gastroduodenal artery

b Inferior pancreaticoduodenal artery

C Pancreatic arcade arteries

d Splenic artery

e Superior pancreaticoduodenal artery

Answer 55

Answer D: Splenic artery

Post-inflammatory pseudoaneurysms can rupture into pre-existing pseudocysts and are caused by digestion of the arterial wall by released enzymes. This occurs in up to 10% of patients with severe pancreatitis. The splenic artery is the most common site and there is significant (approximately 35%) mortality if they rupture.

Question 56

A 44-year-old obese lady was admitted with an episode of acute pancreatitis. Blood tests showed abnormal liver function and a leucocytosis. Her renal function was normal and no complication was clinically evident. Which investigation is most appropriate in this situation?

a Contrast-enhanced CT abdomen and pelvis in 7-10 days

b Immediate contrast enhanced CT abdomen and pelvis

C Immediate contrast-enhanced CT chest, abdomen and pelvis

d No imaging required at present

e Ultrasound of the abdomen

Answer 56

Answer E: Ultrasound of the abdomen

In an overweight middle-aged female the most common cause of acute pancreatitis is gallstone disease. This is even more likely in the context of abnormal liver function tests. A gallstone-causing obstruction in the common bile duct should be excluded with ultrasound as this would probably require intervention. CT is mainly indicated in the context of assessment of complications.

Question 57

A young boy presented after hitting the handlebars of his push bike. Imaging demonstrated pancreatic parenchymal damage that did not involve the main pancreatic duct. What grade of injury has he suffered?

a Grade I injury

b Grade II injury

C Grade III injury

d Grade IV injury

e Grade V injury

Answer 57

Answer B: Grade II injury

Grade I: Minor contusion/haematoma, capsule and major duct intact
Grade II: Parenchymal injury without major duct injury
Grade III: Major ductal injury
Grade IV. Severe crush injury

Question 58

During abdominal ultrasound a patient was noted to have an echogenic pancreas with areas of hypoechogenicity. A contrast-enhanced CT scan was subsequently performed which showed multiple pancreatic cysts. There was no lymphadenopathy. What further feature would make a mucinous cystic neoplasm more likely?

a Cysts with near fluid density

b Calcification

C Hypovascularity

d Cysts of 20 mm in size

e Patient in their eighth decade

Answer 58

Answer C: Hypovascularity.

Question 59

An otherwise fit 54-year-old man presented with non-specific abdominal pain and weight loss. An ultrasound and subsequent CT with biopsy confirmed a diagnosis of pancreatic adenocarcinoma. A resection was planned and the CT was reviewed. Which of the following features is most compatible with a resectable tumour?

a Dilatation of pancreatic duct

b Direct tumour extension of tumour into left hepatic lobe

C Encasement of the superior mesenteric artery

d Thickening of Gerota’s fascia

e 2-cm regional lymph node

Answer 59

Answer A: Dilatation of pancreatic duct

Only 8-15% of pancreatic adenocarcinomas are resectable at the time of presentation. Resectable tumours are typically isolated pancreatic masses with or without dilatation of the pancreatic or biliary ducts. Features of irresectable tumours include: extension of tumour beyond the margins of the pancreas, tumour invasion of adjacent organs, enlarged regional lymph nodes and encasement of peripancreatic arteries and veins.

Question 60

A 38-year-old male with a history of alcohol and drug abuse attended the Emergency Department with severe abdominal pain. His amylase was 5105 IU/L and a diagnosis of pancreatitis was made. The patient was resuscitated and transferred to the surgical ward where, after four days, he became more unwell. A CT was then performed which showed gland oedema, inflammatory changes in the surrounding retroperitoneal fat and hyperdense areas (50-70HU) within the gland. What is the most likely diagnosis?

a Haemorrhagic pancreatitis

b Pancreatic calcification

C Pancreatic necrosis

d Phlegmonous pancreatitis

e Suppurative pancreatitis

Answer 60

Answer A: Haemorrhagic pancreatitis

The hyperdense areas in the gland represent acute haemorrhage. All the other options, except calcification, produce areas of low attenuation and calcification would be greater than 50 70HU

Question 61

An obese 40-year-old male who had been diagnosed with MEN type 1 via genetic screening underwent an abdominal MRI. Two lesions measuring 2.5 and 2 cm were identified in the pancreas. They were hypointense on T1- and hyperintense on T2-weighted images and there was ring enhancement after gadolinium administration. What is the most likely pancreatic pathology?

a Glucagonoma

b Gastrinoma

C Insulinoma

d Non-functioning islet cell tumour

e VIPoma

Answer 61

Answer C: Insulinoma

MEN I syndrome is strongly associated with pancreatic islet cell tumours. Insulinomas are more likely to be multiple in MEN I and are usually hypointense on Ti and hyperintense on T2. Tumours over 2 cm show ring enhancement.

Question 62

An eight-year-old boy was admitted after falling onto the handle bars of his bike and then onto the road. In addition to significant musculoskeletal injuries he complained of abdominal pain and on examination had a rigid abdomen with minimal bowel sounds. An ultrasound of the abdomen showed a small amount of intra-abdominal free fluid and as he was becoming more unwell an urgent CT was performed. This showed oedema in the peripancreatic fat and irregularity of the pancreatic contour. A discrete ill-defined area of low attenuation was seen in the region of the junction of the body and tail and there was bilateral thickening of the para-renal fascia. There was no appreciable loss of gland volume and pancreatic duct was normal. What is the most likely conclusion on the basis of these imaging findings?

a Major ductal injury

b Major vascular injury

C Pancreatic contusion

d Parenchymal injury with haemorrhage without major duct disruption

e Post-traumatic pancreatitis

Answer 62

Answer C: Pancreatic contusion

The area of low attenuation with the gland is consistent with a parenchymal contusion. If haemorrhage was present his would probably be of increased attenuation

Question 63

A patient presented with severe epigastric pain and acute severe pancreatitis was diagnosed. After resuscitation, what is the most useful first-line investigation in the first 24 hours?

a Triple-phase CT

b Dual-phase CT

C Plain abdominal radiograph

d Ultrasound abdomen

e MRI pancreas

Answer 63

d Ultrasound abdomen

Question 64

A patient with pancreatitis underwent a CT scan. In addition to the expected CT findings of acute pancreatitis there was extensive pancreatic calcification and bilateral renal calculi and renal calcification. What underlying diagnosis does this suggest?

a Alcoholic pancreatitis

b Hyperparathyroidism

C Kwashiorkor

d Pancreatic carcinoma

e Sarcoid

Answer 64

Answer B: Hyperparathyroidism

Pancreatitis complicates 10% of hyperparathyroidism. The pattern of pancreatic calcification is indistinguishable from alcoholic pancreatitis, but the presence of renal tract calcification is highly suggestive of hyperparathyroidism.

Question 65

(Ped) 46 A six-year-old girl presented with jaundice and malaise. Examination showed evidence of portal hypertension and a dark ring around the iris of both eyes. An ultrasound demonstrated a small nodular liver with an irregular capsule but no focal lesions. Further imaging in the form of a CT abdomen was performed and the liver was found to be of normal attenuation. Which of the following is the most likely diagnosis?

a Cystic fibrosis

b Galactosaemia

C Wilson’s disease

d Haemochromatosis

e Alpha-1 antitrypsin deficiency

Answer 65

46 Answer C: Wilson’s disease

Wilson’s disease is an autosomal-recessive disease that causes excessive copper retention. The dark ring around the iris is a Kayser-Fleischer ring and is diagnostic of Wilson’s disease. Wilson’s disease causes cirrhosis, neurological, renal and ophthalmological dysfunction. Children usually present with hepatic dysfunction.

Question 66

A 70-year-old man gave a history of recurrent episodes of abdominal pain and weight loss. Ultrasound of the upper abdomen showed a non-specific abnormality for the pancreas and a CT was performed that demonstrated focal enlargement of the pancreatic head. The pancreas contained numerous irregular ductal calcifications and there was duct dilatation. There was no cystic change. What are these features most likely to represent?

a Chronic pancreatitis

b Cystic fibrosis

C Mucinous pancreatic neoplasm

d Pancreatic carcinoma

e Pancreatic islet cell tumour

Answer 66

Answer A: Chronic pancreatitis

In chronic pancreatitis, repeated episodes of mild or subclinical pancreatitis lead to irreversible destruction of the parenchyma. The gland is often small and atrophic, but focal enlargement is present in 40%. Parenchymal calcification, fatty replacement and fibrosis are also features.

Question 67

8. A 50-year-old primary school teacher presents with history of recurrent episodes of loss of consciousness. CT scan of the abdomen shows a enhancing mass in the pancreas. The most likely diagnosis is?

(a) Pancreatic carcinoma

(b) Gastrinoma

(c) Lymphoma

(d) Insulinoma

(e) Adrenocorticotrophic hormone-producing tumour

Answer 67

8. (d) Insulinoma

This is the most common functional islet cell tumour. It is characterised by the Whipple’s triad of starvation, hypoglycaemia and relief with glucose. Patients can lose consciousness secondary to hypoglycaemia. The lesion enhances with contrast and has no predilection for any part of pancreas. On MRI, the tumour returns low signal on T1 and high on T2 images.

Question 68

9. Which of the following investigations is the most sensitive test for localisation of Islet cell tumours?

(a) Transhepatic portal venous sampling (TPVS)

(b) Contrast enhanced MRI

(c) Endoscopic ultrasound

(d) Selective arteriography

(e) Arterial stimulation and venous sampling (ASVS)

Answer 68

9. (e) Arterial stimulation and venous sampling

This involves selective pancreatic arterial injection of a secretogogue and the hepatic venous flow is sampled. Lesions not seen on cross section imaging can be detected. The sensitivity of ASVS is same as TPVS for insulinoma but better for gastrinoma.

Question 69

1. The following statements regarding acute pancreatitis are correct: (T/F)

(a) Mumps is a recognised cause.

(b) Pancreatic necrosis demonstrated on CT is associated with a mortality of 5-10%.

(c) Pancreatic oedema is a late sign.

(d) Haemorrhagic pancreatitis is diagnosed by the presence of hypodense areas of 5-20 Hounsfield units on CT.

(e) Right-sided pleural effusion is seen in 5%.

Answer 69

Answers:

(a) Correct
(b) Not correct
(c) Not correct
(d) Not correct
(e) Not correct

Explanation:

Alcohol and gallstones on the commonest cause of acute pancreatitis. Left-sided pleural effusion is seen commonly. Pancreatic oedema is the earliest sign of acute pancreatitis. Haemorrhagic pancreatitis is diagnosed by the presence of hyperdense areas.

Question 70

3. Regarding pancreatic islet cell tumours: (T/F)

(a) Insulinoma is found predominantly in the pancreatic body and tail.

(b) Glucagonoma is the commonest functioning islet cell tumour.

(c) Glucagonoma is a hypervascular tumour.

(d) Glucagonoma undergoes malignant transformation in 5-10%.

(e) Multiple insulinomas are associated with MEN Type 1.

Answer 70

Answers:

(a) Not correct
(b) Not correct
(c) Correct
(d) Not correct
(e) Correct

Explanation:

Insulinoma does not have any predilection for any part of the pancreas. The undergo malignant transformation in 5- 10% of the cases. Glucagonoma is the second commonest functioning islet cell tumour. The hypervascular and undergoes malignant transformation in 80% of the cases.

Question 71

20. which of the following statements are correct about Insulinomas: (T/F)

(a) The majority are benign.

(b) 90% are less than 2cm in diameter.

(c) Are frequently multiple.

(d) Are associated with MEN 1 syndrome.

(e) More than 50% can be localized using an octreotide scan.

Answer 71

Answers:

(a) Correct
(b) Correct
(c) Not correct
(d) Correct
(e) Correct

Explanation:

Only 10% of insulinomas are multiple. When multiple, the individual lesions are smaller. Malignant lesions tend to be larger than benign. Patients with MEN 1 syndrome tend to have multiple small insulinomas.

Question 72

35. Which of the following are correct of pancreatic carcinoma? (T/F)

(a) The loss of a fat plane around the superior mesenteric artery is indicative of invasion.

(b) CA 19-9 is elevated in more than 80% of patients with ductal adenocarcinoma.

(c) Ductal adenocarcinoma has reduced signal on T1 weighted and T2 weighted MRI relative to normal pancreas.

(d) Solid and papillary neoplasms are usually locally invasive at diagnosis.
q
(e) Intraductal papillary mucinous subtypes are characterised by hyperintense pancreatic ducts on T2 weighted MRI.

Answer 72

Answers:

(a) Correct
(b) Correct
(c) Correct
(d) Not correct
(e) Correct

Explanation:

Solid and papillary pancreatic neoplasms are large tumours that are better demarcated, thick walled and have solid and cystic areas. Imaging shows enhancement of the thick wall and lobular projections from the inner wall margins. They are more common in the body and tail of the pancreas. Calcification may be seen at the periphery.