Unit 8 Pancreatic Pathology- Pancreatitis (Elie)

What is pancreatitis?

• Inflammation of pancreas

What does pancreatitis occur from?

• Damage or malfunction

Pancreatitis can be either _____ or ______

Acute or chronic

Pancreatitis can be classified as:

Mild to severe

What are the lab values for Pancreatitis?

• Increases Amylase and Lipase

• If obstructed: Increased Alk Phos

What are the main causes of Acute Pancreatitis?

• Biliary Tract Disease (Most common cause)

• Alcoholism

What are the lab values for Acute Pancreatitis?

• Amylase

• Lipase

• WBC

What are the clinical symptoms of Acute Pancreatitis?

• Sudden onset Abdominal Pain to back

• Fever; N/V, Distention

• Risk of Abscess/Hemorrhage

What is this image showing?

Acute Pancreatitis

What is this image showing?

Acute Pancreatitis

US Appearance: What are the sonographic findings of Acute Pancreatitis?

• 29% Normal

• 52%  Increased Size

• Hypoechoic – anechoic

• Loss of distinction of SV/Borders

US Appearance Acute Pancreatitis: What should the sonographer check for?

• Check for peripancreatic fluid

• Pancreatic Ductal Dilatation

• Check for stones in GB & bile duct

What are the percentages associated with other complications with Acute Pancreatitis?

• 18-20%  Phlegmon

• 10%  Pseudocyst formation

• 1-9%  Abscess

• 5%  Hemorrhage; Intra & Extra pancreatic Fluid Collections

What is this image showing?

Acute Pancreatitis in Children (9 year old with pancreatitis)

What is this image demonstrating?

Acute Pancreatitis in Children (Dilated CBD)

Where are the most common sites for Extrapancreatic Fluid collections and edema to occur?

• Lesser sac

• Anterior pararenal spaces

• Mesocolon

• Perirenal spaces

• Peripancreatic soft tissue spaces

When looking at extrapancreatic fluid collections and edema what does it look like?

Anechoic or fine linear lines

What is Chronic Pancreatitis?

Recurrent attacks of acute pancreatitis

What are the causes of Chronic Pancreatitis?

• Chronic Alcoholism

• Chronic Biliary Disease

• Hypercalcemia

• Hyperlipidemia

What are the clinical symptoms of Chronic Pancreatitis?

• Epigastric Pain

• GI problems

• Jaundice-CBD obstruction

Sonographically, what are the classic findings of Chronic Pancreatitis?

Calcifications

US Findings for Chronic Pancreatitis:

• Hyperechoic

• Irregular borders decreased in size

• Dilated PD

• Ductal Stones

What percentage of pancreatic calcifications are associated with cancer?

25%

What are the complications of Chronic Pancreatitis?

• Pseudocysts

• PV or SV Thrombosis

What are these images demonstrating?

Chronic Pancreatitis

What are the complications of pancreatitis?

• Fluid collections

• Pseudocysts

• Bile duct or duodenal obstruction

• Ascites

• Pancreatic CA

• SV Thrombosis

• Pseudoaneurysms

• Aneurysms secondary to pancreatitis

  Splenic artery – most common site

What is the most common complication of pancreatitis?

Pancreatic Pseudocyst

What is a Pancreatic Pseudocyst and where does it arise from?

• A collection of fluid

• Arises from loculation of inflammatory processes, necrosis or hemorrhage

When does a pancreatic pseudocyst develop?

• Develops when pancreatic enzymes escape from gland & break down tissue to form sterile abscess somewhere in abdomen

Usually over 4-6 weeks after onset

What are the causes of Pancreatic Pseudocysts?

• Acute pancreatitis

• Chronic pancreatitis

• Loculation of inflammatory processes, necrosis, hemorrhage

Where are the locations of pancreatic pseudocysts?

• Lesser sac

• Pararenal space

• May become large

What is the regression associated with Pancreatic Pseudocysts?

• 20% spontaneous regression

• Decompression into duct or GI tract

• 50% Mortality rate with rupture into peritoneal cavity

US appearance of Pancreatic Pseudocysts:

• Well-defined mass

• Sonolucent interiors

• Possible debris and septations

• Increased through transmission

What are these images showing?

Pancreatic Pseudocysts

What are the classifications of Pseudocysts?

• Septated

• Excessive internal echoes

• Pseudocyst without posterior enhancement caused from calcification

What are these images demonstrating?

Classifications of Pseudocysts

What is the most common complication of Pseudocysts?

Spontaneous rupture

In spontaneous rupture of pseudocysts what percentage ruptures in the peritoneal cavity?

3%

In spontaneous rupture of pseudocysts, what is the mortality rate in the peritoneal cavity?

50%

In spontaneous rupture of the GI tract with a pseudocyst, what is usually shown?

• Typical pseudocyst appearance 1st

• Then disappearance

What is hemorrhagic pancreatitis?

• Rapid progression of Acute pancreatitis

What are the characteristics of hemorrhagic pancreatitis?

• Rupture of pancreatic vessels & hemorrhage

• Necrosis of pancreatic tissue

• Ascites

What are the symptoms of hemorrhagic pancreatitis?

• Intense, severe pain

• Hypotension

What are the decreased lab values for hemorrhagic pancreatitis?

• Decreased hematocrit

• Decreased calcium levels

What is this image showing?

Hemorrhagic Pancreatitis

What is Phlegmonous Pancreatitis?

• Spread of diffuse inflammatory edema of soft tissues

What does Phlegmonous Pancreatitis look like on ultrasound?

• Hypoechoic

• ill-defined mass

• Good through transmission

What is this image showing?

Phlegmonous Pancreatitis

A pancreatic abscess is a complication of pancreatitis and has a low incidence of what percent?

1-9 %

What are the clinical symptoms and lab work for a pancreatic abscess?

• Fever, chills, Hypotension, Tender abdomen with growing mass

• Elevated WBC, Bacteremia

US findings for a pancreatic abscess include:

• Hypoechoic mass with smooth or irregular thick walls; unilocular or multilocular

• May have air/gas bubbles causing “dirty shadows”

• Depends on amount of debris