Pancreas Pathology

Normal pancreas head measurement

3 cm

Normal measurement of the pancreas neck

2 cm

Normal measurement for the pancreas tail

2 cm

Disease that occurs when the pancreas becomes damaged and malfunctions as a result of increased secretion and blockage of ducts

pancreastitis

Caused by inflamed acini releasing pancreatic enzymes into the surrounding pancreatic tissue

Usually does not last more than several days

May be at risk for abscess or hemorrhage

Acute Pancreatitis

Most common cause of acute pancreatits

biliary tract disease

Gallstones are present in what percentage of acute pancreatitis cases

40-60%

Other causes of acute pancreatitis

trauma, inflammation from adjacent peptic ulcer or abd infection, pregnancy, mumps, tumors, congenital causes, vascular thrombosis, and drugs

Symptoms of acute pancreatitis

severe pain after large meals or alcohol

serum amylase increases with 6-12 hours; serum lipase increases within 4-8 hours

Acute pancreatitis can go on to develop other conditions including:

Pseudocyst formation, fat/ parenchymal / blood vessel necrosis, abscess, hemorrhage, or duodenal obstruction

Sonographic findings of acute pancreatitis

If swelling occurs, gland is hypoechoic to anechoic and less echogenic than liver

Borders may be distinct but smooth

Duct may be obstructed as a result of inflammation, spasm, edema, or pseudocyst formation

Peri-pancreatic fluid collection w/ abnormal pancreatic enzymes is highly suggestive of acute pancreatitis

Findings of fluid collections and edema are common with severe

acute pancreatitis

Most common sites of extrapancreatic fluid collections and edema

lesser sac, anterior pararenal spaces, mesocolon, perirenal spaces, mesocolon, perirenal spaces, and peripancratic soft tissue spaces

Fluid filled mass that develops outside of the pancreas

Collection of fluid that arises from the loculation of inflammatory processes, necrosis, or hemorrhage

Few symptoms

pancreatic pseudocysts

Most common location of pseudocysts

lesser sac ( anterior to pancreas and posterior to stomach) on left

2nd most common location of pseudocysts

anterior pararenal space (posterior to lesser sac)

Sonographic appearance of pseudocysts

well-defined masses, anechoic with increase in through transmission

possible debris from infections or hemorrhage

thicker walls with possible wall calcification

What can pseudocysts often be confused with

fluid filled stomach

Most common complication of pancreatic pseudocyst

rupture

Rapid progression of acute pancreatitis with rupture or pancreatic vessels and subsequent hemorrhage

diffuse enzymatic destruction caused by sudden escape of active pancreatic enzymes into the grandular parenchyma

focal areas of fat necrosis found around the pancreas

hemorrhagic pancreatitis

Sonographic findings of hemorrhagic pancreatitis

fresh- well defined homogeneos mass

1 week- cystic with solid elements or sptations

Fat replaces or influtrates the pancreas

hyperechoic

normal size

pancreatic lipomatosis

Most frequent benign pathologic condition of adult pancreas

pancreatic lipomatosis

Uncommon subcutaneous manifestation of intra-abdominal pathlogy that manifests as discloration of the flanks

Gray Turners sign

Gray turners sign correlates with

severe acute necrotizing pancreatitis

Inflammatory process that spreads along fascial pathways, causing localized areas of diffuse inflammatory edema of soft tissue

18-20% of patients with pancreatitis

hypoechoic with good transmission

phlegmonous pancreatitis

abscess development secondary to pancreatitis that develops from post operative procedures

high mortality if untreated

uni or multi locular, can spread superiorly or inferiorly

pancreatic abscess

Sonographic findings of pancreatic abscess

poorly defined hypoechoic mass with smooth or irregular thick walls

results from recurrent attacks of acute pancreatitis and causes continuous destruction

chronic pancreatitis

Chronic pancreatitis is often associated with

chronic alcoholism

biliary disease

hypercalcemia

hyperlipidemia

ductal obstruction with chronic calcifying pancreatitis

nodular irregular surface of pancreas

chronic alcoholic pancreatitis

less ductal epithelial damage and rarely calcified stones

caused by stenosis of sphincter of oddi by gallstones or pancreatic tumor

chronic obstructive pancreatitis

What percent of chronic pancreatitis cases develop pseudocysts

25-40%

Sonographic findings of chronic pancreatitis

localized or diffuse

increased echogenicity, size reduced, irregular borders, and dilated duct

calcification is often found

Ductal diameter exceeding the normal limits

pancreatic duct dilation

Causes of pancreatic duct dilation

acute/chronic pancreatitis

pancreatic neoplasms

A genetic disorder characterized by fluid-filled cysts growing in the kidneys and other organs, including the pancreas

Cysts can be microscopic to large

autosomal dominant polycystic disease

Rare, inherited disorder that increases the risk of developing certain benign and malignant tumors in various parts of the body

Increased risk for developing pancreatic neuroendocrine tumor

Von-hippel lindau syndrome

thick mucus production by the endocrine glands

fatty replacement o the pancreas (calcs)

cysts are single or multiple (mostly microscoptic)

diabetes may develop due to the gradual loss of pancreatic secretion

cystic fibrosis

cystic fibrosis is most commonly seen in which age group

children and young adults

analogous development of the pancreatic duct

single or multiple without septations

more common in the head of pancreas

have epithelial lining

true cysts

Rare cyst usually found in middle aged to elderly males

lesions vary from 1-17cm

Squamous lining and contains kertinous material

lymphoepithelial cysts

Most common primary neoplasm of the pancreas (90%)

Adenocarcinoma

Sonographic findings of adenocarcinoma

loss of normal pancreatic parenchymal pattern

Poorly defined mass in the region of the pancreas

Hypoechoic or isoechoic

irregular borders

pancreatic enlargement

possible dilated CBD and/or pancreatic duct

Rare benign lesion more common in women >60

found in Von-Hippel Lindau disease

Varys insize

Cystic, solid, or echogenic

Microcystic adenoma (cystadenoma, serous adenoma, or glycogen rich adenoma)

slow growing tumor that arises from duct as cystic neoplasm

consists of large cysts

malignant potential occuring more common in tail

macrocystic adenomcarcinoma (muscinos cystadenoma, cystadenocarcinoma)

Sonographic appearance of macrocystic adenomcarcinoma

well-circumscribed, thin or thick walled, with thick mucinous fluid, with or without sepattions

originates from main pancreatic duct or it branches

slow growing lesions affects men in 60-70s

appears as nonvascular nodules within dilated ducts

shows communication with pancreatic duct

Intraductal papillary mucinous tumor

Where do endocrine pancreatic neoplasms arises from

Islet cells of the pancreas

Make up 1/3 of islet cell tumors w/ 92% being malignant

Slow growth rate

Metastases to the liver, regional lymph nodes, lungs, peritoneum, and adrenal glands

Non-functional endocrine pancreatic neoplasms

Most common functional islet cell tumor

Insulinoma

2nd most common functional islet cell tumor

Gastrinoma

Found in patients in their 40-60s with hypoglycemic symptoms

palps

headache

confusion

pallor

Insulinoma

Caused by non insulin secreting pancreatic tumors, which secreting excessive amounts of gastrin

causes stomach to release hypochloric acid an pepsin leads to peptic ulcers

Gastrinoma