DMS 102- Unit 8 Pancreas

Normal appearance of the pancreas

Iso or hyperechoic to liver, dense or slightly more dense than the liver

Normal measurement of pancreatic duct

< 2mm

Average AP measurement of the pancreatic head

2-3 cm

Average length of the pancreas

12-18 cm

Children

The pancreas appears larger or thicker in _________, will become more proportional w/ age

Splenic artery (branches), pancreaticoduodenal artery (GDA branch)

___________ and _____________ supply the pancreas

Splenic vein, SMV

____________ and ___________ drain the pancreas

Posterior

The IVC, AO, SMA, SMV, SV, PV, and CBD lie ___________ to the pancreas

Superior

The SA and stomach lie ____________ to the pancreas

Splenic hilum

This lies in contact with the pancreatic tail

CBD

This lies inf and post in the head of the pancreas, joins pancreatic duct close to the ampulla of vater

Agenesis

Failure of the body/tail to form, hypertrophy of pancreatic head

Pancreatic divisum

Lack of fusion of pancreatic buds, drainage into pancreatic ducts affected

Hypertrophy

The enlargement of an organ/tissue

Ectopic pancreatic tissue

MOST COMMON ANOMALY, small intramural nodules (in the wall), frequent sites are stomach, duodenum, small bowel, and colon

Acute pancreatitis, tumor

___________________ or _________ may still occur in ectopic pancreatic tissue

Annular pancreas

Head of pancreas surrounds 2nd portion of duodenum, RARE, may cause complete or partial atresia of duodenum, occurs more in males

Shapes of the pancreas

Tadpole, dumbbell, sausage, comma/boomerang

Acini cells

Exocrine functioning cells of the pancreas, produces 2 L of pancreatic juice a day

Lipase

Exocrine enzyme that digests fats

Amylase

Exocrine enzyme that digests carbohydrates

Carboxypeptidase, trypsin, and chymotripsin

Exocrine enzymes that digest proteins

Nucleases

Exocrine enzymes that digest nucleic acids

Sodium Bicarbonate

Exocrine component that neutralizes gastric acids, VERY high content in pancreatic juices

Chyme

Partially digested food in stomach

Hormones that stimulate pancreatic juice formation

Gastrin, CCK, acetylcholine, and secretin

Islets of Langerhans

Cells of endocrine function in the pancreas

Alpha cells

These produce glucagon (glycogen to glucose)

Beta cells

These produce insulin (glucose to glycogen)

Delta cells

These produce somatostatin (inhibits both insulin and glucagon)

Amylase, Lipase

____________ and __________ are the 2 notable pancreatic function labs

Acute pancreatitis

Amylase elevated x2 and elevation in lipase is a good indicator of ____________________

Chronic pancreatitis

Elevated amylase is a good indicator of ______________________

Pancreatic carcinoma

Just elevated lipase is a good indicator of _________________

Indications for Pancreatic US

• Abd pain

• Clinically acute or chronic pancreatitis

• Abnormal labs

• Cholecystitis

• Obstructive jaundice

Normal echotexture of the pancreas

Finer than surrounding retroperitoneum, coarser than the liver, homogenous

Younger, acute pancreatitis

A decreased echogenicity of the pancreas may indicate the patient is _________ or has ________________

Older, diabetes, fatty infiltrate, fibrous

An increased echogenicity of the pancreas may indicate that the patient is _________, has ____________ or ______________. Can also indicates ________ changes.

Water

The stomach can be used as a window if the patient drinks________.

Pancreatic tissue

You can ensure you’re imaging the pancreatic duct by making sure there is ______________ on either side of the duct.

Pancreatitis

Inflammation of the pancreas, occurs form damage or malfunction

Acute pancreatitis

Sudden onset pancreatitis, MOST COMMON CAUSE IS BILIARY TRACT DISEASE, can be caused by alcoholism

Chronic pancreatitis

Recurrent attacks of acute pancreatitis, caused by chronic biliary disease or chronic alcoholism

Complications of pancreatitis

Fluid collections, pseudocysts, bile duct or duodenal obstruction, ascites, pancreatic CA, SV thrombosis, psuedoaneurysms, splenic artery aneurysms secondary to pancreatitis (more vessels are possible)

Pseudocysts

A collection of fluid typically pancreatic juices,arises from loculation of inflammatory processes, necrosis or hemorrhage, MOST COMMON COMPLICATION OF PANCREATITIS

50

Rupture of pancreatic pseudocyst into the peritoneal cavity has a ____% mortality rate

Hemorrhagic pancreatitis

Rupture of pancreatic vessels & hemorrhage, necrosis of pancreatic tissue, ascites, RAPID progression of acute pancreatitis

Hematocrit, calcium

Hemorrhagic pancreatitis has decreased ________ and ________ levels

Phlegmonous pancreatitis

Spread of diffuse inflammatory edema of soft tissues

(Big BOGGY mass)

Pancreatic abcess

Low incidence, collection of infectious material as a complication of pancreatitis

Abcess

An __________ can be differentiated from a fluid collection due to air/gas bubbles producing a dirty shadow

True cyst

Congenital or acquired, multiple microscopic sacs, contain pancreatic enzymes and arise from within the gland

Types of Acquired cysts

Pseudocysts (most common), retention cysts, parasitic cysts, and neoplastic cysts

Congenital cysts

Cysts caused from abnormal development of pancreatic ducts, multiple are present, anywhere from 3-5 cm

Polycystic

Even though this is most common in the liver, __________ disease can also be present in the pancreas

Von Hippel-Lidau Syndrome

Syndrome in which the formation of tumors and cysts take place in many different parts of the body, can be single or multiple, ranging widely in size (microscopic to many cm), well defined mass w/ thick fluid

CF (cystic fibrosis)

A fibrocystic disease of pancreas, heredity disorder of endocrine glands, acini are replaced by fibrous tissue producing an overall nodular/firm pancreas

Serous cystadenoma

Tiny cystic masses approx 60% in tail and 30% in head, benign disease, rare, occurs more in females, cysts similar to pseudocysts on US,

Mucinous cystadenoma

Rare/slow growing cystic mass arising from the ducts, SIGNIFICANT malignant potential, more common in tail (60%) and body

Intraductal Papillary Mucinous Neoplasm

Originates from main pancreatic duct or branches, benign to malignant, a form of mucinous cystic neoplasm, slow growing and more common in elderly populations

Solid pseudopapillary neoplasm

Neoplasms common in young women, with low incidence of malignancy, usually asymptomatic, frequently seen in tail

Categories of Pancreatic Islet Cell Tumors

Functional or nonfunctional

Insulinoma

Most common functional islet cell tumor, hard to visualize, in body or tail typically, HYPERVASCULAR, may have calcifications, slow growing

Gastrinoma

2nd most common functional islet cell tumor, excessive amounts of Gastrin, 60% are malignant, HYPERVASCULAR

Adenocarcinoma

Most common nonfunctional islet cell tumor, most common primary neoplasm, 90% of all malignant pancreas tumor, considered fatal due to late catch, more common in females, head most common location

Mets to Pancreas

Uncommon, found in 10% of CA patients, Mets from melanomas, breast, GI tract, and lungs

Lymphoma

Most common parapancreatic neoplasm, spread to pancreas, displacement anteriorly of superior mesenteric vessels, multiple enlarged nodes in the area of the porta hepatis

IDDM

Insulin dependent diabetes mellitus

NIDDM

Non insulin dependant diabetes mellitus

Polydipsia

Excessive thirst

Glycosuria

Glucose excreted in the urine

Pancreatic transplant types

Cadaveric and islet cell

Auto transplant

Islet cells retrieved from the patient, pancreatectomy performed due to chronic pain such as pancreatitis or trauma (rarely)

Allotransplant

Islet cells come from a donor, cells are isolated and purified, cell clusters infused into the hepatic sinusoids via PV

Pancreatic Transplant Doppler Eval

Iliacs, anastamoses site, pancreatic vessels, follow all the way to the pancreatic tissue

Indirect

With __________ Doppler, it is NOT necessary to angle correctly. This is typically done within the organ.

Direct

With ________ Doppler, it IS necessary to angle correctly. With this, anastomoses site, mid, and righty before the vessel enters the pancreatic tissue should be dopplered.

Pathologies

Transplants can still get ____________, just like the original pancreas.

Complications of pancreatic transplant

Rejection, pancreatitis, infection, ischemia, anastomotic leak, pancreatic Adenocarcinoma, post-transplant lymphoproliferative disorder

EUS (endoscopic ultrasonography)

Specialized ultrasound probe on the end of an endoscope, high frequency (7-12 MHz), aids in and is MOST accurate in staging pancreatic CA