pancreas

The pancreas is located in the (intra/retro)peritoneum.

Retroperitoneum

1. Inside of the retroperitoneum, the pancreas lies anterior to what?

2. Posterior to?

1. Pararenal space

2. The lesser sac

Label the renal spaces/fascia seen here.

1. Anterior renal fascia

2. Anterior pararenal space

3. Posterior pararenal fascia

4. Retrorenal fascia

5. Perirenal space

1. What is the name of the area in ‘red’?

2. Blue?

1. Greater sac

2. Lesser sac

The pancreas head lies _______ to the 2nd part of the duodenal loop.

Medial

What structures does the pancreas lie between?

• Duodenal loop

• Splenic hilum

The tail of the pancreas lies anterior to which 2 structures?

• Splenic hilum

• Upper pole of the left kidney

Label the parts of the pancreas.

1. Head

2. Neck

3. Body

4. Tail

Label the crossed-out parts of this image.

1. IVC

2. Pancreatic head

3. SMV/Portal Confluence

4. Uncinate process

5. Right renal artery

6. Aorta

7. Splenic vein

8. Pancreatic tail

What are the two small vessels that can be seen to the right of the pancreatic head?

1. Gastroduodenal artery

2. Common bile duct

What is the relationship of the pancreatic head to the IVC?

Anterior

What is the relationship of the SMA to the neck/body of the pancreas?

Posterior

What is the relationship of the CBD to the GDA?

Posterior

Is the SMA on the patient’s right or left?

Left

What is the relationship of the portal confluence to the pancreatic neck?

Posterior

What is the relationship of the portal confluence to the uncinate process?

Anterior

What is the relationship of the pancreas to the splenic vein?

Anterior

The ‘U’ in this image stands for what?

Uncinate process

List the 4 landmarks that lie behind the pancreas.

• Aorta/IVC

• Superior mesenteric vein and Superior mesenteric artery

• Splenic vein

• Portal confluence

Where does the portal splenic confluence lie in relation to the uncinate process?

Anterior

Where does the pancreas lie in relation to the posterior wall of the stomach?

Posterior

The arrows point to a structure that is often times mistaken for the pancreatic duct, what is it actually?

Stomach wall

The celiac axis comes off the _________ border of the pancreas.

Superior

The superior mesenteric artery comes off the _________ border of the pancreas.

Inferior

Where does the splenic artery lie in relation to the pancreas?

• Superior

• Anterior

Which 2 structures does the superior mesenteric artery and superior mesenteric vein lie anterior to?

• 3rd part of the duodenum

• The uncinate process

What are the labeled numbers pointing to?

1. Gastroduodenal artery

2. Common bile duct

What is the crossed out portion if the ‘P’ stands for pancreas?

Common bile duct

Where does the gastroduodenal artery (GDA) lie in relation to the pancreas?

• Anterior

• Lateral

Where does the common bile duct (CBD) lie in relation to the pancreas?

• Posterior

• Lateral

The pancreaticoduodenal arteries supply what 2 structures?

• Pancreatic head

• Part of the duodenum

The pancreas receives blood from what 3 vessels?

• Celiac axis

• Splenic artery

• Superior mesenteric artery

Venous drainage of the pancreas is through the tributaries of what 2 vessels??

• Splenic vein

• Superior mesenteric vein

Where does the superior mesenteric vein lie in relation to the superior mesenteric artery?

To the right

What is the name of the vessel crossed out and to the right of the SMA?

Superior mesenteric vein

What does the white arrow point to?

Duct of wirsung

What does the white arrow point to?

Duct of wirsung

What are the 2 types of pancreatic ducts?

• Duct of Wirsung

• Duct of Santorini

The duct of wirsung is the (1)_______ duct that extends the entire length of the (2)______.

1. Primary

2. Gland

What duct meets with the CBD to become the ampulla of vater (hepaticopancreatic ampulla)?

Duct of wirsung

What forms the ampulla of vater?

• CBD

• Duct of wirsung

What is another term for ampulla of vater?

Hepaticopancreatic ampulla

1. What are the normal dimension measurements for the duct of wirsung?

2. Does it need to be measured?

1. 3 mm head and 2 mm body

2. No, only needs to be measured if the body is larger than 2 mm

The duct of santorini is a (1)_________ duct that drains the (2)___________________ head.

1. Secondary

2. Upper, anterior

What are the 2 physiological functions of the pancreas?

• Endocrine function

• Exocrine function

Which function has a ductal system?

Exocrine function

The endocrine function of the pancreas…

1. Secretes ________ through the ___________________ into the blood or tissue

2. Controls ________ and ________ secretion

1. Insulin, Islets of Langerhans

2. Glucagon, insulin

What can endocrine function failure lead to?

Diabetes

1. The exocrine function of the pancreas secretes what 3 enzymes?

2. The pancreas will secrete these through the _______.

3. What do they assist with?

1. Lipase, amylase, and trypsin

2. Ducts

3. Breaking down foods

What is the mnemonic for remembering the pancreatic lab values?

Amy likes carbs and sugars,

Tripped over proteins,

and broke her fat lip

What does amylase do?

Digests carbs and turns them into sugar

What does lipase do?

Breaks down fats

What does trypsin do?

Digest proteins

1. What lab values are used to diagnose acute pancreatitis?

2. Why?

1. Amylase and lipase

2. They both rise significantly with it

1. Which lab value is more reliable for the diagnosis of acute pancreatitis?

2. Why?

1. Lipase

2. Because amylase does not stay elevated for long

Why are labs not useful with chronic pancreatitis?

Because the levels won’t rise much due to the irreversible damage done to the pancreas.

Anytime there is inflammation or abscess, what can lab increase?

WBCs

These are the 7 indications for a pancreatic evaluation:

1. Severe _________ pain

2. Abdominal pain radiating to the ______

3. _______ disease

4. Abnormal pancreatic ________

5. Painless ________ with ____ mass (_________’s sign)

6. Unexplained weight _____

7. Nausea/vomiting

1. Epigastric

2. Back

3. Biliary

4. Enzymes (amylase, lipase, trypsin)

5. Jaundice, RUQ, Courvoisier’s

6. Loss

7. Nausea/vomiting

Define Courvoisier’s sign.

An enlarged GB from occlusion.

1. What is the patient prep. for a pancreatic exam?

2. What can this ensure?

1. NPO for 6-8 hours

2. Ensures an empty stomach and reduced bowel/gas

1. If the pancreas is difficult to see, what is a useful tip?

2. Why would this tip be useful?

1. Have the patient drink water (16 oz.) on their left side and then have them turn on to their right side.

2. The water in the stomach can be used as a window.

How should the probe be positioned/angled to view the pancreas?

Starting at the xiphoid process, angle inferiorly to the left liver lobe or to the spleen as windows.

What 2 organs are mistakenly taken as the pancreas?

• Stomach

• Duodenum

1. What is the pancreas protocol in transverse?

2. Sagittal?

1. Entire visualized pancreas in transverse

2. Only the pancreatic head in sagittal

What 4 positions can be utilized for a pancreatic exam?

• Supine

• Semi upright

• Oblique

• Decubitus

What 3 breathing techniques can be used for examining the pancreas?

• Inspiration

• Expiration

• Pushing out the abdomen

What are 2 limitations for visualizing the pancreas?

• Overlying bowel gas

• Patient body habitus

What texture does a normal pancreas have?

• Homogenous

• Coarse echotexture

1. What does the surface of the pancreas look like?

2. Why would it look like this?

1. Smooth to slightly lobular

2. The Islets of Langerhans

Why is the pancreas difficult to see sometimes?

Because it is a non-encapsulated organ.

Compared to the liver, what is the echogenicity of the pancreas?

• Isoechoic

• OR hyperechoic

What echogenicity does a child’s pancreas have?

Hypoechoic

What echogenicity does an adult’s pancreas have?

Hyperechoic

1. If a child has a hyperechoic pancreas, is that normal?

2. If abnormal, what can that be an indication for?

1. No

2. Cystic fibrosis

What is the typical AP measurement for the pancreas?

Less than 3 cm

1. What measurements are these?

2. What is the normal measurement for these?

1. AP

2. Less than 3 cm

1. This image was taken in what plane?

2. Explain your answer.

1. Transverse

2. The entire pancreas is visualized

1. This image was taken in what plane?

2. Explain your answer.

1. Sagittal

2. The pancreas head is the only part visualized

Label the structures with the colored arrows/circle.

Red = GDA

Orange = CBD

Yellow = Portal confluence

Green = Splenic vein

Blue = Uncinate process

Purple = IVC

Pink = RRA

White = LRV

What are the 4 pancreatic congenital anomalies?

• Agenesis

• Pancreas Divisum

• Ectopic Pancreatic Tissue

• Annular Pancreas

What is pancreatic agenesis?

• Absence of the body and tail

• With hypertrophy of the pancreatic head

Pancreas divisum is when there is a failure of the _______ and _______ pancreatic ductal systems to fuse during embryonic development.

• Dorsal

• Ventral

2 of the 4 congenital pancreatic anomalies are challenging diagnoses with US. What are they?

• Pancreas divisum

• Ectopic pancreatic tissue

Which of the 4 congenital anomalies is the most common pancreatic anomaly?

Ectopic pancreatic tissue

1. What is ectopic pancreatic tissue?

2. Where can it be found?

1. When pancreatic tissue is outside and separated

2. Along the GI tract

What is an annular pancreas?

When the pancreatic tissue encircles the 2nd portion of the duodenum.

An annular pancreas can cause what?

Duodenal atresia

What causes duodenal atresia?

Annular pancreas

1. Duodenal atresia creates what sign?

2. What is this sign essentially?

1. Double bubble sign in the fetus

2. Dilated stomach and duodenum

The pancreas is wrapped around the duodenum. What can be assumed here?

Annular pancreas

A patient with gallstones presented to the ER and this was seen at the pancreas. What can be assumed?

Acute pancreatitis

What are the 2 most common causes of acute pancreatitis?

• Biliary tract disease (gallstones)

• Chronic alcohol disease

How does acute pancreatitis appear on US?

• Enlarged

• Hypoechoic

This patient has been getting follow up USs regarding their pancreatitis. The patient has a history of consuming large amounts of alcohol. What can be assumed here?

Chronic pancreatitis

The patient has on their chart that they consume alcoholic beverages daily. When an US was performed, this was seen at the pancreas. What is can be assumed here?

Chronic pancreatitis

How does chronic pancreatitis occur?

From repeated episodes of pancreatitis

What is the most common cause of chronic pancreatitis?

Alcoholism

How does chronic pancreatitis appear on US? (3)

• Small

• Echogenic gland

• Calcifications

The patient presented with some jaundice and an US was ordered. What can be assumed here?

Adenocarcinoma

The patient presented with a palpable mass in the RUQ and an US was ordered. What can be assumed here?

Adenocarcinoma