Pancreas Pathology

Islet Cells (Langerhans)

Endocrine cells produced in the pancreas. Produces Alpha and Beta cells

Alpha and Beta cells

types of islet cells responsible for insulin and glucagon production in the pancreas.

Islet Cell Tumors

rare tumors (7%) that arise from abnormal growth of islet cells.

Can be functioning or non-functioning.

Most common: Insulinomas, glucagonomas

Insulinoma

a type of islet cell tumor that secretes excess insulin, leading to hypoglycemia.

Benign

Small, well-encapsulated, good vascular supply

Endoscopic Ultrasound (EUS)

Best imaging modality for pancreatic masses < 2cm

Sensitivity: 87-100% vs. CT 66-86%

Assists with FNA

Best for SOLID lesions

Gastrinoma

20% of islet cell tumors

Usually malignant

Hard to locate

Cystic Neoplastic Lesions

Pancreatic tumors that form cysts

10% of all pancreatic growths are cystic, the rest are solid

Two types: Benign Serous and Malignant Mucinous

Differentiate from pseudocyst (elevated amylase/lipase/inflammation)

Benign Serous Cystadenoma

< 2cm

Cystic/septated on US

Head of pancreas

thin, well-defined capsule with septations/fluid-filled cysts

“Central star” appearance

Malignant Mucinous Cystic Adenoma (AKA cystadenocarcinoma)

> 2 cm

Peripheral rim calcifications

Large, uni or multilocular, encapsulated mass

Most found in the tail = good prognosis

Intraductal Papillary Mucinous Tumor (IPMT)

A type of mucinous cystic neoplasm

Origin = pancreatic duct

Slow growing (60-70s)

Benign then malignant

Pancreas Transplant

Treats diabetes

Placed in the pelvis

Von Hippel-Lindau Disease (VHL)

Autosomal dominant disorder (genetic)

Causes tumors and cysts to grow

Affects the CNS and other organs (65-75% of pt’s have pancreas involvement)

Sono: rim-like peripheral calcifications. Carcinoma is solid and irregular plus liver mets

Biliary/ductal dilatations 

When sweeping through the liver, if you see dilated structures, investigate the surrounding organs and make sure to confirm whether it’s a duct or a vessel (color, turn on it)

Why are we seeing these?

What hereditary disease causes excessive production of mucous by the endocrine glands?

Cystic Fibrosis

Sudden inflammation of the pancreas caused by inflamed acini cells that release pancreatic enzymes to surrounding parenchyma?

Acute pancreatitis

Acute pancreatitis is associated with:

Biliary disease, ETOH (alcohol) abuse, trauma, drugs, infection

Ultrasound appearance of severe pancreatitis

Fibrotic

Ultrasound appearance of pseudocysts

Phlegmon

Sonographic appearance of Chronic Pancreatitis

Signs of atrophy and calcifications, very bright with hyperechoic areas, possibly smaller in size

Sonographic appearance of Acute Pancreatitis

Swelling, fluid around the pancreas, increase in size

Sonographic appearance: adenocarcinoma

Ill-defined/irregular borders, hypoechoic, solid lesion

Also shows dilated ducts and biliary obstruction, no vascularity

(ie. Abnormally dilated CBD due to mass in head of pancreas, jaundice, weight loss)

Indications for Pancreas ultrasound

Epigastric pain

Assess for malignancy, pancreatitis, complications

Abnormal labs (elevated LFTs or enzymes)

Jaundice

Hx of cholelathiasis

Labs to look for

Elevated amylase, lipase, fat in feces, bilirubin, LFTs

Abnormal Amylase levels:

elevated: acute pancreatitis/pancreatic disease

low: pancreas damage, hepatitis, cirrhosis

Abnormal Lipase

Elevated: sudden acute pancreatitis, ductal dilatation, pancreatic carcinoma, acute cholecystitis

Fecal fat removal

undigested fat ~ pancreatitis

Abnormal bilirubin/LFTs

enlargement/neoplasia of pancreas head → stenosis or complete obstruction of the distal common bile duct

(when there’s a mass or inflammation in panc head, it compresses or obstructs CBD so bile can’t drain and bilirubin rises)

“head hits the hepatic highway”

Pancreas location

Retroperitoneum (except tail)

Sits between the duodenal loop and splenic hilum

12.5-15 cm

Pancreatic duct = < 2 mm

Landmarks

Left liver lobe

Splenic vein (elongate to follow tail)

SMA posterior to it

Congenital diseases

Cystic Fibrosis (CF) - inherited that causes damage to lungs, digestive system, other organs by overproducing mucus, sweat, and digestive juices

Decreased enzyme production (exocrine failure in children)

Improper digestion

Causes recurrent pancreatitis

Cystic Fibrosis ultrasound

Makes pancreas hyperechoic and small

Hypoechoic areas can represent pancreatic fibrosis

Small cysts/calcifications, gallstones, liver disease associated with CF

Acute pancreatitis with stone obstructing the pancreatic duct

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Diagnosis?

Gallbladder with wall thickening and a stone obstructing the common bile duct causing dilatation (posterior shadowing). Results in pancreatitis

Dx: gallstones/pancreatitis

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Diagnosis?

Transverse view of the pancreas

Pancreas appears to be swollen/enlarged with increased echogenicity and has peripancreatic fluid

Dx: acute pancreatitis

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Diagnosis?

Transverse image of pancreas

Pancreatic parenchyma appears hyperechoic with echogenic foci (calcifications) throughout. 

Pseudocyst

Most common cystic lesion of the pancreas

Fluid-filled loculus with no epithelial lining

Located outside the pancreas often in lesser sac

Pancreatic tissue is damaged and leaks enzymes and body fluid to form a cyst

Often occurs in the tail

Complications of pseudocyst (fatal)

Hemorrhagic pancreatitis (high mortality rate) *see image

Ruptured pseudocyst

Phlegmonous pancreatitis

Describe this image

US guided FNA of a pancreatic tumor located in the head of the pancreas (based on landmarks)

Adenocarcinoma

Most common malignant mass of pancreas

Poor prognosis (7% chance u live 5 years)

Most common in pancreas head

Can’t differentiate without bx

Hard to diagnose

Often shows increased vascularity around the tumor

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Differential dx?

A well-defined, solid, round, hypoechoic mass located in the head of the pancreas. Most likely adenocarcinoma but needs to be confirmed with biopsy

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Dx?

A well-defined, hypoechoic, complex mass located in the head of the pancreas

Dx: adenocarcinoma

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Dx:

An ill-defined, irregularly shaped, hypoechoic, solid lesion located in the head of the pancreas.

Dx: Adenocarcinoma

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Dx:

Gallbladder in both the longitudinal and transverse planes with low level echoes suggestive of sludge and distention (gallbladder hydrops). 

Dx: Likely diagnosis is choledocholithiasis 

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Dx?

A small, well-defined, hypoechoic, cystic lesion located in the body of the pancreas towards the tail end.

Dx: most likely a cystadenoma

Describe this mass

Dx?

A large, ill-defined, hypoechoic, complex mass located within the pancreatic tail.

Dx: most likely cystic adenocarcinoma but requires biopsy

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Dx?

A large, hypoechoic, complex mass with both solid and cystic components.

Dx: pancreatic adenocarcinoma with cystic mass

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Dx?

A small, hypoechoic, complex mass with microcysts located in the body of the pancreas

Dx: microcystic adenoma of pancreas

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Dx?

An EUS image of a well-defined, hypoechoic cyst with a “central star” and microcysts/septations.

Dx: benign serous cystadenoma