Pancreatic Pathologies PDF

# Essa Health ## Dr. Farah Essa Academy **Education+Health+Consultancy** # Pancreatic Pathologies ## Acute Pancreatitis - Acute pancreatitis is acute inflammation of the pancreas (and, sometimes, adjacent tissues). The most common triggers are gallstones and alcohol intake. Other causes include va...

# Essa Health ## Dr. Farah Essa Academy **Education+Health+Consultancy** # Pancreatic Pathologies ## Acute Pancreatitis - Acute pancreatitis is acute inflammation of the pancreas (and, sometimes, adjacent tissues). The most common triggers are gallstones and alcohol intake. Other causes include various drugs, viruses and some metabolic disorders. - Diagnosis is based on clinical presentation, serum amylase and lipase levels, and imaging studies. - **Clinical features include:** - acute abdominal pain, that penetrates to back in 50% of cases. When acute pancreatitis is caused by gallstones, the pain usually starts suddenly and reaches its maximum intensity in minutes. When pancreatitis is caused by alcohol, pain typically develops over a few days. - nausea and vomiting: most patients feel nauseated and have to vomit, sometimes to the point of dry heaves (retching without producing any vomit). - abdominal distention: some patients develop ileus which results in abdominal distention. - **Laboratory tests:** - serum amylase and lipase are usually considerably raised. - white blood cell count is also often raised. - BUN is usually raised. ## Role of Ultrasound Examination - Ultrasound is frequently used as an initial diagnostic tool in patients with acute abdominal pain, it can both diagnose acute pancreatitis and rule out other causes of acute abdominal pain. - One of the major roles of ultrasound in patients with suspected acute pancreatitis is to evaluate the biliary tract for stone disease. - **Limitations:** - In addition to excessive intestinal gas, ultrasound has limited capabilities in evaluating the presence and extent of necrosis, in detecting the full extent of pancreatic related fluid collections and in identifying gastrointestinal tract complications. - The accuracy of diagnostic ultrasound in acute pancreatitis depends on the evolution of the disease and its severity. It is likely that the examination would be inconclusive in the early phases and in the mild forms. ## Sonographic Features of Acute Pancreatitis - Sonographic hallmarks for acute pancreatitis include the following: - a) Pancreatic enlargement - b) Decreased pancreatic echogenicity - c) Parenchymal heterogeneity - d) Peripancreatic fluid collections (30-50%) - The determination of pancreatic echogenicity relies on comparison with the echogenicity of the liver. When the liver is fatty infiltrated and abnormally echogenic, the pancreas may appear hypoechoic even though it is normal. - The changes with acute pancreatitis are usually diffuse but can on certain occasions be focal. ## Edemaous Pancreas Seen In Acute Pancreatitis - The image shows an ultrasound image demonstrating an edemaous pancreas. ## Pancreatitis With Peripancreatic Fluid Collection - The image shows an ultrasound image demonstrating pancreatitis with peripancreatic fluid collection. ## Diffusely Enlarged Pancreas With Hypoechoic Heterogenous Parenchyma - The image shows an ultrasound image demonstrating a diffusely enlarged pancreas with hypoechoic hetergenous parenchyma. ## Swollen Pancreas With Peripancreatic Fluid Collection - The image shows an ultrasound image demonstrating a swollen pancreas with peripancreatic fluid collection. ## Peripancreatic Fluid Collection - Fluid collections occur in more than 30-50% of patients with pancreatitis. - Using an anterior subxiphoid approach, sonography can visualize fluid collections around the body of the pancreas in many patients. - Fluid may accumulate in a mantle anterior, superior and inferior to the pancreas. It may also dissect round the portal splenic confluence. - Using a left lateral approach and the spleen as a window, sonography can identify in the left anterior pararenal space, the left perirenal space and the interfascial plane. These fluid collections are extremely useful when visualization of pancreas is limited. ## Complications of Acute Pancreatitis - Pseudocyst formation - Bile duct obstruction - Pancreatic/peripancreatic abscess - Pancreatic/peripancreatic necrosis - Venous thrombosis - Pseudoaneurysm ## Pancreatic Pseudocyst - Fluid collections that become encapsulated are seen more than 4 weeks after the onset of symptoms are called pseudocysts because they have a capsule made up of fibrous tissue rather than true epithelial cells. - **Location**: they can be seen anywhere, but most are located near the pancreas. - **Sonographic appearance**: they have well-defined smooth margins. Internal contents are usually anechoic, but the presence of debris can result in low level internal echoes. Hemorrhage & infection can also produce complex internal echoes. ## Differential Diagnosis of Pseudocyst - Other causes of pancreatic cyst include the following: - 1. Cystic neoplasm - 2. Cysts related to autosomal dominant PCKD - 3. Von Hippel-Lindau disease - 4. Cystic fibrosis ## Round Anechoic Mass With Few Internal Echoes Seen In Pancreatic Head - The image shows an ultrasound image demonstrating a round anechoic mass with few internal echoes seen in the pancreatic head. ## Pancreatic Pseudocyst With Debris Showing Internal Echoes - The image shows an ultrasound image demonstrating a pancreatic pseudocyst with debris showing internal echoes. ## Hemorrhagic Pseudocyst - The image shows an ultrasound image demonstrating a hemorrhagic pseudocyst. ## Pancreatic Pseudocyst With Septations - The image shows two ultrasound images demonstrating a pancreatic pseudocyst with septations. ## Biliary Obstruction Due To A Multiloculated Pseudocyst At Pancreatic Head - The image shows two ultrasound images demonstrating biliary obstruction due to a multiloculated pseudocyst at the pancreatic head. ## Chronic Pancreatitis - **DEFINITION:** chronic pancreatitis is the permanent impairment of the exocrine pancreatic function and permanent morphologic change in the gland as a result of persistent pancreatic inflammation. - **SONOGRAPHIC SIGNS:** classical sonographic sign is pancreatic calcifications. These typically appear as multifocal, punctate, hyperechoic foci in the pancreas. Shadowing may or may not be present depending upon the size of calcification. These calcifications are intraductal but because they are present in small side branches, they appear to be scattered in the pancreatic parenchyma. Calcifications are mostly seen with alcoholic pancreatitis but infrequently with biliary pancreatitis. ## Sonographic Signs of Chronic Pancreatitis - **DILATATION OF PANCREATIC DUCT** is another sign of chronic pancreatitis. In many cases small strictures produce alternating areas of narrowing and dilatation that are referred to as chain of lakes. - **TORTUOSITY & IRREGULARITY OF THE PANCREATIC DUCT** are also typical of chronic pancreatitis. - **PARENCHYMAL ATROPHY** is seen in advanced chronic pancreatitis. - **FOCAL MASS** may develop that is difficult to distinguish from pancreatic cancer. ## Chronic Pancreatitis - The image shows an ultrasound image demonstrating chronic pancreatitis. ## Enlarged Echogenic Pancreas With Multiple Hyperechoic Non Shadowing Foci - The image shows an ultrasound image demonstrating an enlarged echogenic pancreas with multiple hyperechoic non shadowing foci. ## Pancreas With Heterogenous Parenchyma & Calcifications - The image shows an ultrasound image demonstrating a pancreas with heterogenous parenchyma and calcifications. ## Advanced Chronic Pancreatitis - The image shows an ultrasound image demonstrating advanced chronic pancreatitis. ## Advanced Chronic Pancreatitis With Atrophy And Calcifications - The image shows an ultrasound image demonstrating advanced chronic pancreatitis with atrophy and calcifications. ## Pancreatic Carcinoma - Pancreatic carcinoma is an adenocarcinoma arising from the ductal epithelium and constitutes more than 90% of all pancreatic tumors. - Epithelial tumors arising from the acini are rare. - The 1 year survival rate is 10% with median survivals ranging from 3-8 months. - Pancreatic carcinoma occurs primarily in 60-80 years old patients and is rare in patients under the age of 40. - Approximately 60-70% of the tumors arise in the pancreatic head. 10-20% in the body and 5-10% in tail. ## D/D of Hypoechoic Solid Pancreatic Mass - Carcinoma - Focal pancreatitis - Lymphoma - Neuroendocrine tumors - Metastasis - Islet cell tumors - Thrombosed aneurysms ## Clinical Features - Typical presenting symptom of pancreatic head cancer is painless jaundice. - Tumors in body and tail present with non-specific symptoms of weight loss and pain. - Tumors in the head maybe detected when small and potentially resectable because of biliary tract obstruction and jaundice that occur. - Tumors in the body and tail tend to present as larger masses and are only rarely resectable. ## Sonographic Features of Pancreatic Cancer - Vast majority of pancreatic cancers appear as hypoechoic masses as compared to the adjacent pancreatic parenchyma. - Distortion of pancreatic contour may or may not be present depending upon the size and location. - Obstruction of common bile duct is commonly seen and can be followed distally and abrupt narrowing can be seen at the level of pancreatic mass. - Obstruction of pancreatic duct is also a common finding. Simultaneous dilatation of common bile duct and pancreatic duct should always prompt a consideration of pancreatic carcinoma. - Pancreatic atrophy maybe present focally. ## Mass In Pancreatic Head With Dilated Common Bile Duct - The image shows an ultrasound image demonstrating a mass in the pancreatic head with dilated common bile duct. ## Pancreatic Head Mass With Dilated Pancreatic Duct - The image shows an ultrasound image demonstrating a pancreatic head mass with dilated pancreatic duct. ## Pancreatic Mass With Atrophy of the Gland And Dilated Pancreatic Duct - The image shows an ultrasound image demonstrating a pancreatic mass with atrophy of the gland and dilated pancreatic duct. ## Enlarged Lymph Nodes - The image shows two ultrasound images demonstrating enlarged lymph nodes. ## Neuroendocrine Tumors - Pancreatic neuroendocrine tumors (pancreatic NETs or PNETs) account for about 7 percent of all pancreatic tumors. They may be benign or malignant and they tend to grow slower than exocrine tumors. They develop from the abnormal growth of endocrine (hormone-producing) cells in the pancreas called islet cells. - **INSULINOMAS** account for 70-75% of NETs. They are usually small and solitary and 90-95% are benign. - NETs affect patients either because they are malignant and metastasize or because of excessive hormone production. ## Sonographic Features of NETs - Overall these endocrine tumors of the pancreas tend to be highly vascular and well-circumscribed, often displacing adjacent structures. They can demonstrate calcific or cystic change. - Characteristic features include the following: - Well-circumscribed with smooth margins - Round or oval - Hypoechoic - Liver metastases may be hyperechoic or targetoid ## Hypoechoic Insulinoma In Tail - The image shows an ultrasound image demonstrating a hypoechoic insulinoma in the tail. ## Cystic Pancreatic Neoplasms - Cystic tumors of the pancreas are less frequent than solid lesions and are often detected incidentally, as many of these lesions are small and asymptomatic. However, they may be associated with pancreatitis or have malignant potential. - Cystic tumors of the pancreas are formed by serous or mucinous structures showing all stages of cellular differentiation. - Cystic pancreatic tumors can be subdivided into peripheral (serous cystadenomas, mucinous cystic tumors, solid and papillary epithelial neoplasms, cystic islet cell tumors), which do not communicate with the main pancreatic duct, and ductal tumors (mucinous tumor), according to their site of origin. On the basis of imaging criteria alone, it can be very difficult to differentiate non-tumoral cystic lesions from neoplastic ones. ## Pancreatic Mucinous Cystadenoma - The image shows a Doppler ultrasound image demonstrating a pancreatic mucinous cystadenoma. ## Thank You - B36/2, Main Khayaban e Bahria, Phase 7, DHA, Karachi, Pakistan - +92 333 2137867 - [email protected]