Imaging of the Pancreas

IMAGING OF PANCREASUSG &CT

DR. MEGHA SANGHVIM.D. RADIODIAGNOSIS

ASSISTANT PROFESSORB.J.M.C., CIVIL HOSPITAL,

AHMEDABAD.

ANATOMY OF PANCREAS

• Length – 15 cm.• Head, uncinate process,

neck, body, tail• Gradually tapering “Horse

shoe” shape.• Head – 23 +/- 3 mm• Neck – 19 +/- 2.5 mm• Body – 20 +/- 3 mm• Tail – 15 +/- 2.5 mm

• Length – 15 cm.• Head, uncinate process,

neck, body, tail• Gradually tapering “Horse

shoe” shape.• Head – 23 +/- 3 mm• Neck – 19 +/- 2.5 mm• Body – 20 +/- 3 mm• Tail – 15 +/- 2.5 mm

IMAGING MODALITIESImaging of pancreas

• Radiograph – detect calcification (practicallyof no help)

• Barium studies – indirect signs (not helpful)• USG – differentiation of cystic and solid

lesions (screening tool & for follow-up)• CT scan – modality of choice• MRI and MRCP – complimentary to CT

• Radiograph – detect calcification (practicallyof no help)

• Barium studies – indirect signs (not helpful)• USG – differentiation of cystic and solid

lesions (screening tool & for follow-up)• CT scan – modality of choice• MRI and MRCP – complimentary to CT

ULTRASONOGRAPHYImaging of pancreas

• Widely available• Easily accessible• Can be repeated as often as necessary• Cheap• No ionizing radiation• Portability• Other causes of medical and surgical acute abdomen can be

identified and excluded

• Widely available• Easily accessible• Can be repeated as often as necessary• Cheap• No ionizing radiation• Portability• Other causes of medical and surgical acute abdomen can be

identified and excluded

PRIMARILY USED AS SCREENING TOOL & FOR FOLLOW UP

CT SCANImaging of pancreas

• Gold standard for all pancreatic pathologies• Detects complications• Helps in staging of tumors• Post processing techniques are of additional help

MPR MIP-VESSELS CURVED MPR-DUCTS

GOLD STANDARD FOR PANCREAS

MRI/MRCPImaging of pancreas

• Pancreatic Duct

• Side branches

• Lower end of CBD

• Pancreatic Duct

• Side branches

• Lower end of CBD

MAINLY A PROBLEM SOLVING TOOL

PATHOLOGYImaging of pancreas

• Pancreatitis

• Pancreatic divisum

• Tumors

• Traumatic – Laceration and pancreatic ductinjury

• Pancreatitis

• Pancreatic divisum

• Tumors

• Traumatic – Laceration and pancreatic ductinjury

ACUTE PANCREATITISImaging of pancreas

• Increase in the volume of pancreas• Oedematous changes• Peripancreatic fluid collections• Peripancreatic fat stranding• Haemorrhagic areas• Pancreatic necrosis• Superinfection• Vascular complications

• Increase in the volume of pancreas• Oedematous changes• Peripancreatic fluid collections• Peripancreatic fat stranding• Haemorrhagic areas• Pancreatic necrosis• Superinfection• Vascular complications

ACUTE PANCREATITISUltrasonography

ACUTE PANCREATITISCT Scan


NECROSIS SPL.V.THROMBOSIS

PSEUDOANEURYSM

PSEUDOANEURYSM


INFECTEDCOLLECTION

CT severity index - CTSI

What is CTSI?

A scoring index for grading acute

pancreatitis based on CT scan findings

and extent of pancreatic and

peripancreatic inflammatory changes

A scoring index for grading acute

pancreatitis based on CT scan findings

and extent of pancreatic and

peripancreatic inflammatory changes

Prognostic Indicator points Pancreatic inflammation Normal pancreas 0 Intrinsic pancreatic abnormalities with or without

inflammatory changes in peripancreatic fat 2 Pancreatic or peripancreatic fluid collection or

peripancreatic fat necrosis 4

Pancreatic necrosis None 0 0 minimal 2 substantial 4

Extrapancreatic complications (one or more ofpleural effusion, ascites, vascular complications,parenchymal complications, or gastrointestinal tractinvolvement) 2

CT severity index - CTSIPrognostic Indicator points

Pancreatic inflammation Normal pancreas 0 Intrinsic pancreatic abnormalities with or without

inflammatory changes in peripancreatic fat 2 Pancreatic or peripancreatic fluid collection or

peripancreatic fat necrosis 4

Pancreatic necrosis None 0 0 minimal 2 substantial 4

Extrapancreatic complications (one or more ofpleural effusion, ascites, vascular complications,parenchymal complications, or gastrointestinal tractinvolvement) 2

Mild - 0 to 2Moderate - 4 to 6Severe - 8 to 10

CTSI (Modified)

Mild - 0 to 2Moderate - 4 to 6Severe - 8 to 10

Modified CTSI correlates with length of hospitalstay, need for intervention or surgery, infectionand organ failure

CHRONIC PANCREATITISImaging of pancreas

• Parenchymal atrophy / focal bulge

• Parenchymal Calcification

• Ductal dilatation

• Pseudocyst and other complications

• Peripancreatic fascial thickening and blurring of pancreatic

margins

• Vascular Cx : PV/SV thrombosis, SA pseudoaneurysm

• Parenchymal atrophy / focal bulge

• Parenchymal Calcification

• Ductal dilatation

• Pseudocyst and other complications

• Peripancreatic fascial thickening and blurring of pancreatic

margins

• Vascular Cx : PV/SV thrombosis, SA pseudoaneurysm

CHRONIC PANCREATITISUltrasonography

USG cannot diagnose chronic pancreatitis despiteadvanced disease stage at times.

CHRONIC PANCREATITISCT Scan

CT is more sensitive in diagnosing pancreatic calcification andparenchymal atrophy than USG.CT is considered as modality of choice in diagnosing chronicpancreatitis.

Chronic pancreatitis Pseudocyst

RECURRENT PANCREATITISImaging of pancreas

GALLSTONES

PANCREATICDIVISUM

GALLSTONES

Causes repeated acute pancreatitis.Failure of the dorsal and ventral pancreaticprimordia to fuse.

The dorsal duct drains into the duodenum atthe minor papilla, and the ventral duct drainsvia the major ampulla with the CBD.

MRCP easily reveals the dorsal pancreatic ductin patients with divisum, whereas cannulationof the minor papilla of such patients for ERCP isfrequently unsuccessful .

PANCREATIC DIVISUMRecurrent pancreatitis

Causes repeated acute pancreatitis.Failure of the dorsal and ventral pancreaticprimordia to fuse.

The dorsal duct drains into the duodenum atthe minor papilla, and the ventral duct drainsvia the major ampulla with the CBD.

MRCP easily reveals the dorsal pancreatic ductin patients with divisum, whereas cannulationof the minor papilla of such patients for ERCP isfrequently unsuccessful .

36-year-old woman with h/O Pancreatitis.

MRCP shows separate dorsal and ventral pancreaticduct systems consistent with divisum.

Ventral PD

Dorsal PD

PANCREATIC TUMORSImaging of pancreas

• Benign

• Primary malignant

• Endocrine tumors

• Metastasis

• Benign

• Primary malignant

• Endocrine tumors

• Metastasis

PANCREATIC TUMORSImaging modalities

• US is the first line imaging test.

• The overall sensitivity & specificity of USG for

determining resectability of all pancreatic

carcinomas is only 63% and 83%

• CT – gold standard for diagnosis & staging

• MRCP – for periampullary tumors

• EUS - most sensitive - head tumors < 2 cm.

• US is the first line imaging test.

• The overall sensitivity & specificity of USG for

determining resectability of all pancreatic

carcinomas is only 63% and 83%

• CT – gold standard for diagnosis & staging

• MRCP – for periampullary tumors

• EUS - most sensitive - head tumors < 2 cm.

PANCREATIC TUMORSImaging features

• Morphologic and contourchanges

• Mass effect• Density changes• Contrast enhancement• Pancreatic duct changes• Secondary signs

• Morphologic and contourchanges

• Mass effect• Density changes• Contrast enhancement• Pancreatic duct changes• Secondary signs

Hypovascular

PANCREATIC TUMORSCT Scan

LymphnodesPeritonealnodules


Involvement of duodenum – T3Involvement of CBD –T3


Pancreatic Carcinoma withKrukenberg metastasis

PANCREATIC TUMORSStaging and resectability

• Stage I

• Stage II

• Stage III

• StageIV

Resectable

• Stage I

• Stage II

• Stage III

• StageIVUnresectable

• Grade 0: normal fat plane b/w tumor and vessel.• Grade 1: loss of fat plane b/t tumor and vessel,

with or without smooth displacement of thevessel.

• Grade 2: flattening and/or slight irregularity of oneside of the vessel (<180o)

• Grade 3: encased vessel with tumor encasing>180o, altering its contour and producingconcentric or eccentric lumen narrowing

• Grade 4: atleast one major occluded vessel

VENOUS ENCASEMENT & RESECTABILITYPancreatic tumors

• Grade 0: normal fat plane b/w tumor and vessel.• Grade 1: loss of fat plane b/t tumor and vessel,

with or without smooth displacement of thevessel.

• Grade 2: flattening and/or slight irregularity of oneside of the vessel (<180o)

• Grade 3: encased vessel with tumor encasing>180o, altering its contour and producingconcentric or eccentric lumen narrowing

• Grade 4: atleast one major occluded vessel

• Grade 0

• Grade 1 Resectable

• Grade 2

• Grade 3 With en bloc venous resection

• Grade 4 Unresectable


• Grade 0

• Grade 1 Resectable

• Grade 2

• Grade 3 With en bloc venous resection

• Grade 4 Unresectable


Resectable


Unresectable

• Encasement or involvement of celiactrunk, hepatic artery, gastroduodenalartery or superior mesenteric artery –unresectable.

• See for – perivascular cuff of soft tissue

ARTERIAL ENCASEMENT & RESECTABILITYPancreatic tumors

• Encasement or involvement of celiactrunk, hepatic artery, gastroduodenalartery or superior mesenteric artery –unresectable.

• See for – perivascular cuff of soft tissue

ARTERIAL ENCASEMENT & RESECTABILITYPancreatic tumors

SMA encasementCoeliac trunkencasement

MUCINOUS CYSTADENOMAPANCREATIC TUMORS

•40-50 YEARS•“MOTHER LESION”•MALIGNANT POTENTIAL•MACROCYSTIC•USUALLY 1 CYST•PERIPHERAL CALCIFICATION (25%)•BODY AND TAIL (90%)

•40-50 YEARS•“MOTHER LESION”•MALIGNANT POTENTIAL•MACROCYSTIC•USUALLY 1 CYST•PERIPHERAL CALCIFICATION (25%)•BODY AND TAIL (90%)

•60-70 YEARS“GRANDMOTHER LESION”•BENIGN•LOBULATED•MICROCYSTIC•CENTRAL SCAR (18%)

SEROUS CYSTADENOMAPANCREATIC TUMORS

•60-70 YEARS“GRANDMOTHER LESION”•BENIGN•LOBULATED•MICROCYSTIC•CENTRAL SCAR (18%)

• Classification based on the ductarchitecture

Main duct type- diffuse or segmentaldilatation of the MPD

Branch duct type-dilatation of branchducts

Combined type – Main + branch ducts

Branch duct type IPMTDilatation of the branch ducts

INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN)PANCREATIC TUMORS

• Classification based on the ductarchitecture

Main duct type- diffuse or segmentaldilatation of the MPD

Branch duct type-dilatation of branchducts

Combined type – Main + branch ducts

INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN)PANCREATIC TUMORS

•Rare – low grademalignancy.

•Commonly seen inyoung femalesinvolving pancreatictail – “Daughter’stumor”

SOLID PAPILLARY & EPITHELIAL NEOPLASM (SPEN)PANCREATIC TUMORS

•Rare – low grademalignancy.

•Commonly seen inyoung femalesinvolving pancreatictail – “Daughter’stumor”

• Neoplasms ofneuroendocrinecells.

• 50% - functioningand 50% -malignant.

• Diagnostic clue -Hypervascularity.

ISLET CELL TUMORPANCREATIC TUMORS

• Neoplasms ofneuroendocrinecells.

• 50% - functioningand 50% -malignant.

• Diagnostic clue -Hypervascularity.

ISLET CELL TUMORPANCREATIC TUMORS

•Focal or diffuse masswithout dilatation of PD.

•Associated with largelymphnodes.

•Common in immuno-compromised patients.

LYMPHOMAPANCREATIC TUMORS

•Focal or diffuse masswithout dilatation of PD.

•Associated with largelymphnodes.

•Common in immuno-compromised patients.

• The diagnosis of duct injury is critical to subsequenttreatment of the patient.

• MRCP can accurately depict the integrity of the pancreaticduct as well as the site of disruption

• MRCP can reveal the duct that is upstream from the siteof disruption, which is difficult with ERCP.

PANCREATIC TRAUMA

• The diagnosis of duct injury is critical to subsequenttreatment of the patient.

• MRCP can accurately depict the integrity of the pancreaticduct as well as the site of disruption

• MRCP can reveal the duct that is upstream from the siteof disruption, which is difficult with ERCP.

25 year old male with blunt abdominalinjury.MRCP shows complete disruption ofpancreatic duct in body region with distaldilatation

• USG – Used as primary screening tool.• MDCT – modality of choice – for most

pancreatic pathologies• CTSI – important to decide prognosis• MRCP - complimentary tool for evaluation

of duct and variations of ductal anatomy• Staging has a very important role in the

management and prediction of prognosisin pancreatic tumors.

CONCLUSIONImaging of pancreas

• USG – Used as primary screening tool.• MDCT – modality of choice – for most

pancreatic pathologies• CTSI – important to decide prognosis• MRCP - complimentary tool for evaluation

of duct and variations of ductal anatomy• Staging has a very important role in the

management and prediction of prognosisin pancreatic tumors.

THANK YOU

Documents

Imaging of the Pancreas