Diagnostic Ultrasound - Abdomen and Pelvis
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Diagnostic Ultrasound - Abdomen and Pelvis

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09.07.2019 Views

Pancreatic Pseudocyst (Left) Transverse ultrasound shows a slightly lobular pseudocyst ſt within the pancreatic body with a welldefined capsule and layering sediment dependently . Note the mass effect on the stomach which is displaced anteriorly. (Right) Axial CECT in the same patient shows the pseudocyst ſt in the pancreatic body. The layering debris is not readily evident on this image, and is much better demonstrated on the ultrasound. Diagnoses: Pancreas (Left) Transverse ultrasound at the pancreatic tail shows a complex unilocular pseudocyst ſt with internal echogenic debris , likely hemorrhage. Note the faint posterior shadowing . (Right) Axial CECT in the same patient is shown. Although the pseudocyst ſt is well delineated, the internal debris is barely visible, and much better depicted with ultrasound. (Left) Transverse transabdominal ultrasound shows a large pseudocyst ſt at the pancreatic tail. Internal echoes are the result of hemorrhage within the pseudocyst. (Right) Thick-slab MRCP shows a pseudocyst superior to the tail of the pancreas in a patient with acute on chronic pancreatitis. The pseudocyst communicated with the dilated irregular duct in the tail of pancreas st. Note undilated irregular duct in the head and body , edematous stomach ſt, and inflammatory fluid in the left retroperitoneum . 361

Chronic Pancreatitis Diagnoses: Pancreas TERMINOLOGY • Progressive, irreversible inflammatory and fibrosing disease of pancreas IMAGING • Dilated main pancreatic duct (MPD) with intraductal calculi is highly specific for chronic pancreatitis • Diffuse or focal involvement of pancreatic parenchyma with inflammation and fibrosis • Gland is usually atrophic, but can have focal enlargement, especially in head • Parenchymal calcifications associated with alcohol abuse • US can demonstrate dilated MPD, atrophy, and calcifications • MRCP best to visualize dilated MPD and side branches ○ Assess for ductal disruption: Continuity of MPD with pseudocyst, bowel, or pleural space • MR with contrast helpful to distinguish tumor from enlargement related to inflammation KEY FACTS • CT best to evaluate extent of calcifications and inflammation related to acute on chronic pancreatitis TOP DIFFERENTIAL DIAGNOSES • Infiltrating pancreatic carcinoma • Acute pancreatitis • Groove pancreatitis • Autoimmune pancreatitis • IPMN (intraductal papillary mucinous neoplasm) of pancreas DIAGNOSTIC CHECKLIST • Glandular atrophy, dilated MPD, and intraductal calculi/parenchymal calcifications are best signs for chronic pancreatitis • May be very difficult to distinguish chronic pancreatitis with focal fibrotic enlargement of head from pancreatic adenocarcinoma (Left) Transverse ultrasound demonstrates marked pancreatic ductal dilatation , intraductal stones , and parenchymal calcifications within the atrophic parenchyma. (Right) Transverse ultrasound demonstrates a dilated main pancreatic duct (MPD) with intraductal calculus and parenchymal calcifications ſt, consistent with chronic pancreatitis. A bilobed fluid collection in the head is consistent with a small pseudocyst. The parenchyma st has normal size and echogenicity. (Left) Transverse ultrasound shows predominantly parenchymal calcifications without intraductal calculi. The gland is normal in size in this example. (Right) Transverse ultrasound demonstrates a dilated pancreatic duct with intraductal calcifications in the head/neck region . 362

Chronic Pancreatitis<br />

Diagnoses: Pancreas<br />

TERMINOLOGY<br />

• Progressive, irreversible inflammatory <strong>and</strong> fibrosing disease<br />

of pancreas<br />

IMAGING<br />

• Dilated main pancreatic duct (MPD) with intraductal calculi<br />

is highly specific for chronic pancreatitis<br />

• Diffuse or focal involvement of pancreatic parenchyma<br />

with inflammation <strong>and</strong> fibrosis<br />

• Gl<strong>and</strong> is usually atrophic, but can have focal enlargement,<br />

especially in head<br />

• Parenchymal calcifications associated with alcohol abuse<br />

• US can demonstrate dilated MPD, atrophy, <strong>and</strong><br />

calcifications<br />

• MRCP best to visualize dilated MPD <strong>and</strong> side branches<br />

○ Assess for ductal disruption: Continuity of MPD with<br />

pseudocyst, bowel, or pleural space<br />

• MR with contrast helpful to distinguish tumor from<br />

enlargement related to inflammation<br />

KEY FACTS<br />

• CT best to evaluate extent of calcifications <strong>and</strong><br />

inflammation related to acute on chronic pancreatitis<br />

TOP DIFFERENTIAL DIAGNOSES<br />

• Infiltrating pancreatic carcinoma<br />

• Acute pancreatitis<br />

• Groove pancreatitis<br />

• Autoimmune pancreatitis<br />

• IPMN (intraductal papillary mucinous neoplasm) of<br />

pancreas<br />

DIAGNOSTIC CHECKLIST<br />

• Gl<strong>and</strong>ular atrophy, dilated MPD, <strong>and</strong> intraductal<br />

calculi/parenchymal calcifications are best signs for chronic<br />

pancreatitis<br />

• May be very difficult to distinguish chronic pancreatitis with<br />

focal fibrotic enlargement of head from pancreatic<br />

adenocarcinoma<br />

(Left) Transverse ultrasound<br />

demonstrates marked<br />

pancreatic ductal dilatation<br />

, intraductal stones , <strong>and</strong><br />

parenchymal calcifications <br />

within the atrophic<br />

parenchyma. (Right)<br />

Transverse ultrasound<br />

demonstrates a dilated main<br />

pancreatic duct (MPD) <br />

with intraductal calculus <br />

<strong>and</strong> parenchymal<br />

calcifications ſt, consistent<br />

with chronic pancreatitis. A<br />

bilobed fluid collection in the<br />

head is consistent with a<br />

small pseudocyst. The<br />

parenchyma st has normal<br />

size <strong>and</strong> echogenicity.<br />

(Left) Transverse ultrasound<br />

shows predominantly<br />

parenchymal calcifications <br />

without intraductal calculi.<br />

The gl<strong>and</strong> is normal in size in<br />

this example. (Right)<br />

Transverse ultrasound<br />

demonstrates a dilated<br />

pancreatic duct with<br />

intraductal calcifications in<br />

the head/neck region .<br />

362

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