Imaging of the Pancreas

1. IMAGING OF PANCREAS
USG &CT
DR. MEGHA SANGHVI
M.D. RADIODIAGNOSIS
ASSISTANT PROFESSOR
B.J.M.C., CIVIL HOSPITAL,
AHMEDABAD.

2. 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

3. IMAGING MODALITIES
Imaging of pancreas
•Radiograph–detect calcification (practically
of 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 (practically
of 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

4. ULTRASONOGRAPHY
Imagingof 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

5. CT SCAN
Imaging 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

6. MRI/MRCP
Imaging of pancreas
•Pancreatic Duct
•Side branches
•Lower end of CBD
•Pancreatic Duct
•Side branches
•Lower end of CBD
MAINLY A PROBLEM SOLVING TOOL

7. PATHOLOGY
Imaging of pancreas
•Pancreatitis
•Pancreatic divisum
•Tumors
•Traumatic–Laceration and pancreatic duct
injury
•Pancreatitis
•Pancreatic divisum
•Tumors
•Traumatic–Laceration and pancreatic duct
injury

8. ACUTE PANCREATITIS
Imaging 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

9. ACUTE PANCREATITIS
Ultrasonography

10. ACUTE PANCREATITIS
CT Scan

11. ACUTE PANCREATITIS
CT Scan
NECROSIS
SPL.V.THROMBOSIS
PSEUDOANEURYSM
PSEUDOANEURYSM

12. ACUTE PANCREATITIS
CT Scan
INFECTED
COLLECTION

13. CT severity index-CTSI
What is CTSI?
A scoring index for grading acute
pancreatitis based on CT scan findings
and extent of pancreatic and
peripancreaticinflammatory changes
A scoring index for grading acute
pancreatitis based on CT scan findings
and extent of pancreatic and
peripancreaticinflammatory changes

14. Prognostic Indicator points
Pancreatic inflammation
Normal pancreas 0
Intrinsic pancreatic abnormalities with or without
inflammatory changes inperipancreaticfat 2
Pancreatic orperipancreaticfluid collection or
peripancreaticfat necrosis 4
Pancreatic necrosis
None 0 0
minimal 2
substantial 4
Extrapancreaticcomplications(one or more of
pleural effusion,ascites,vascularcomplications,
parenchymalcomplications, orgastrointestinaltract
involvement) 2
CT severity index-CTSI
Prognostic Indicator points
Pancreatic inflammation
Normal pancreas 0
Intrinsic pancreatic abnormalities with or without
inflammatory changes inperipancreaticfat 2
Pancreatic orperipancreaticfluid collection or
peripancreaticfat necrosis 4
Pancreatic necrosis
None 0 0
minimal 2
substantial 4
Extrapancreaticcomplications(one or more of
pleural effusion,ascites,vascularcomplications,
parenchymalcomplications, orgastrointestinaltract
involvement) 2

15. Mild -0 to 2
Moderate-4 to 6
Severe-8 to 10
CTSI (Modified)
Mild -0 to 2
Moderate-4 to 6
Severe-8 to 10
Modified CTSI correlates with length of hospital
stay, need for intervention or surgery, infection
and organ failure

16. CHRONIC PANCREATITIS
Imaging 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

17. CHRONIC PANCREATITIS
Ultrasonography
USG cannot diagnose chronic pancreatitis despite
advanced disease stage at times.

18. CHRONIC PANCREATITIS
CT Scan
CT is more sensitive in diagnosing pancreatic calcification and
parenchymal atrophy than USG.
CT is considered as modality of choice in diagnosing chronic
pancreatitis.
Chronic pancreatitis
Pseudocyst

20. RECURRENT PANCREATITIS
Imaging of pancreas
GALL
STONES
PANCREATIC
DIVISUM
GALL
STONES

21. Causes repeated acute pancreatitis.
Failure of the dorsal and ventral pancreatic
primordia to fuse.
The dorsal duct drains into the duodenum at
the minor papilla, and the ventral duct drains
via the major ampulla with the CBD.
MRCP easily reveals the dorsal pancreatic duct
in patients with divisum, whereas cannulation
of the minor papilla of such patients for ERCP is
frequently unsuccessful .
PANCREATIC DIVISUM
Recurrent pancreatitis
Causes repeated acute pancreatitis.
Failure of the dorsal and ventral pancreatic
primordia to fuse.
The dorsal duct drains into the duodenum at
the minor papilla, and the ventral duct drains
via the major ampulla with the CBD.
MRCP easily reveals the dorsal pancreatic duct
in patients with divisum, whereas cannulation
of the minor papilla of such patients for ERCP is
frequently unsuccessful .
36-year-old woman with h/O Pancreatitis.
MRCP shows separate dorsal and ventral pancreatic
duct systems consistent with divisum.
Ventral PD
Dorsal PD

22. PANCREATIC TUMORS
Imaging of pancreas
•Benign
•Primary malignant
•Endocrine tumors
•Metastasis
•Benign
•Primary malignant
•Endocrine tumors
•Metastasis

23. PANCREATIC TUMORS
Imaging 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.

24. PANCREATIC TUMORS
Imaging features
•Morphologic and contour
changes
•Mass effect
•Density changes
•Contrast enhancement
•Pancreatic duct changes
•Secondary signs
•Morphologic and contour
changes
•Mass effect
•Density changes
•Contrast enhancement
•Pancreatic duct changes
•Secondary signs

25. Hypovascular
PANCREATIC TUMORS
CT Scan
Lymphnodes
Peritoneal
nodules

26. PANCREATIC TUMORS
CT Scan
Involvement of duodenum–T3Involvement of CBD–T3

27. PANCREATIC TUMORS
CT Scan
Pancreatic Carcinoma with
Krukenberg metastasis

28. PANCREATIC TUMORS
Staging andresectability
•Stage I
•Stage II
•Stage III
•StageIV
Resectable
•Stage I
•Stage II
•Stage III
•StageIV
Unresectable

29. •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 the
vessel.
•Grade 2:flattening and/or slight irregularity of one
side of the vessel (<180
o
)
•Grade 3:encased vessel with tumor encasing
>180
o
, altering its contour and producing
concentric or eccentric lumen narrowing
•Grade 4:atleast one major occluded vessel
VENOUS ENCASEMENT & RESECTABILITY
Pancreatic 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 the
vessel.
•Grade 2:flattening and/or slight irregularity of one
side of the vessel (<180
o
)
•Grade 3:encased vessel with tumor encasing
>180
o
, altering its contour and producing
concentric or eccentric lumen narrowing
•Grade 4:atleast one major occluded vessel

30. •Grade 0
•Grade 1 Resectable
•Grade 2
•Grade 3 With en bloc venous resection
•Grade 4 Unresectable
VENOUS ENCASEMENT & RESECTABILITY
Pancreatic tumors
•Grade 0
•Grade 1 Resectable
•Grade 2
•Grade 3 With en bloc venous resection
•Grade 4 Unresectable

31. VENOUS ENCASEMENT & RESECTABILITY
Pancreatic tumors
Resectable

32. VENOUS ENCASEMENT & RESECTABILITY
Pancreatic tumors
Unresectable

33. •Encasement or involvement of celiac
trunk, hepatic artery, gastroduodenal
artery or superior mesenteric artery–
unresectable.
•See for–perivascular cuff of soft tissue
ARTERIAL ENCASEMENT & RESECTABILITY
Pancreatic tumors
•Encasement or involvement of celiac
trunk, hepatic artery, gastroduodenal
artery or superior mesenteric artery–
unresectable.
•See for–perivascular cuff of soft tissue

34. ARTERIAL ENCASEMENT & RESECTABILITY
Pancreatic tumors
SMA encasement
Coeliac trunk
encasement

35. MUCINOUS CYSTADENOMA
PANCREATIC 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%)

36. •60-70 YEARS
“GRANDMOTHER LESION”
•BENIGN
•LOBULATED
•MICROCYSTIC
•CENTRAL SCAR (18%)
SEROUS CYSTADENOMA
PANCREATIC TUMORS
•60-70 YEARS
“GRANDMOTHER LESION”
•BENIGN
•LOBULATED
•MICROCYSTIC
•CENTRAL SCAR (18%)

37. •Classificationbased on the duct
architecture
Main duct type-diffuse or segmental
dilatation of the MPD
Branch duct type-dilatation of branch
ducts
Combined type–Main + branch ducts
Branch duct type IPMT
Dilatation of the branch ducts
INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN)
PANCREATIC TUMORS
•Classificationbased on the duct
architecture
Main duct type-diffuse or segmental
dilatation of the MPD
Branch duct type-dilatation of branch
ducts
Combined type–Main + branch ducts

38. INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN)
PANCREATIC TUMORS

39. •Rare–low grade
malignancy.
•Commonly seen in
young females
involving pancreatic
tail–“Daughter’s
tumor”
SOLID PAPILLARY & EPITHELIAL NEOPLASM (SPEN)
PANCREATIC TUMORS
•Rare–low grade
malignancy.
•Commonly seen in
young females
involving pancreatic
tail–“Daughter’s
tumor”

40. •Neoplasms of
neuroendocrine
cells.
•50%-functioning
and 50%-
malignant.
•Diagnostic clue-
Hypervascularity.
ISLET CELL TUMOR
PANCREATIC TUMORS
•Neoplasms of
neuroendocrine
cells.
•50%-functioning
and 50%-
malignant.
•Diagnostic clue-
Hypervascularity.

41. ISLET CELL TUMOR
PANCREATIC TUMORS

42. •Focal or diffuse mass
without dilatation of PD.
•Associated with large
lymphnodes.
•Common in immuno-
compromised patients.
LYMPHOMA
PANCREATIC TUMORS
•Focal or diffuse mass
without dilatation of PD.
•Associated with large
lymphnodes.
•Common in immuno-
compromised patients.

43. •Thediagnosisofductinjuryiscriticaltosubsequent
treatmentofthepatient.
•MRCPcanaccuratelydepicttheintegrityofthepancreatic
ductaswellasthesiteofdisruption
•MRCPcanrevealtheductthatisupstreamfromthesite
ofdisruption,whichisdifficultwithERCP.
PANCREATIC TRAUMA
•Thediagnosisofductinjuryiscriticaltosubsequent
treatmentofthepatient.
•MRCPcanaccuratelydepicttheintegrityofthepancreatic
ductaswellasthesiteofdisruption
•MRCPcanrevealtheductthatisupstreamfromthesite
ofdisruption,whichisdifficultwithERCP.
25 year old male with blunt abdominal
injury.MRCP shows complete disruption of
pancreatic duct in body region with distal
dilatation

44. •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 prognosis
in pancreatic tumors.
CONCLUSION
Imaging 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 prognosis
in pancreatic tumors.

45. THANK YOU