IMAGING OF PANCREAS      USG &CT      DR. MEGHA SANGHVI     M.D. RADIODIAGNOSIS    ASSISTANT PROFESSOR    B.J.M.C., CIVIL ...
ANATOMY OF PANCREAS• Length – 15 cm.• Head, uncinate process,  neck, body, tail• Gradually tapering “Horse  shoe” shape.• ...
IMAGING MODALITIES                Imaging of pancreas• Radiograph – detect calcification (practically  of no help)• Barium...
ULTRASONOGRAPHY                      Imaging of pancreas  •   Widely available  •   Easily accessible  •   Can be repeated...
CT SCAN                 Imaging of pancreas•   Gold standard for all pancreatic pathologies•   Detects complications•   He...
MRI/MRCP                     Imaging of pancreas• Pancreatic Duct• Side branches• Lower end of CBD           MAINLY A PROB...
PATHOLOGY                 Imaging of pancreas• Pancreatitis• Pancreatic divisum• Tumors• Traumatic – Laceration and pancre...
ACUTE PANCREATITIS               Imaging of pancreas•   Increase in the volume of pancreas•   Oedematous changes•   Peripa...
ACUTE PANCREATITIS    Ultrasonography
ACUTE PANCREATITIS      CT Scan
ACUTE PANCREATITIS                 CT Scan   NECROSIS                SPL.V.THROMBOSISPSEUDOANEURYSM                       ...
ACUTE PANCREATITIS      CT Scan      INFECTED     COLLECTION
CT severity index - CTSI            What is CTSI?A scoring index for grading acutepancreatitis based on CT scan findingsan...
CT severity index - CTSI      Prognostic Indicator                                  points    Pancreatic inflammation   ...
CTSI (Modified)         Mild     -          0 to 2         Moderate -          4 to 6         Severe -           8 to 10Mo...
CHRONIC PANCREATITIS                      Imaging of pancreas• Parenchymal atrophy / focal bulge• Parenchymal Calcificatio...
CHRONIC PANCREATITIS                UltrasonographyUSG cannot diagnose chronic pancreatitis despite      advanced disease ...
CHRONIC PANCREATITIS                           CT Scan    Chronic pancreatitis                    PseudocystCT is more sen...
RECURRENT PANCREATITIS      Imaging of pancreas      GALL     STONES    PANCREATIC      DIVISUM
PANCREATIC DIVISUM                         Recurrent pancreatitisCauses repeated acute pancreatitis.Failure of the dorsal ...
PANCREATIC TUMORS               Imaging of pancreas• Benign• Primary malignant• Endocrine tumors• Metastasis
PANCREATIC TUMORS                        Imaging modalities• US is the first line imaging test.• The overall sensitivity &...
PANCREATIC TUMORS                     Imaging features• Morphologic and contour  changes• Mass effect• Density changes• Co...
PANCREATIC TUMORS                   CT Scan                             Hypovascular                                      ...
PANCREATIC TUMORS                         CT ScanInvolvement of CBD –T3      Involvement of duodenum – T3
PANCREATIC TUMORS         CT ScanPancreatic Carcinoma with  Krukenberg metastasis
PANCREATIC TUMORS              Staging and resectability• Stage I                  Resectable• Stage II• Stage III        ...
VENOUS ENCASEMENT & RESECTABILITY                   Pancreatic tumors • Grade 0: normal fat plane b/w tumor and vessel. • ...
VENOUS ENCASEMENT & RESECTABILITY             Pancreatic tumors • Grade 0 • Grade 1   Resectable • Grade 2 • Grade 3   Wit...
VENOUS ENCASEMENT & RESECTABILITY           Pancreatic tumors            Resectable
VENOUS ENCASEMENT & RESECTABILITY           Pancreatic tumors           Unresectable
ARTERIAL ENCASEMENT & RESECTABILITY               Pancreatic tumors• Encasement or involvement of celiac  trunk, hepatic a...
ARTERIAL ENCASEMENT & RESECTABILITY            Pancreatic tumors                                Coeliac trunkSMA encasemen...
MUCINOUS CYSTADENOMA                PANCREATIC TUMORS•40-50 YEARS•“MOTHER LESION”•MALIGNANT POTENTIAL•MACROCYSTIC•USUALLY ...
SEROUS CYSTADENOMA              PANCREATIC TUMORS•60-70 YEARS“GRANDMOTHER LESION”•BENIGN•LOBULATED•MICROCYSTIC•CENTRAL SCA...
INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN)                   PANCREATIC TUMORS                                        ...
INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN)            PANCREATIC TUMORS
SOLID PAPILLARY & EPITHELIAL NEOPLASM (SPEN)               PANCREATIC TUMORS•Rare – low grademalignancy.•Commonly seen iny...
ISLET CELL TUMOR            PANCREATIC TUMORS• Neoplasms of  neuroendocrine  cells.• 50% - functioning  and 50% -  maligna...
ISLET CELL TUMOR  PANCREATIC TUMORS
LYMPHOMA                   PANCREATIC TUMORS•Focal or diffuse masswithout dilatation of PD.•Associated with largelymphnode...
PANCREATIC TRAUMA• The diagnosis of duct injury is critical to subsequent  treatment of the patient.• MRCP can accurately ...
CONCLUSION             Imaging of pancreas• USG – Used as primary screening tool.• MDCT – modality of choice – for most  p...
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Imaging of the Pancreas
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Imaging of the Pancreas

  1. 1. IMAGING OF PANCREAS USG &CT DR. MEGHA SANGHVI M.D. RADIODIAGNOSIS ASSISTANT PROFESSOR B.J.M.C., CIVIL HOSPITAL, AHMEDABAD.
  2. 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
  3. 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
  4. 4. ULTRASONOGRAPHY Imaging 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 excludedPRIMARILY USED AS SCREENING TOOL & FOR FOLLOW UP
  5. 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. 6. MRI/MRCP Imaging of pancreas• Pancreatic Duct• Side branches• Lower end of CBD MAINLY A PROBLEM SOLVING TOOL
  7. 7. PATHOLOGY Imaging of pancreas• Pancreatitis• Pancreatic divisum• Tumors• Traumatic – Laceration and pancreatic duct injury
  8. 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
  9. 9. ACUTE PANCREATITIS Ultrasonography
  10. 10. ACUTE PANCREATITIS CT Scan
  11. 11. ACUTE PANCREATITIS CT Scan NECROSIS SPL.V.THROMBOSISPSEUDOANEURYSM PSEUDOANEURYSM
  12. 12. ACUTE PANCREATITIS CT Scan INFECTED COLLECTION
  13. 13. CT severity index - CTSI What is CTSI?A scoring index for grading acutepancreatitis based on CT scan findingsand extent of pancreatic andperipancreatic inflammatory changes
  14. 14. CT severity index - CTSI 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 of pleural effusion, ascites, vascular complications, parenchymal complications, or gastrointestinal tract involvement) 2
  15. 15. CTSI (Modified) Mild - 0 to 2 Moderate - 4 to 6 Severe - 8 to 10Modified CTSI correlates with length of hospitalstay, need for intervention or surgery, infectionand organ failure
  16. 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
  17. 17. CHRONIC PANCREATITIS UltrasonographyUSG cannot diagnose chronic pancreatitis despite advanced disease stage at times.
  18. 18. CHRONIC PANCREATITIS CT Scan Chronic pancreatitis PseudocystCT is more sensitive in diagnosing pancreatic calcification andparenchymal atrophy than USG.CT is considered as modality of choice in diagnosing chronicpancreatitis.
  19. 19. RECURRENT PANCREATITIS Imaging of pancreas GALL STONES PANCREATIC DIVISUM
  20. 20. PANCREATIC DIVISUM Recurrent pancreatitisCauses 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 . Dorsal PD36-year-old woman with h/O Pancreatitis. Ventral PDMRCP shows separate dorsal and ventral pancreaticduct systems consistent with divisum.
  21. 21. PANCREATIC TUMORS Imaging of pancreas• Benign• Primary malignant• Endocrine tumors• Metastasis
  22. 22. 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.
  23. 23. PANCREATIC TUMORS Imaging features• Morphologic and contour changes• Mass effect• Density changes• Contrast enhancement• Pancreatic duct changes• Secondary signs
  24. 24. PANCREATIC TUMORS CT Scan Hypovascular LymphnodesPeritonealnodules
  25. 25. PANCREATIC TUMORS CT ScanInvolvement of CBD –T3 Involvement of duodenum – T3
  26. 26. PANCREATIC TUMORS CT ScanPancreatic Carcinoma with Krukenberg metastasis
  27. 27. PANCREATIC TUMORS Staging and resectability• Stage I Resectable• Stage II• Stage III Unresectable• StageIV
  28. 28. 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 (<180o) • Grade 3: encased vessel with tumor encasing >180o, altering its contour and producing concentric or eccentric lumen narrowing • Grade 4: atleast one major occluded vessel
  29. 29. VENOUS ENCASEMENT & RESECTABILITY Pancreatic tumors • Grade 0 • Grade 1 Resectable • Grade 2 • Grade 3 With en bloc venous resection • Grade 4 Unresectable
  30. 30. VENOUS ENCASEMENT & RESECTABILITY Pancreatic tumors Resectable
  31. 31. VENOUS ENCASEMENT & RESECTABILITY Pancreatic tumors Unresectable
  32. 32. 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
  33. 33. ARTERIAL ENCASEMENT & RESECTABILITY Pancreatic tumors Coeliac trunkSMA encasement encasement
  34. 34. MUCINOUS CYSTADENOMA PANCREATIC TUMORS•40-50 YEARS•“MOTHER LESION”•MALIGNANT POTENTIAL•MACROCYSTIC•USUALLY 1 CYST•PERIPHERAL CALCIFICATION (25%)•BODY AND TAIL (90%)
  35. 35. SEROUS CYSTADENOMA PANCREATIC TUMORS•60-70 YEARS“GRANDMOTHER LESION”•BENIGN•LOBULATED•MICROCYSTIC•CENTRAL SCAR (18%)
  36. 36. INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN) PANCREATIC TUMORS Branch duct type IPMT Dilatation of the branch ducts• Classification based on the duct architectureMain duct type- diffuse or segmental dilatation of the MPDBranch duct type-dilatation of branch ductsCombined type – Main + branch ducts
  37. 37. INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN) PANCREATIC TUMORS
  38. 38. SOLID PAPILLARY & EPITHELIAL NEOPLASM (SPEN) PANCREATIC TUMORS•Rare – low grademalignancy.•Commonly seen inyoung femalesinvolving pancreatictail – “Daughter’stumor”
  39. 39. ISLET CELL TUMOR PANCREATIC TUMORS• Neoplasms of neuroendocrine cells.• 50% - functioning and 50% - malignant.• Diagnostic clue - Hypervascularity.
  40. 40. ISLET CELL TUMOR PANCREATIC TUMORS
  41. 41. LYMPHOMA PANCREATIC TUMORS•Focal or diffuse masswithout dilatation of PD.•Associated with largelymphnodes.•Common in immuno-compromised patients.
  42. 42. PANCREATIC TRAUMA• The diagnosis of duct injury is critical to subsequent treatment of the patient.• MRCP can accurately depict the integrity of the pancreatic duct as well as the site of disruption• MRCP can reveal the duct that is upstream from the site of disruption, which is difficult with ERCP. 25 year old male with blunt abdominal injury.MRCP shows complete disruption of pancreatic duct in body region with distal dilatation
  43. 43. 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.
  44. 44. THANK YOU
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