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
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
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
MRI/MRCP Imaging of pancreas• Pancreatic Duct• Side branches• Lower end of CBD MAINLY A PROBLEM SOLVING TOOL
PATHOLOGY Imaging of pancreas• Pancreatitis• Pancreatic divisum• Tumors• Traumatic – Laceration and pancreatic duct injury
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
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.
RECURRENT PANCREATITIS Imaging of pancreas GALL STONES PANCREATIC DIVISUM
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.
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.
PANCREATIC TUMORS Imaging features• Morphologic and contour changes• Mass effect• Density changes• Contrast enhancement• Pancreatic duct changes• Secondary signs
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 Unresectable• StageIV
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
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
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
ISLET CELL TUMOR PANCREATIC TUMORS• Neoplasms of neuroendocrine cells.• 50% - functioning and 50% - malignant.• Diagnostic clue - Hypervascularity.
ISLET CELL TUMOR PANCREATIC TUMORS
LYMPHOMA PANCREATIC TUMORS•Focal or diffuse masswithout dilatation of PD.•Associated with largelymphnodes.•Common in immuno-compromised patients.
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
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.