Chapter 5-The pancreas (Penny)

Exocrine function

1. Amylase: digests carbohydrates and converts starch to sugar 2. Lipase: digests fats and converts fats to fatty acids and glycerol 3. Sodium bicarbonate: neutralizes stomach acid 4.Trypsin, chymotrypsin, and carboxypolypeptidase: digests proteins

The anteroposterior diameter of the main pancreatic duct should not exceed

2 mm

is the inflammation of the pancreas secondary to the leakage of pancreatic enzymes from the acinar cells into the parenchyma of the organ.

Acute pancreatitis

The pancreas can frequently be a neglected abdominal organ because of the challenge that it presents for the sonographer. ___________ and _________________ are two obstacles that the sonographer encounters when attempting to assess the pancreas using sound.

Adjacent bowel gas and body habitus

is typically elevated with gallstone pancreatitis.

Alanine aminotransferase (ALT)

appears to be more specific for diagnosing pancreatitis because hyperamylasemia can be associated with other abnormalities

Lipase

which is the most common congenital variant of pancreatic anatomy, results from abnormal fusion of the pancreatic ducts during embryologic development.

Pancreatic divisum

pancreatic pseudocyst

a cyst surrounded by fibrous tissue that consists of pancreatic enzymes that have leaked from the pancreas

von Hippel-Lindau disease

a hereditary disease that includes the development of cysts within the pancreas and other organs

insulinoma

a islet cell tumor found within the pancreas

Duct of Santorini

accessory duct to the pancreas

what part of the pancreas carries out the exocrine process?

acinar cells

The most common causes of acute pancreatitis are

alcohol abuse and biliary tract disease, such as choledocholithiasis

Whipple procedure

also known as a pancreaticoduodenectomy; a procedure in which the pancreas and duodenum are removed to treat conditions such as cancer

From the main pancreatic duct, the enzymes collect in the

ampulla of Vater

What vital digestive enzymes does the panc secrete?

amylase, lipase, and sodium bicarbonate

This abnormal duct arrangement can cause people to be be

asymptomatic, some may be prone to suffer from both chronic and acute pancreatitis

The opening of the sphincter of Oddi is triggered by __________________

cholecystokinin

The breakdown of the various food products into useful derivatives for the body ensues once the pancreatic enzymes and bile mix with

chyme in the proximal portion of the duodenum.

double duct sign

co-existing enlargement of the common bile duct and pancreatic duct

Cholecystokinin causes the simultaneous

contraction of the gallbladder and relaxation of the sphincter of Oddi

what does amylase do?

digests carbs

what does lipase do?

digests fats

To improve visualization of the pancreatic head, the sonographer can ask the patient to _______________________. The water, once in the C-loop of the duodenum, will provide a delineated view of the pancreatic head in most individuals.

drink a small cup of water

cholecystokinin is released by the

duodenum as a result of the presence of chyme.

With an annular pancreas, the most ventral part of the pancreas _______________________ and may lead to ___________. This anomaly is typically detected in the neonate with the use of radiography.

encases the duodenum and may consequently lead to duodenal obstruction

The involvement of the gland can be

focal or diffuse

The arterial blood supply to the head of the pancreas is via the

gastroduodenal artery

The normal measurement of the pancreatic head and body is between _____________, while the tail should measure between __________

head & body-2 and 3 cm tail-1 and 2 cm

Four parts of the pancreas

head, neck, body, tail

The pediatric pancreas may appear more ___________ because of the lack of fat surrounding the pancreas in younger patients

hypoechoic

The pancreatic margins may appear as

ill-defined with areas of fluid collections noted within and around the pancreas

acute pancreatitis

inflammation of the pancreas secondary to the leakage of pancreatic enzymes from the acinar cells into the parenchyma of the organ

The endocrine function of the pancreas is performed by the

islets of Langerhans

These clusters of tissue, which are dispersed like islands throughout the pancreas, are composed of alpha, beta, and delta cells

islets of Langerhans

Duct of Wirsung

main pancreatic duct

At the ampulla of Vater, the pancreatic digestive enzymes are mixed with bile from the liver and released into the duodenum through the

major sphincter, or sphincter of Oddi.

Acute pancreatitis may be classified as

mild, moderate, or severe

Higher _____________________ are associated with acute pancreatitis when the disease progresses and leads to severe necrosis and hemorrhage of the organ (termed hemorrhagic pancreatitis).

mortality rate

The pancreas is identified sonographically by its

neighboring vasculature

The __________ develops initially in the embryo from two separate parts that eventually fuse together to constitute its typical comma-shaped appearance.

pancreas

The two most common congenital anomalies of the pancreas are __________ and __________

pancreatic divisum and annular pancreas

Pancreatic divisum results in a shortened main

pancreatic duct (duct of Wirsung)

works to drain only the pancreatic head and not the entire pancreas

pancreatic duct (duct of Wirsung)

This abnormal duct arrangement causes a functional obstruction, disallowing proper pancreatic drainage and increasing the risk for

pancreatic inflammation secondary to the obstruction

the leakage of pancreatic enzymes can destroy the

pancreatic tissue and the tissues surrounding the pancreas

Chyme

partially digested food

This peripancreatic fluid collection may be referred to as

phlegmon

Milder cases of pancreatitis can

resolve spontaneously

In these situations (hemorrhagic pancreatitis), patients may suffer from

shock, ileus, and have a decreased hematocrit secondary to hemorrhage

Unfortunately, sonography is not always successful at diagnosing cases of acute pancreatitis because the pancreas may appear completely normal with mild disease. But it can provide useful information as to the __________ and ___________ of the gland and determine if any peripancreatic fluid collections exist.

size and echogenicity

Isles of Langerhans

small islands of tissue found within the pancreas that produce insulin and glucagon

The accessory duct (duct of Santorini), which is much

smaller than the main pancreatic duct

The body and tail of the pancreas receive their blood supply from the

splenic and superior mesenteric arteries

Color-flow Doppler imaging is helpful to differentiate the _______ from the ________________ because these two structures can have parallel paths within the body.

splenic artery; main pancreatic duct

These pancreatic enzymes drain from the pancreas into _______________ or ____________, which travels the length of the pancreas.

the main pancreatic duct, or duct of Wirsung

Pancreatic adenocarcinoma

the most common form of pancreatic malignancy; typically found within the head of the pancreas

Sphincter of Oddi

the muscle that controls the emptying of bile and pancreatic juices into the duodenum; also referred to as the hepatopancreatic sphincter

Phlegmon

the peripancreatic fluid collection that results from the inflammation of the pancreas

uncinate process

the posteromedial extension of the pancreatic head

choledocholithiasis

the presence of a gallstone or gallstones within the biliary tree

chronic pancreatitis

the recurring destruction of the pancreatic tissue that results in atrophy, fibrosis, scarring, and the development of calcification within the gland

The accessory duct (duct of Santorini), which is much smaller than the main pancreatic duct, is therefore forced to drain

the rest of the pancreas and empty a larger than normal amount of pancreatic juices through the minor sphincter

pancreaticoduodenectomy

the surgical procedure in which the head of the pancreas, the gallbladder, some of the bile ducts, and the proximal duodenum are removed because of a malignant pancreatic neoplasm; aka Whipple procedure

Zollinger-Ellison syndrome

the syndrome that includes an excessive secretion of acid by the stomach caused by the presence of a functional gastrinoma within the pancreas

jaundce

the yellow discoloration of the skin, mucous membranes and sclerae; found in presence of liver disease and or biliary obstruction

What other enzymes does the panc secrete?

trypsin, chymotrypsin, and carboxypolypeptidase

islet cell tumors

tumor found within the isles of Langerhans of the pancreas

In some individuals, there exists a posteromedial extension of the pancreatic head, referred to as the

uncinate process

autosomal dominant polycystic kidney disease

Inherited disease that results in the development of renal, liver, and pancreatic cysts late in life; also referred to as adult polycystic kidney disease

results from the maldevelopment of the two embryologic elements of the pancreas.

The annular pancreas

lesser sac

a peritoneal cavity space located between the stomach and pancreas where fluid can accumulate

Pancreatic divisum can lead to both

acute and chronic pancreatitis

Gastrinoma

an islet cell tumor found within the pancreas

Depending on the resolution of the ultrasound system, the normal main pancreatic duct may be noted during a routine sonographic examination. It will appear as an

anechoic tube, consisting of two parallel lines and an anechoic lumen

The sonographic analysis of the pancreas may include measurements of the various parts of the organ. The pancreas is typically measured in the ____________________ dimension in the transverse scan plane.

anteroposterior

hyperamylasemia

elevated amylase

The pancreas functions as an __________ and ___________ gland

endocrine and exocrine

endoscopic retrograde cholangiopancreatography

endoscopic procedure that utilizes fluoroscopy to evaluate the biliary tree and pancreas

Focal pancreatitis will lead to an

enlargement of the gland in a particular segment, most often in the head, appearing as a hypochoic region

Diffuse enlargement of the gland can also occur with pancreatitis, and with this manifestation the

entire pancreas will most likely become enlarged and hypoechoic

The pancreas is both an ______________ and an_____________________________

exocrine gland (uses ducts to transport digestive juices) and endocrine gland (releases hormone directly into the bloodstream).

Primary function of the pancreas?

exocrine gland that aids in digestion

In the transverse plane, two round anechoic structures may be noted within the pancreatic head. The anterior structure is the _________________________, and the more posterior structure is the _____________________

gastroduodenal artery; common bile duct

Insulin stimulates the body to use up

glucagon to produce energy

Glucagon promotes the release of ________________________, which in turn __________________

glucose by the liver; increases blood sugar levels

The normal echogenicity of the pancreas is

greater than that of the liver, and equal to, or greater than, that of the spleen in the adult.

The islets of Langerhans produce vital hormones, including _______ and ________, which are released directly into the bloodstream

insulin and glucagon

To better visualize the pancreatic tail area, the sonographer can scan through the

left kidney and spleen while the patient is in the right lateral decubitus position.

Additionally, the __________________________ position may help improve visualization of the pancreatic head.

left lateral decubitus

Amylase levels will rise first, and within 72 hours an accompanying rise in _______ should occur.

lipase

__________ is located within the epigastrium between the C-loop of the duodenum and the splenic hilum.

pancreas

Other causes of acute pancreatitis include

post endoscopic retrograde cholangeopancreatography and trauma

Although some of the pancreatic head may be covered by peritoneum, the pancreas is considered to be a

retroperitoneal organ

Venous drainage is achieved by means of the

splenic vein, superior mesenteric vein, inferior mesenteric vein, and portal vein

Patients suffering from acute pancreatitis may find relief from symptoms in certain positions. For example, the _______ position is often most painful, while ________________ may temporarily relieve pain

supine; sitting or leaning forward

acinar cells

the cells of the pancreas that carry out the exocrine function and therefore produce amylase, lipase, and sodium bicarbonate

Courvoisier gallbladder

the clinical detection of an enlarged, palpable gallbladder caused by a biliary obstruction in the area of the pancreatic head

An accessory duct, _______________________, which is typically a branch of the main pancreatic duct, has a separate minor sphincter into the duodenum.

the duct of Santorini

Ampulla of Vater

the merging point of the pancreatic duct and common bile duct just before the sphincter of Oddi