Penny Book Chapter 5: The Pancreas

A cystadenoma within the pancreas may be referred to as either _________________________ or ____________________________. Serous tumors are small and always benign, while mucinous tumors are larger and have malignant potential.

(microcystic) serous cystadenoma or (macrocystic) mucinous cystadenoma

pancreatic transplant fluid collection

- Abscess - Ascites - Hematoma - Urinoma (secondary to anastomosis problems at urinary bladder) - Pseudocysts

endocrine function of the pancreas

- Alpha Cells > Glucagon > promotes the release of glucose by the liver - Beta Cellas > Insulin > stimulates the body's use of glucagon - Delta Cells > Somatostatin > restrains insulin and glucose level

Pancreatic neck is

- Anterior to portal confluence

Pancreatic body is

- Anterior to superior mesenteric vein, splenic vein, and superior mesenteric artery

pancreatic transplant vascular complications

- Arterial stenosis: focal areas of increased velocities - Arterial thrombosis - Graft thrombosis - Pseudoaneurysms - Splenic vein thrombosis: elevated pulsed-wave Doppler resistive index in the arterial inflow Doppler waveform, often greater than 1.0; absent splenic inflow • Strictures: evident with turbulent flow

clinical findings of chronic pancreatitis

- Asymptomatic - Persistent epigastric pain - Jaundice - Back pain - Possible elevation in amylase or lipase (but they may remain normal) - Possible elevation in ALP - Anorexia - Vomiting - Weight loss - Constipation

sonographic findings of a serous cystadenoma

- Cystic mass - May actually appear solid and echogenic secondary to the small size of the cysts

clinical findings of acute pancreatitis

- Elevated amylase (within 24 h) - Elevated lipase (within 72 h) - Leukocytosis - Elevated ALT and other liver function labs when biliary obstruction is present 5. Abdominal pain (especially in the supine position) - Back pain - Fever - Nausea and vomiting - Severe acute pancreatitis may lead to hemorrhage and a decreased hematocrit

clinical findings of pancreatic adenocarcenoma

- Elevated amylase and/or lipase - Loss of appetite - Weight loss - Jaundice - Courvoisier gallbladder (enlarged palpable gallbladder) - Epigastric pain - Elevated ALP and possibly other liver function labs associated with biliary obstruction

sonographic findings of chronic pancreatitis

- Heterogeneous, or hyperechoic, atrophic gland with poor margins - Calcifications within the gland - Pancreatic pseudocyst - Dilated pancreatic duct - Stone(s) within the pancreatic duct that may lead to biliary obstruction - Possible portosplenic vein thrombosis

sonographic findings of chronic pancreatic transplant rejection

- Hyperechoic echotexture - Atrophy - Pancreas may contain calcifications

sonographic findings of pancreatic adenocarcinoma

- Hypoechoic mass in the head of the pancreas - Dilated common bile duct and pancreatic duct (double-duct sign) - Liver and other abdominal organs should be evaluated for possible metastasis - Enlarged (hydropic) gallbladder

sonographic findings of Islet Cell tumors

- Hypoechoic mass that may contain calcifications - Visualization is hard because of their small size

sonographic findings of acute pancreatic transplant rejection

- Hypoechoic or heterogeneous gland - Elevated resistive indices

clinical findings of islet cell tumors

- Insulinoma: low blood sugar symptoms - Gastrinoma: Zollinger-Ellison syndrome

clinical findings of cystadenomas and cystadenocarcinomas

- May be asymptomatic initially - Epigastric pain - Weight loss - Palpable mass - Jaundice

sonographic findings of mucinous cystadenoma and cystadenocarcinoma

- Multilocular cystic masses that may contain mural nodules and calcifications - There may be associated dilation of the pancreatic duct

clinical findings of true pancreatic cyst

- Possible history of von Hippel-Lindau disease or cystic fibrosis - Possible history of ADPKD

Uncinate process is

- Posterior to superior mesenteric vein; may completely surround superior mesenteric vein - Anterior to aorta

Pancreatic head is

- Right lateral to superior mesenteric vein - Anterior to inferior vena cava and inferior to portal vein

Pancreatic tail is

- Splenic vein marks posterior border of pancreatic tail

sonographic findings of true pancreatic cysts

- Well-defined, anechoic mass with posterior enhancement

sonographic findings of acute pancreatitis

1- The pancreas may appear normal - Diffusely enlarged, hypoechoic pancreas (diffuse manifestation) - Focal hypoechoic area within the pancreas (focal manifestation) - Unencapsulated anechoic fluid collection surrounding all or part of the pancreas (peripancreatic fluid) - Pancreatic pseudocyst - Abscess formation can occur and is seen as echogenic fluid containing gas bubbles - Biliary obstruction may be present (possibly choledocholithiasis) - Vascular complications such as splenic vein thrombosis and pseudoaneurysm of the splenic artery

Exocrine function of the pancreas

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

Transplantation techniques can vary, however; and in up to 80% of the time, patients undergo a renal transplant at the same time.

If this occurs, the pancreas is placed within the right side of the abdomen and the renal transplant is placed on the left.

______________ are solitary, while ____________ are often multiple and difficult to image.

Insulinomas gastrinomas

pancreatic pseudocyst

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

Diffuse acute pancreatitis will result in

a diffusely enlarge, hypoechoic gland.

von Hippel-Lindau disease

a hereditary disease that includes the development if cysts within the pancreas an other organs

lesser sac

a peritoneal cavity located between the stomach and pancreas where the fluid accumulates

uncinate process

a posteromedial extension of the pancreatic head

The most common causes of acute pancreatitis are

alcohol abuse and biliary tract disease, such as choledocholithiasis, post endoscopic retrograde cholangeopancreatography and trauma.

Chronic pancreatitis can result in

an atrophic, hyperechoic pancreas with calcifications and a prominent pancreatic duct.

gastrinoma

an islet cell tumor found within the pancreas

insulinoma

an islet cell tumor found within the pancreas

Pancreatic divisum is the most common congenital variant of the pancreas and can lead to

both acute and chronic pancreatitis

ileus

bowel obstruction caused by the lack of normal peristalsis

double duct sign

coexisting enlargement of the common bile duct and pancreatic duct

pancreatic divisum

congenital anomaly of the pancreas that results in a shortened main pancreatic duct that only works to drain the pancreatic head and not the entire pancreas

annular pancreas

congenital anomaly of the pancreas that results in maldevelopment of the pancreas in which the most ventral part of the pancreas encases the duodenum and may consequently lead to duodenal obstruction

hypermylasemia

elevated amylase

endoscopic retrograde cholangiopancreatography

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

The arterial blood supply to the head of the pancreas comes from the

gastroduodenal artery

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

In addition to chronic alcohol abuse, other causes for chronic pancreatitis are

hyperparathyroidism, congenital anomalies (pancreatic divisum), genetic disorders, pancreatic duct obstruction, and trauma.

cystic fibrosis

inherited disorder that can affect the lungs, liver, pancreas, or other organs; this disorder changes how the body creates mucus and sweat

The pancreas is identified sonographically by

its neighboring vasculature

True pancreatic cysts

may be seen with von Hippel-Lindau disease, cystic fibrosis, or autosomal dominant polycystic kidney disease (ADPKD), the latter of which is associated with the development of cysts in many organs.

The pediatric pancreas may appear

more hypoechoic because of the lack of fat surrounding the pancreas in younger patients.

The most common primary pancreatic malignancy, which is most commonly found in men.

pancreatic adenocarcinoma

Islets of Langerhans

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

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

splenic and superior mesenteric arteries

Venous drainage of the pancreas is achieved by means of the

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

duct of Santorini

the accessory duct of the pancreas

Cystadenomas are most often located in

the body and tail of the pancreas.

acinar cells

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

duodenum

the first segment of the small intestine

duct of Wirsung

the main pancreatic duct

pancreatic adenocarcinoma

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

The most common location for a pancreatic adenocarcinoma is within

the pancreatic head

phlegmon

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

hyperparathyroidism

the presence of elevated parathyroid hormone

chronic pancreatitis

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

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; also referred to as the Whipple procedure

Whipple procedure

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 malignant pancreatic neoplasm, also referred to as pancreaticoduodenectomy

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

islet cell tumors

tumor found within the islets of Langerhans of the pancreas

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

uncinate process

Acute pancreatitis will cause a rise in amylase first and then a rise in lipase,

with lipase being the most helpful laboratory finding for the diagnosis of the disease (presenting 72 hrs later)

The pancreas is considered a retroperitoneal organ located

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