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THE PANCREAS 131 G H I Figure 5.5 cont’d (G) Dilated pancreatic duct due to a carcinoma in the head (arrow). (H) Colour Doppler helps to differentiate the dilated pancreatic duct (measured), which does not contain flow, from the splenic vein posterior to the duct. (I) Endoscopic retrograde cholangiopancreatography (ERCP) demonstrating a long stricture of the pancreatic duct (arrow) involving the side branches, in a large pancreatic carcinoma. The CBD is compressed (arrowhead) by nodes, causing biliary dilatation. A palliative stent was inserted.
132 ABDOMINAL ULTRASOUND Table 5.2 Differential diagnoses of focal pancreatic masses Mass Characteristics Solid Adenocarcinoma Hypoechoic, usually in the head of pancreas Focal acute pancreatitis Hypoechoic. Clinical history of pancreatitis Focal chronic pancreatitis Hyperechoic, sometimes with calcification. History of pancreatitis Endocrine tumour Less common. Small, hypoechoic, well-defined Metastases Late manifestation, widespread disease Cystic 17 Pseudocyst History of pancreatitis Mucinous tumour Less common than adenocarcinoma, tending to form in the body or tail of pancreas. Favourable prognosis following resection Necrotic or haemorrhagic tumour Simple cyst Rare. Exclude polycystic disease by scanning the liver and kidneys Ultrasound appearances of pancreatic carcinoma The adenocarcinoma, which comprises 80% of pancreatic neoplasms, is a solid tumour, usually hypoechoic or of mixed echogenicity, with an irregular border (Fig. 5.5). Because the mass is most frequently located in the head of the pancreas, which lies behind the duodenum, it may be difficult to identify at first. Endocrine tumours, which arise from the islet cells in the pancreas, include insulinomas, which are benign, and gastrinomas, which are more often malignant. They are usually hypoechoic, welldefined and exhibit a mass effect, often with a distally dilated main pancreatic duct. They are generally smaller at presentation than adenocarcinomas, and tend to arise in the body or tail of pancreas. Up to 40% of these tumours go undetected by both transabdominal ultrasound and CT, with endoscopic ultrasound and laparoscopic ultrasound having the highest detection rates for insulinomas. Gastrinomas tend to be multiple and may also be extrapancreatic. A small proportion of pancreatic cancers contain an obvious fluid content. Cystadenocarcinomas, which produce mucin, are similar in acoustic appearance to a pseudocyst, but unlike a pseudocyst, a mucinous neoplasm is not associated with a history of pancreatitis. It is also possible within a lesion to see areas of haemorrhage or necrosis which look complex or fluid-filled. Calcification is also seen occasionally within pancreatic carcinomas. 18 The adenocarcinoma is vascular and highvelocity arterial flow may be identified within it in many cases (Fig. 5.5C, F). The pancreatic duct distal to the mass may be dilated. It may, in fact, be so dilated that it can be initially mistaken for the splenic vein. The walls of the duct, however, are usually more irregular than the smooth, continuous walls of the splenic vein. Colour Doppler is useful in confirming the lack of flow in the duct and in identifying the vein behind it (Fig. 5.5G, H). Secondary ultrasound findings in pancreatic adenocarcinoma The most obvious secondary feature of carcinoma of the head of pancreas is the dilated biliary system (see Obstructive jaundice, Chapter 3). In a recent series of 62 pancreatic cancers, biliary dilatation occurred in 69%, pancreatic duct dilatation in 37% and the double duct sign (pancreatic and biliary duct dilatation) in 34% of patients. 18 Although the gallbladder is frequently dilated with no visible stones, this is not always the case; incidental gallstones may be present, causing chronic inflammation which prevents the gallbladder from dilating. For this reason it is imperative that the common duct is carefully traced down to the head of pancreas to identify the cause of obstruction. A thorough search for lymphadenopathy and liver metastases should always be made. CT is usually the method of choice for staging purposes. If the mass is large, it is not possible to differentiate whether it arises from the ampulla of Vater or the
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Abdominal Ultrasound
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Abdominal Ultrasound How, Why and W
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v Contents Contributors Preface ix
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vii Contributors Rosemary Arthur FR
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ix Preface Ultrasound continues to
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ABBREVIATIONS xi MHA MHV MI MPV MRA
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Chapter 1 1 Optimizing the diagnost
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OPTIMIZING THE DIAGNOSTIC INFORMATI
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Chapter 2 17 The normal hepatobilia
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THE NORMAL HEPATOBILIARY SYSTEM 19
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Chapter 3 41 Pathology of the gallb
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PATHOLOGY OF THE GALLBLADDER AND BI
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Chapter 4 79 Pathology of the liver
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Page 136 and 137: THE PANCREAS 123 the patient’s le
Page 138 and 139: THE PANCREAS 125 Acute pancreatitis
Page 140 and 141: THE PANCREAS 127 E F G Figure 5.3 c
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Page 146 and 147: THE PANCREAS 133 head of pancreas.
Page 148 and 149: THE PANCREAS 135 pancreatic juice i
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Page 172 and 173: THE RENAL TRACT 159 junctions of or
Page 174 and 175: THE RENAL TRACT 161 A B Figure 7.5
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Page 178 and 179: THE RENAL TRACT 165 the vesicourete
Page 180 and 181: THE RENAL TRACT 167 Table 7.1 Sourc
Page 182 and 183: THE RENAL TRACT 169 A B Figure 7.13
Page 184 and 185: THE RENAL TRACT 171 Table 7.2 Diffe
Page 186 and 187: THE RENAL TRACT 173 Ultrasound stil
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THE RENAL TRACT 181 der with increa
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THE RENAL TRACT 183 ● ● Morphol
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THE RENAL TRACT 185 ● ● hydrone
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THE RENAL TRACT 187 A Figure 7.27 A
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THE RENAL TRACT 189 vascular reject
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THE RENAL TRACT 191 B A C Figure 7.
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THE RENAL TRACT 193 computerised ul
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Chapter 8 195 The retroperitoneum a
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THE RETROPERITONEUM AND GASTROINTES
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Chapter 9 215 The paediatric abdome
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THE PAEDIATRIC ABDOMEN 217 A B SPLE
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THE PAEDIATRIC ABDOMEN 219 B A B Fi
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THE PAEDIATRIC ABDOMEN 221 probe de
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THE PAEDIATRIC ABDOMEN 223 When the
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THE PAEDIATRIC ABDOMEN 225 + 78 A 2
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THE PAEDIATRIC ABDOMEN 227 A B C D
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THE PAEDIATRIC ABDOMEN 229 Table 9.
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THE PAEDIATRIC ABDOMEN 231 A LT B C
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THE PAEDIATRIC ABDOMEN 237 mesenter
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THE PAEDIATRIC ABDOMEN 239 E F G Fi
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THE PAEDIATRIC ABDOMEN 241 system i
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Chapter 10 The acute abdomen 243 CH
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THE ACUTE ABDOMEN 245 scan of the p
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THE ACUTE ABDOMEN 247 LIVER LS GB S
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THE ACUTE ABDOMEN 249 D A RT B C E
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THE ACUTE ABDOMEN 251 17. Patlas M,
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Chapter 11 253 Interventional and o
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INTERVENTIONAL AND OTHER TECHNIQUES
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275 Bibliography and further readin
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277 Index A Abdomen, acute gastroin
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INDEX 279 Continuous ambulatory per
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INDEX 281 Intravenous urography (IV
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INDEX 283 Phrygian cap, 29 Pneumobi
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