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THE PANCREAS 135 pancreatic juice into the abdominal cavity and severe cases result in complete pancreatic transection with pancreatic ascites. The release of pancreatic enzymes triggers pancreatitis and/or peritonitis, with the gland appearing enlarged and hypoechoic. Ultrasound may be helpful in localizing a collection, but will not differentiate pancreatic secretions from haematoma. CT is the method of choice in cases of suspected pancreatic trauma, although even here the signs of injury can be surprisingly subtle considering the damage. 22 PANCREATIC TRANSPLANT In patients with insulin-dependent diabetes mellitus with end-stage renal disease, simultaneous pancreatic and kidney transplant is a successful treatment which improves the quality of life and the survival of the patients. Typically such patients also have severe complications, such as retinopathy and vascular disease, which may be stabilized, or even reversed, by transplantation. Simultaneous pancreas and kidney transplantation now has a 1-year graft survival of almost 90% due to improved organ preservation techniques, surgical techniques and immunosuppression. 23 The transplanted kidney is placed in the iliac fossa with the pancreas on the contralateral side. The donor kidney is transplanted in as usual, with anastomoses to the recipient iliac artery and vein. The pancreatic vessels are anastamosed to the contralateral iliac vessels. The pancreatic secretions are primarily by enteric drainage, as the previous method of bladder drainage was associated with an increased incidence of urologic complications such as urinary tract infection, haematuria or reflux pancreatitis. 24 Postoperative monitoring of the pancreatic transplant is difficult, on both clinical and imaging grounds. No one imaging modality has proved without limitations and a combination of ultrasound, CT, MRI, angiography and nuclear medicine may be required. 25 Postoperative complications include thrombosis, infection, inflammation, anastomotic leaks and rejection. Localized postoperative bleeding usually resolves spontaneously. Ultrasound appearances The donor pancreas is usually situated in the iliac fossa but can be placed more centrally, particularly if a renal transplant has also been performed. Ultrasound is limited in its ability to assess the transplanted pancreas, even if it can be located amongst the bowel loops. The lack of an adjacent reference organ, such as the liver, makes assessment of its echogenicity subjective, and therefore subtle degrees of inflammation are difficult to detect. Fluid collections are frequently concealed beneath bowel and, when identified, their appearance is non-specific. Contrast CT is more successful in detecting anastomotic leaks and collections, and is usually used for guided aspiration. Colour Doppler should display perfusion throughout the pancreas and the main vessels may be traced to their anastomoses, depending on overlying bowel (Fig. 5.10). Neither CT nor ultrasound is particularly helpful in evaluating rejection, and it is difficult to differentiate transplant pancreatitis from true rejection. The Doppler resistance index does not correlate with a rejection process and has not been found useful. MRI has been found to display more positive findings in pancreatic rejection than other imaging modalities. Figure 5.10 The transplanted pancreas may be difficult to identify in the iliac fossa. The main artery is seen here running through the body of the pancreas.
136 ABDOMINAL ULTRASOUND References 1. Brambs HJ. 1996 Developmental anomalies and congenital disorders of the pancreas. Radiologe 36: 381–388. 2. Calvo MM, Bujanda L, Calderson A et al. 2002 Comparison between magnetic resonance cholangiopancreatography and ERCP for evaluation of the pancreatic duct. American Journal of Gastroenterology 97: 347–353. 3. Siech M, Boker M, Beger HG. 1996 Extracorporeal shock wave lithotripsy as a cause of acute pancreatitis. Digestive Surgery 13: 210–221. 4. Yamaguchi K, Chijiiwa K, Saiki S et al. 1996 ‘Massforming’ pancreatitis masquerades as pancreatic carcinoma. International Journal of Pancreatology 20: 27–35. 5. Pezzilli R, Billi P, Barakat B et al. 1999 Ultrasonic evaluation of the common bile duct in biliary acute pancreatitis patients: comparison with endoscopic retrograde cholangiopancreatography. Journal of Medical Ultrasound 18: 391–394. 6. Madhotra R, Lombard M. 2002 Endoscopic retrograde cholangiopancreatography should no longer be used as a diagnostic test: the case against. Digestive Liver Disease 34: 375–380. 7. Gumaste VV, Pitchumoni CS. 1996 Pancreatic pseudocyst. Gastroenterologist 4: 33–43. 8. Glasbrenner B, Kahl S, Malfertheiner P. 2002 Modern diagnostics of chronic pancreatitis. European Journal of Gastroenterology and Hepatology 14: 935–941. 9. Bolondi L, LiBassi S, Gaiani S, Barbara L. 1989 Sonography of chronic pancreatitis. Radiology Clinics of North America 27: 815–833. 10. Friedman AC, Krudy AG, Shawker TH et al. 1987 Pancreatic neoplasms. In: Radiology of the Liver, Biliary Tract, Pancreas and Spleen. Williams & Wilkins, Baltimore, 735–837. 11. Damjanov I. 1996 Pancreatic neoplasms. In: Pathology for Health Related Professionals. Saunders, Philadelphia, 324–326. 12. Lichtenstein DR, Carr-Locke DL. 1995 Mucinsecreting tumours of the pancreas. Gastrointestinal Endoscopy Clinics of North America 5: 237–258. 13. Cooperman AM, Kini S, Snady H et al. 2000 Current surgical therapy for carcinoma of the pancreas. Journal of Clinical Gastroenterology 31: 107–113. 14. Ishikawa O, Ohigashi H, Imaoka S et al. 1994 Is the long-term survival rate improved by preoperative irradiation prior to Whipple’s procedure for adenocarcinoma of the pancreatic head? Archives of Surgery 129: 1075–1080. 15. Di Stasi M, Lencioni R, Solmi L et al. 1998 Ultrasound-guided fine needle biopsy of pancreatic masses: results of a multicenter study. American Journal of Gastroenterology 93: 1329–1333. 16. Wieersema M. 2001 Accuracy of endoscopic ultrasound in diagnosing and staging pancreatic carcinoma. Pancreatology 1: 625–632. 17. Hammond N, Miller F, Sica G, Gore R. 2002 Imaging of cystic diseases of the pancreas. Radiology Clinics of North America 40:1243–1262. 18. Yassa N, Yang J, Stein S et al. 1997 Gray-scale and colour flow sonography of pancreatic ductal adenocarcinoma. Journal of Clinical Ultrasound 25: 473–480. 19. Angeli E, Venturini M, Vanzulli A et al. 1997 Color Doppler imaging in the assessment of vascular involvement by pancreatic carcinoma. American Journal of Roentgenology 168: 193–197. 20. Tomiyama T, Ueno N, Tano S et al. 1996 Assessment of arterial invasion in pancreatic cancer using colour Doppler ultrasonography. American Journal of Gastroenterology 91: 1410–1416. 21. Jacobs JE, Coleman BG, Arger PH, Langer JE. 1994 Pancreatic sparing of focal fatty inflitration. Radiology 190: 437–439. 22. Craig MH, Talton DS, Hauser CJ, Poole GV. 1995 Pancreatic injuries from blunt trauma. American Surgeon 61: 125–128. 23. Krishnamurthi V, Philosophe B, Bartlett ST. 2001 Pancreas transplantation: contemporary surgical techniques. Urology Clinics of North America 28: 833–838. 24. Sutherland DE, Gruessner RW, Dunn DL et al. 2001 Lessons learned from more than 1000 pancreas transplants at a single institution. Annals of Surgery 233: 463–501. 25. Pozniak MA, Propeck PA, Kelcz F, Sollinger H. 1995 Imaging of pancreas transplants. Radiologic Clinics of North America 33: 581–594
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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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PATHOLOGY OF THE LIVER AND PORTAL V
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PATHOLOGY OF THE LIVER AND PORTAL V
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Page 134 and 135: Chapter 5 121 The pancreas CHAPTER
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
Page 142 and 143: A C DISTANCE = 3.43 CM 5%. 13 Over
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Page 146 and 147: THE PANCREAS 133 head of pancreas.
Page 150 and 151: Chapter 6 137 The spleen and lympha
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Page 166 and 167: Chapter 7 153 The renal tract CHAPT
Page 168 and 169: THE RENAL TRACT 155 As with any oth
Page 170 and 171: THE RENAL TRACT 157 A B q 0 LRA AO
Page 172 and 173: THE RENAL TRACT 159 junctions of or
Page 174 and 175: THE RENAL TRACT 161 A B Figure 7.5
Page 176 and 177: THE RENAL TRACT 163 carcinomas, the
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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Page 190 and 191: THE RENAL TRACT 177 Xanthogranuloma
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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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