Spleen and Pancrease

Pancreas and Spleen

亞東醫院急診醫學部孫仁堂醫師

2011年8月6日星期六

Pancrease

• Normal picture

➡ vascular marker

• Pathological pancrease

➡inflammation- acute/chronic pancretitis

➡tumor


When


When

• Jaundice

• abdominal pain

• Not suitable for CT

- Pregnant, contrast allergies.....



Anatomy

• Retroperitoneal

• Post to stomach

• Water

• Duodenal C-loop

• Vascular


Anatomy

• Retroperitoneal

• Post to stomach

• Water

• Duodenal C-loop

• Vascular


Transverse view


Vessel of pancreas

• Splenic vein

• Post to body and tail

• Cobra head

• Pancreatic mass located anterior to splenic vein



SMV

• Parallel and right of SMA

• Landmark of pancrease

- Head is lateral

- Neck is anterior

- Uncinate is postierior


Sagittal view



Main portal vein and IVC

• Pancreatic head inferiorly

• Marker for the head

• 4cm in length


SMA

• Anterior to aorta

• Echogenic mesenteric fat

• Marker for the body

• Shallow angle


SMA




• Shallow angle


SMA




• Shallow angle



Splenic artery

• Along with cranial border of body and tail

• Tortuous course


Pitfall


Pitfall


Pitfall


Pitfall


Normal size

• Head: <4cm

• Body: <2cm

• Tail: <2.5cm


Sagittal view


Sagittal view


Sagittal view


Sagittal view


Sagittal view


Sagittal view


Vascular marker


Vascular marker


Vascular marker


Pancreatic duct

• Size<2mm

• Center of gland


Pancreatic duct

• Size<2mm

• Center of gland


Uncinate process

• Dorsal and ventral anlage that fuse

• Different fat content and echogenicity


Pathologic

• Inflammation

- Acute

- Chronic

- Complication

• Pancreatic tumor


Acute pancreatitis


Acute pancreatitis

• Biliary pancreatitis

• Complication

• Fluid collection

• Unsuspected cases


Acute pancreatitis

• 20% is normal

• Diffuse and focal

• Hypoechoic


Acute pancreatitis:focal

• Mimic carcinoma

• Usually in head


Acute pancreatitis:focal

• Mimic carcinoma

• Usually in head


Complication

• Pancreatic infection and abscess

• Pseudocyst formation

• Pseudoaneurysm, thrombosis


Acute pancreatitis


Acute pancreatitis


Acute pancreatitis


Acute pancreatitis




Complication


Pseudocyst

• 90% of cystic mass

• Encapsulated, fluid collection

• Multiple

• Calcified

• Complication


Pseudocyst



• Multiple

• Calcified

• Complication


Pseudocyst



• Multiple

• Calcified

• Complication



Complication of pseudocyst

Infection

Rupture

Hemorrhage


Chronic pancreatitis

• Calcification

• Heterogeneous

• Irregular dilated duct and outline

• Decrease size

• Pseudotumor penetrating duct sign




Pancreatic tumor

• Pancreatic carcinoma

• Islet cell tumor

• Cystic tumor


Pancreatic cancer

• Head(60%), body and tail(40%)

• Solid, focal, irregular, hypoechoic mass

• Vessel invasion, encasement

• P duct, bile duct dilation



Pancreatic carcinoma


Pancreatic tail carcinoma


1. Microcystic adenoma(serous)

2. Macrocystic adenomas(Mucinous)

3. Intraductal paipillary mucinous neoplasm

* Mucinous tumors have malignant potential

Cystic tumor


Microcystic adenoma

• Smooth margin

• Heterogenic


Macrocystic adenoma


Cystic tumor


IPMN


Islet cell tumor

• Insulinoma, gastrinoma, VIP-oma...

• Small homogenous hypoechoic tumor

• EUS Sensitive and FNA biopsy


Pancreatic trauma


Pancreatic trauma


Pancreatic trauma


Spleen


Spleen

• Normal picture

• Post. axillary line

• Accessory spleen

• Splenomegaly

• Splenic cystic lesion

• Splenic solid lesion


Longitudinal

Splenic hilum


Longitudinal

Splenic hilum


Longitudinal

Lt Kidney

Adrenal

Spleen


Longitudinal

Lt Kidney

Adrenal

Spleen


Longitudinal

Lt Kidney

Adrenal

Spleen


Longitudinal

Lt Kidney

Adrenal

Spleen


Normal spleen

• Homogeneous

• Moderate echogenic

• Wandering spleen


Splenomegaly

• Lymphoproliferative disease (lymphoma)

• Portal hypertension

• Infectious (mononucleosis, AIDS)

• Infiltrative (Gaucher’s)


Size

• A>10cm & B>5cm

• A*B >30

• A*B>20A

B


Size

• A>10cm & B>5cm

• A*B >30

• A*B>20A

B


Size

• A>10cm & B>5cm

• A*B >30

• A*B>20A

B


Accessory spleen

• Isoechoic, round, small mass

• Splenic hilum

• 10% patient

• Solitary or multiple



Cystic mass

• Cyst

• Hematoma

• Abscess

• Pseudoaneurysm


Cyst

• Primary: rare

• Secondary old trauma pseudocyst

• Hemorrhage, infection


Trauma

• Irregular hyperechoic or hypoechoic

• Subcapsular hematoma dopplar can help

• Perisplenic fluid

• Contrast ultrasound


Splenic laceration



Subcapsular hematoma


Subcapsular hematoma


Contrast ultrasound



Infection

• Usually secondary causeIE, septicemia......

• Bacterial: hypoehcoic or complex with irregular margin

• Fungal: target sign, small(1cm)

• Granulomatous: calcification


Microabscesses

• Target lesion, bull’s eye lesion

• Fungal: candidiasis


Candidiasis


Bacterial abscess



Psuedoaneurysm

• Trauma or pancretitis

• Dopplar


Solid masses

• Infarct

• Hemangioma

• Lymphoma

• Metastasis


Gamm-Gandy bodies

• Hyperechoic without PAS

• Siderotic nodule

• Splenomegaly

• Portal hypertension

• Sickle cell anemia

• PCP infection



Infarct

• Most common focal lesion

• Peripheral, wedge shape hypoechoic lesion

• Septic emboli

• Thrombosis of splenic vessel



Calcification

• Hyperechoic with PAS

• TB or histoplasmosis



Hemangioma

• Rare

• Hyperechoic mass

• Spleen size usually normal


Lymphoma

• Splenomegaly

• diffuse or focal

• Hypoechoic

• LAP




Metastasis

• Lung, breast, melanoma

• May be target lesion



Cystic metastasis


Thank you


splenic granuloma

• Hyperechoic lesion

• Tiny shadow

• TB?


Spleen and Pancrease

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