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D. E. F.
Head fills concavity of duodenum Body crosses left kidney Tail reaches hilus of the spleen
Pancreas in situ
I.
Uncinate process:
a. Lies posterior to SMA and SMV
SMV
Introduction, continued
L. Body related
posteriorly to left crus, left adrenal, left renal vein, and splenic vein K. Celiac Axis (trunk, artery) lies superior to body
2. Hepatic Artery:
a. Branch of celiac trunk b. courses left to right c. along upper margin of neck and head
3. Superior Mesenteric Artery: at its origin from aorta, points at body of pancreas
4. Splenic Vein:
a. runs parallel to artery b. on posterior surface of pancreas c. Terminates in portal vein
B. Head of Pancreas
1. Important clinically because:
a. Numerous ducts and vessels traverse it b. Carcinoma usually located here
2. Tumor will compress surrounding structures a. First indication may be jaundice b. Tumor may compress duodenum c. May involve local vessels *Metastases may spread through these vessels*
4. Vessels supplying head of pancreas a. Superior & inferior pancreaticoduodenal arteries b. Both divide into two parallel vessels c. one anterior and one posterior to head
b. inferior branch:
anterior inferior pancreaticoduodenal artery
b. inferior branch:
posterior inferior pancreaticoduodenal artery
Epiploic foramen
4. Lesser sac bounded by: a. Liver, superiorly b. Below, extends to greater omentum c. Anteriorly: lesser omentum, stomach, greater omentum
2. Posterior surface: a. b. c. d. e. f.
Aorta Splenic vein Left kidney and renal vessels Left adrenal gland Left Crus of diaphragm SMA and SMV
3. Inferior surface of Pancreatic body: a. Rests on duodeno-jejunal flexure b. Left extremity (tail)
1. Rests on splenic flexure 2. Abuts hilus of spleen
d. joins CBD at Ampulla of Vater 3 - 4 below pylorus e. results from fusion of ducts during fetal development
1. One from ventral pancreas 2. One from dorsal pancreas (see Netters Embryology, p. 142, for Pancreas
development)
Duct of Wirsung
Duct of Wirsung
2. Duct of Santorini:
a. accessory pancreatic duct
Duct of Santorini
3. In 10% of population
a. ducts fail to fuse b. result is drainage of tail, body, & most of head through minor papilla c. Not pathological
III. Scanning Anatomy A. Depends on recognition of pancreatic margins B. Sonography best used as screening procedure 1. May be interference from bowel gas (especially in tail region)
2. Extremely accurate in detection of pseudocysts 3. U/S can show texture of organ 4. By ID-ing vessels, can delineate head, portions of body
5. U/S can frequently detect dilation of pancreatic duct 6. Splenic Vein: landmark vessel a. usually seen along posterior margin of body, tail b. May be anterior (~30%)
C. Head: 1. SMV outlines medial head to neck region 2. Duodenum & GB outline lateral head 3. Superiorly, delineated by gastroduodenal artery (GDA) 4. Inferiorly, bounded by CBD
D. Further delineation by vascular landmarks: 1. SMA: a. Lies immediately posterior to body, points to it! b. Recognized by echogenic fat collar surrounding vessel
2. SMV: a. Delineates medial head b. Larger diameter than SMA c. Lies to right of SMA d. Uncinate process wraps it (and SMA), lies posterior & medial
Venous landmarks of the pancreas include the SMV and renal veins
3. Left Renal Vein: a. as it enters IVC b. head & uncinate process should lie within 1 2 cm c. Landmark vessel posterior to body of pancreas
E. Tail of Pancreas
1. May be visualized through fluid-filled stomach 2. Tail seen as 2-3 cm rounded mass anterior to hilus of left kidney
3. Infrequent causes: a. Infectious diseases b. Trauma d. Drugs e. Hyperparathyroidism 4. Inflammation may be diffuse or spotty
5. Important factor is release of protein kinins a. Increase permeability of vessels & cells b. Releases tissue fluid c. Edema may compress vessels d. Tissue damage occurs
6. WBCs may increase to 20,000/ml 7. Increase in pancreatic enzymes a. serum bilirubinase (by 25%) b. serum amylase c. serum lipase
B. Pseudocysts:
b. Rarely, mediastinum
5. Pseudocyst appearance
a. unilocular or multilocular
b. echoes from pus & cellular debris
C. Acute Pancreatitis
1. Diffuse enlargement
2. Less echogenic due to edema 3. Echogenicity usually > liver parenchyma
D. Chronic Pancreatitis 1. organ usually appears as small, atrophic 2. Contains scattered echoes from calcifications 3. Primary cause is alcoholism
c. Nausea
d. Weight loss
3. In Body of Pancreas: Sx a. Gnawing pain radiating to back b. Pain increases after eating or lying down c. Weight loss, anorexia d. Large tumor may compress IVC, portal vein
4. In Tail of Pancreas: Sx
a. Often silent until local metastasis occurs b. May metastasize to: 1. para-aortic lymph nodes
2. spleen
H. Fibrocystic Disease
I. Pancreaticolithiasis
1. Characteristic stone echoes in pancreatic duct
Pancreatolithiasis, continued