26DAVID SUTTON

DAVID SUTTON PICTURES

DR. Muhammad Bin Zulfiqar PGR-FCPS III SIMS/SHL

• Fig. 26.1 Pancreatic calcification in a middle-aged woman. (A) AP film. (B) Lateral film.

• Fig. 26.2 Barium swallow. Carcinoma in the tail of the pancreas elevating the intra abdominal oesophagus.

Fig. 26.3 Barium meal. Large cyst in the head of the pancreas widening and compressing the duodenal loop.

• Fig. 26.4 Barium meal, supine film. Carcinoma of the body of the pancreas indenting the posterior wall of the stomach (arrows).

• Fig. 26.5 Barium meal. Carcinoma of the head of the pancreas invading the duodenal loop with deformity of the mucosal pattern.

• Fig. 26.6 Barium meal. A double contour (arrows) of the duodenal loop. Carcinoma of the head of the pancreas.

• Fig. 26.7 Enlarged duodenal loop with 'reversed 3' sign of Frostberg. Earlier percutaneous transhepatic cholangiogram shows characteristic ' gloved finger' obstruction of intrapancreatic common bile duct pathognomonic of carcinoma of the pancreatic head. (Courtesy of Dr R. Dick.)

• Fig. 26.8 Hypotonic duodenogram. Annular constriction of second part of the duodenum with preservation of folds (arrows). Proven annular pancreas. (Courtesy of Dr R. Dick.)

• Fig. 26.9 ERCP. Duct of Wirsung (arrows) encircling gas-filled second part of duodenum. Annular pancreas. Duct of Santorini not filled. (See also Fig. 26.8.) (Courtesy of Dr R. Dick.)

• Fig. 26.10 CT scan. Acute pancreatitis. Swollen pancreas with extension of the inflammatory process into the mesentery. Some necrotic low-density areas are present in the pancreatic head.

• Fig. 26.11 Acute pancreatitis. Dilated duodenal and jejuna) loops.

• Fig. 26.12 Acute pancreatitis with fat necrosis. Multiple irregular lucencies in the left upper quadrant.

• Fig. 26.13 ERCP. Chronic pancreatitis. A smooth stricture of the common bile duct (arrowheads) with calcification in the pancreatic head (arrows).

• Fig. 26.14 Chronic pancreatitis. Extensive pancreatic calcification.

• Fig. 26.15 Coeliac angiogram; delayed film to show the venous phase. Carcinoma of the pancreas. Obstructed splenic vein with multiple collaterals and splenomegaly.

• Fig. 26.16 CT scan. Carcinoma of the head of the pancreas. A large pancreatic mass (arrowheads) with a dilated gallbladder (GB). Note left renal calculus.

• Fig. 26.17 Coeliac angiogram. Pancreatic carcinoma encasing the left gastric artery (arrowheads). The splenic artery is occluded (arrow). There is splaying of the gastroduodenal artery.

• Fig. 26.18 Percutaneous transhepatic cholangiogram. Carcinoma of the head of the pancreas. A long irregular stricture of the common bile duct.

• Fig. 26.19 Cystadenocarcinoma of the tail of the pancreas. (Courtesy of Dr O. Chan.)

• Fig. 26.20 Barium meal. Carcinoma of the ampulla producing a filling defect in the duodenum.

• Fig. 26.21 CT scan. Insulinoma. Small mass protruding from the posterior surface of the pancreas (arrows).

• Fig. 26.22 Coeliac axis angiogram, capillary and venous phase. Subtraction film. The well-defined blush in the pancreatic head (arrowed) is an insulinoma. (Courtesy of Dr R. Dick.)

• Fig. 26.23 Transhepatic venous sampling of pancreatic head vein in patient with suspected glucagonoma. ('23' is the sample number.) (Courtesy of Dr R. Dick.)

• Fig. 26.24 (A) Single axial section through the pancreatic neck from multislice acquisition in a patient with ampullary obstruction. (B) Corona) reformat. (C) Sagittal reformat. In all images, the mildly dilated pancreatic duct can be clearly identified (arrowheads). (Courtesy of Dr H. Burnett,

• Fig. 26.24 (A) Single axial section through the pancreatic neck from multislice acquisition in a patient with ampullary obstruction. (B) Corona) reformat. (C) Sagittal reformat. In all images, the mildly dilated pancreatic duct can be clearly identified (arrowheads). (Courtesy of Dr H. Burnett,

• Fig. 26.25 (A,B) Acute pancreatitis. Minimal abnormality with soft-tissue density strands in the retroperitoneal fat around the tail of the pancreas (asterisk) and thickening of the anterior pararenal fascia on the left side (arrow). Note the gallstone in the gallbladder neck.

• Fig. 26.26 Acute pancreatitis with necrosis and replacement of the pancreatic body by a fluid collection (asterisk). Note some persisting viable pancreatic tissue in the tail (arrow).

• Fig. 26.27 (A,B) Acute pancreatitis with ascites (arrowheads) and focal adjacent vessels, particularly the portal and splenic veins, with fluid collection within the pancreas containing gas loculi (asterisk). consequent thrombosis. Thickening of Gerota's fascia is evident (arrow).

• Fig. 26.28 Chronic calcific pancreatitis with a dilated pancreatic duct (asterisk) containing a calculus (arrow).

• Fig. 26.29 (A,B) Chronic calcific pancreatitis with thrombosis of the portal vein and consequent splenic collateral veins (arrow).

• Fig. 26.30 Pancreatic carcinoma. III-defined poorly enhancing pancreatic mass

Fig. 26.31 Pancreatic carcinoma and adjacent adenopathy encasing the coeliac axis (arrow). (Courtesy of Dr H. Burnett, Hope Hospital, Salford.)

• Fig. 26.32 (A) Calcified pancreatic carcinoma. (B) Calcification in a metastatic lymph node deposit (arrow).

• Fig. 26.33 Pancreatic cystadenocarcinoma. III-defined cystic mass in the pancreatic head with dilated pancreatic duct (arrow) and dilated gallbladder (asterisk) from duct obstructions.

• Fig. 26.34 Retroperitoneal lymphadenopathy in the region of the pancreas simulating a pancreatic mass. Note the anterior displacement of the pancreas which is marked by the position of the biliary stent.

• Fig. 26.35 Microcystic adenoma in the uncinate process (asterisk). Note the dilated pancreatic duct.

• Fig. 26.36 Pancreatic cysts (arrows) in a patient with von Hippel-Lindau syndrome.

• Fig. 26.37 Multifocal gastrinoma. Enhancing, hypervascular lesions are seen in the tail of the pancreas (A), and in the pancreatic head anterior to the IVC (B) (arrowheads).

• Fig. 26.38 Postoperative assessment of pancreatic transplant. (A) Good enhancement of head of right iliac fossa transplant with main vessel shown. Free fluid is present. (B) The pancreatic transplant tail is enhancing, and there is dilatation of proximal small bowel. Obstruction at the enteric anastamosis was found at laparotomy. There is a renal transplant in the left iliac fossa.

• Fig. 26.39 Normal pancreas on T, image with fat suppression by the water excitation method. The pancreas appears slightly hyperintense to liver.

• Fig. 26.40 Annular pancreas. T, image postgadolinium shows pancreatic tissue surrounding the second part of duodenum (arrow).

• Fig. 26.47 Carcinoma of the ampulla. MRCP (A) shows grossly dilated common bile duct with mild dilatation of the pancreatic duct (arrows); fat suppressed T 1 image (B) shows brightly enhancing normal pancreatic parenchyma (p) surrounding a small tumour with lower signal intensity (arrows); postgadolinium T, coronal image (C) shows the tumour (t) growing into the lower end of the common bile duct (b).

• Fig. 26.47 Carcinoma of the ampulla. MRCP (A) shows grossly dilated common bile duct with mild dilatation of the pancreatic duct (arrows); fat suppressed T 1 image (B) shows brightly enhancing normal pancreatic parenchyma (p) surrounding a small tumour with lower signal intensity (arrows); postgadolinium T, coronal image (C) shows the tumour (t) growing into the lower end of the common bile duct (b).

• Fig. 26.42 Unresectable carcinoma of the pancreas. MRCP (A) shows obstruction of both pancreatic ducts and common bile duct; postgadolinium T coronal image (B) shows the ducts are obstructed by an ill-defined tumour (t), which is slightly of lower signal intensity than adjacent pancreas; maximum intensity projection (C) shows the lower end of the portal vein to be encircled (arrows) by extension of the tumour (t) from the head of the pancreas.

• Fig. 26.42 Unresectable carcinoma of the pancreas. MRCP (A) shows obstruction of both pancreatic ducts and common bile duct; postgadolinium T coronal image (B) shows the ducts are obstructed by an ill-defined tumour (t), which is slightly of lower signal intensity than adjacent pancreas; maximum intensity projection (C) shows the lower end of the portal vein to be encircled (arrows) by extension of the tumour (t) from the head of the pancreas.

• Fig. 26.43 Resectable carcinoma of the pancreas. MRCP (A) shows dilated pancreatic duct (arrows); postgadolinium T corona) image (B) shows the tumour (arrow) with reduced signal intensity compared with adjacent parenchyma; maximum intensity projection image (C) shows the (arrow) superior mesenteric and portal veins are not involved by the tumour.

• Fig. 26.43 Resectable carcinoma of the pancreas. MRCP (A) shows dilated pancreatic duct (arrows); postgadolinium T corona) image (B) shows the tumour (arrow) with reduced signal intensity compared with adjacent parenchyma; maximum intensity projection image (C) shows the (arrow) superior mesenteric and portal veins are not involved by the tumour.

Fig. 26.44 Insulinomas. Tz image (A) shows a tumour as an area of high signal close to the surface of the head of pancreas and uncinate process (arrow); immediate postgadolinium T 1 image (B) shows marked enhancement in the adjacent parenchyma; delayed image 10 min after gadolinium (C) shows delayed enhancement in the lesion, while the pancreatic enhancement has faded.

• Fig. 26.44 Insulinomas. Tz image (A) shows a tumour as an area of high signal close to the surface of the head of pancreas and uncinate process (arrow); immediate postgadolinium T 1 image (B) shows marked enhancement in the adjacent parenchyma; delayed image 10 min after gadolinium (C) shows delayed enhancement in the lesion, while the pancreatic enhancement has faded.

• Fig. 26.45 Chronic pancreatitis. MRCP (A) shows dilated main pancreatic duct and multiple small cysts within the pancreatic head; postgadolinium coronal T, image (B) shows the pancreatic head is enlarged and heterogeneous with cystic areas of low signal.

• Fig. 26.46 Chronic pancreatitis with inflammatory mass. MRCP (A) shows dilated pancreatic duct, side branches and common bile duct; postgadolinium coronal T, image (B) shows a mass within the pancreatic head (m) which is obstructing the ducts; maximum intensity projection (C) shows the veins to be uninvolved.

• Fig. 26.47 Acute pancreatitis. Unenhanced images show the tail of the pancreas is replaced by an inflammatory mass which is hypo intense on T, (A) and heterogeneously hyperintense on T z (B); postgadolinium T, image (C) shows total lack of enhancement in the mass, indicating focal necrosis.

• Fig. 26.47 Acute pancreatitis. Unenhanced images show the tail of the pancreas is replaced by an inflammatory mass which is hypo intense on T, (A) and heterogeneously hyperintense on T z (B); postgadolinium T, image (C) shows total lack of enhancement in the mass, indicating focal necrosis.

• Fig. 26.48 (A-C) Normal variations in the shape of the pancreatic duct. Note complete filling of the duct system, both main and side ducts.

• Fig. 26.48 (A-C) Normal variations in the shape of the pancreatic duct. Note complete filling of the duct system, both main and side ducts.

• Fig, 26.49 (A,B) Pancreatic carcinoma producing complete occlusion of the main pancreatic duct (arrows). Note that the side branches downstream from the block are of normal calibre, aiding the differential diagnosis from main duct obstruction in chronic pancreatitis. (C) 'Acinarisation' has occurred because of excessive injection of contrast medium. This appearance of a block in the head of the gland must be distinguished from the ventral pancreas of pancreas divisum. The distinction can be made in this case because the main pancreatic duct is of normal calibre.

• Fig, 26.49 (A,B) Pancreatic carcinoma producing complete occlusion of the main pancreatic duct (arrows). Note that the side branches downstream from the block are of normal calibre, aiding the differential diagnosis from main duct obstruction in chronic pancreatitis. (C) 'Acinarisation' has occurred because of excessive injection of contrast medium. This appearance of a block in the head of the gland must be distinguished from the ventral pancreas of pancreas divisum. The distinction can be made in this case because the main pancreatic duct is of normal calibre.

• Fig. 26.50 ' Scrambled egg' appearance in pancreatic carcinoma. Numerous necrotic cavities within the tumour in the head of the gland have filled with contrast medium. Note upstream dilatation of main duct and side branches resulting from obstruction.

• Fig. 26.51 Severe chronic pancreatitis. The main duct and the side branches are dilated and beaded.

• Fig. 26.52 Mild chronic pancreatitis. The main pancreatic duct is normal but there are subtle dilatations of some of the side branches. Note the slight narrowing of the main duct at the junction of the head and body in (A); this is a normal variant.

• Fig. 26.53 Cavities have filled from the main duct in the tail of the gland (arrows). Chronic or recurrent pancreatitis.

• Fig. 26.54 The main pancreatic duct is dilated and contains numerous lucent stones. These findings are pathognomonic of chronic pancreatitis.

Fig. 26.55 (A) Tiny ventral component (arrow). The bile duct is also opacified.

• Fig. 26.55 (B) The dorsal component (in a different patient) has been filled (arrows) from the minor papilla. The bile duct terminates at the major papilla, below the minor.

• Fig. 26.56 Embryological development of the pancreas. (A) Dorsal segment (d) draining through the duct of Santorini and minor papilla. Ventral segment (v) developing in association with the bile duct and draining through the duct of Wirsung and major papilla. (B) The ventral segment has rotated with the bile duct to occupy its definitive position. This is the arrested embryological position of the adult pancreas divisum. Failure to rotate can give rise to annular pancreas (Fig. 26.9). (C) A wide communication (c) has developed between the dorsal and ventral ducts. (D) The terminal portion of the dorsal duct or duct of Santorini (s) becomes relatively smaller and may disappear completely. This is the normal adult arrangement.

• Fig. 26.57 Fluid in the fundus and body of the stomach together with some particulate matter afford visualisation of the tail of the pancreas. Harmonic imaging provides good quality images of an obese patient.

• Fig. 26.58 Normal neck and body of a pancreas. Note the inferior mesenteric artery and vein situated to the left of the aorta in a slim patient.

• Fig. 26.59 Anteroposterior diameter of the pancreatic head. At 2.5 cm this is at the upper limit of normal.

• Fig. 26.60 Normal variation in the size of the pancreas. A small but normal pancreas in a 42-year-old female.

• Fig. 26.61 Echogenic pancreas in an elderly obese woman. Note the poor definition of outline and poor differentiation from surrounding retroperitoneal fat, in spite of the use of tissue harmonic imaging.

• Fig. 26.62 Normal pancreas. Note the echo-poor ventral anlage.

• Fig. 26.63 Normal pancreatic duct at age 50.

• Fig. 26.64 Echogenic pancreas in duct at age 50. the elderly. Note the pancreatic duct.

• Fig. 26.65 Pancreatic head to the left of the aorta. Note the position of the superior mesenteric artery and vein.

• Fig. 26.66 Pancreatic carcinoma. Echo-poor rounded mass in the head of the pancreas with early dilatation of the pancreatic duct demonstrated anterior to the splenic vein.

• Fig. 26.67 Echo-poor tumour of the pancreatic body. Note the relatively large size of tumour prior to clinical presentation.

• Fig. 26.68 Oblique scan through the Aorta hepatis demonstrating dilated common bile duct measuring 18 mm

• Fig. 26.69 Distended gallbladder containing partial layering sludge in a patient with a carcinoma of the pancreatic head. This is the ultrasound Courvoisier sign.

• Fig. 26.70 Ultrasound of the liver. Note the dilated intrahepatic bile ducts and the small rounded echo-poor metastases.

• Fig. 26.71 Dilatation of the pancreatic duct in a patient with carcinoma of the head of the pancreas.

• Fig. 26.72 Carcinoma of the uncinate process. An echo-poor tumour is demonstrated within the uncinate process without evidence of dilatation of the pancreatic or bile ducts.

• Fig. 26.73 Carcinoma associated with lymphadenopathy extending into the coeliac axis group of nodes, thickening of omentum and ascites.

• Fig. 26.74 Abnormality of flow pattern in the portal vein consequent upon invasion by tumour.

• Fig. 26.75 The portal vein is filled with echogenic material. There is an irregular, partially cystic mass in the region of the head of the pancreas. Early bile duct dilatation is noted within the liver.

• Fig. 26.76 Complex cystic mass in the head of the pancreas with adjacent lymphadenopathy. Cystadenocarcinoma.

• Fig. 26.77 Acute pancreatitis. Markedly enlarged and echo-poor pancreatic head is partially obscured by thickened omentum. Note the small amount of fluid beneath the liver.

• Fig. 26.78 Mild pancreatic enlargement but with significant heterogeneity of the parenchyma.

• Fig. 26.79 Acute pancreatitis. Dilatation of the pancreatic duct in a 16-year-old. Note the enlargement of the pancreatic tail.

• Fig. 26.80 Chronic cholecystitis. Multiple gallstones within a contracted gallbladder.

Fig. 26.81 Acute pancreatitis. Marked thickening and oedema of the gallbladder wall.

• Fig. 26.82 Severe acute pancreatitis. Right pleural effusion.

• Fig. 26.83 Severe acute pancreatitis. The pancreas is markedly enlarged. There is increased reflectivity and oedema of the retroperitoneal fat and prepancreatic mesentery. There is thickening of the wall of the stomach.

• Fig. 26.85 Chronic pancreatitis. Marked dilatation of the pancreatic duct in longstanding pancreatitis. Note the intraduct calculus in the region of the tail.

• Fig. 26.86 Chronic pancreatitis. (A) Multiple bright non-shadowing foci within the head of the pancreas thought to represent protein plugs. (B) Several shadowing foci within the neck of the pancreas consistent with pancreatic calcification.

• Fig. 26.87 Chronic pancreatitis. A large pancreatic calculus is demonstrated in association with two small pancreatic cysts and presumably consequent upon ductal branch ectasia.

• Fig. 26.88 Pancreatic pseudocyst. The large mass in the left upper quadrant adjacent to the spleen with evidence of layering debris.

• Fig. 26.89 Pancreatic pseudocyst. Large cystic mass in the midabdomen in the region of the pancreatic bed demonstrating echogenic material posteriorly, representing pancreatic necrosis.

• Fig. 26.90 Pancreatic pseudocyst Large septated cystic mass in the midabdomen with nodular component. In the absence of history of pancreatitis it would be difficult to differentiate this from a cystic pancreatic tumour

• Fig. 26.91 Small pancreatic pseudocyst. A size less than 4.0 cm implies that the cyst is more likely to resolve spontaneously.

• Fig. 26.92 Primary pancreatic islet cell tumour. SRS (A) shows normal uptake in liver, spleen and kidneys, but also a small focus of abnormal activity corresponding with a functioning islet cell tumour; repeat study after resection (B) shows no abnormality.

• Fig. 26.93 Malignant islet cell tumour. SRS shows primary tumour (arrow) but also nodal deposits in the abdomen (A) and chest (B).

• Fig. 26.94 Malignant islet cell tumour with adjacent lymph node and single liver metastasis (m) shown by SRS.

• Fig. 26.95 Malignant islet cell tumour. Extensive liver replacement by functioning metastases shown on initial study (A). Six months after liver transplantation, further widespread metastases developed (B).