Angiographic evaluation of the abnormal endoscopic pancreatogram

Out of 1,269 pancreatograms, 122 were abnormal. Angiography was performed in these patients. Fifty-five were found to have pancreatic carcinoma. In the remaining 67 patients a false positive angiographic diagnosis of either chronic pancreatitis or pancreatic cancer was made in 11%. In one patient a hemangioma was diagnosed as a pancreatic cyst. The remaining 58 patients all had normal pancreatic angiograms in spite of gross ductal abnormality on endoscopic retrograde cholangiopancreatography (ERCP). All these patients were followed for an average of 19 months and showed no clinical evidence of pancreatic disease. It is suggested that angiography should be considered a complementary examination to ERCP and is particularly useful to exclude carcinoma when the pancreatogram is abnormal.     

Helical CT anatomy of pancreatic arteries

Background: To assess the frequency of visualization of pancreatic arteries in the arterial phase of helical computed tomography (CT). Methods: The visibility of pancreatic and peripancreatic arteries in helical CT images was evaluated in 20 consecutive patients who had no evidence of pancreatic disease. CT examinations were performed by using a continuously rotating CT scanner and intravenous injection of contrast media. The scans were taken 35 s after the start of injection and with a table speed of 3 mm/s. Images were reconstructed in 3-mm section increments. Results: Frequently visualized arteries were the gastroduodenal, anterior and posterior superior pancreaticoduodenal, and right gastroepiploic arteries. Infrequently visualized arteries were the dorsal pancreatic, pancreatica magna, caudal pancreatic, transverse pancreatic, and common, anterior, and posterior inferior pancreaticoduodenal arteries. Conclusion: Helical CT enabled us to recognize small pancreatic arteries, and the evaluation of these arteries should be considered in the staging of pancreatic carcinoma. Received: 6 June 1995/Accepted: 22 July 1995     

Improved survival with early CT diagnosis of pancreatic abscess

Until recently pancreatic abscess was often a lethal complication of acute pancreatitis. A major factor contributing to this high mortality has been delay in diagnosis. When combined with diagnostic needle aspiration, computed tomography (CT) has greatly enhanced the early detection of pancreatic abscesses. In the past 5 years at our institutions 23 patients with proven pancreatic abscesses were evaluated early in their clinical course by CT. In follow-up ranging from 4 months to 4 1/2 years there were only 4 deaths: a mortality rate of 17%. Many of the surviving patients had a long and protracted clinical course (mean length of hospitalization, 58 days) and reoperation for recurrent abscess or gastrointestinal complications was required in 9 patients (39%). Computed tomography proved helpful both in localizing the site of de novo or recurrent pancreatic abscess and in detecting postoperative complications. An aggressive approach to early CT scanning with diagnostic needle aspiration appears to be a factor in the improved survival of these patients.     

Pancreatic lesions and transfascial perirenal spread: Computed tomographic demonstration

Computed tomographic (CT) findings in 105 cases of pancreatitis and 107 cases of pancreatic carcinoma were analyzed retrospectively to determine the occurrence and roentgenologic signs of penetration of the anterior renal fascial planes in relation to clinical symptoms. In pancreatitis, the perirenal fat was infiltrated in 7% to variable extents by extrapancreatic fluid collections, either as asymptomatic fluid lying alongside renal fascial planes and perirenal septa (5 cases) or as well-circumscribed fluid collections causing clinical symptoms (2 cases). In pancreatic carcinoma the occurrence of retropancreatic extension to a perirenal space was rarer (3%). Distinction on CT between perirenal involvement from the pancreas and primary adrenal or renal lesions with anterior spread can prevent unnecessary surgery.     

CT evaluation of pancreatic injury following splenectomy

A fluid collection in the left subphrenic space immediately after splenectomy is often associated with pancreatic injury. The configuration, location, and vascular supply of the tail of the pancreas explain this postoperative complication. Depending on the degree of injury, the CT findings may show swelling of the tail of the pancreas, ill-defined fluid collections, or a well-encapsulated pancreatic pseudocyst. The diagnosis is confirmed by percutaneous aspiration with amylase determinations and the demonstration of a pancreatic fistula. Failure to diagnose this complication promptly may lead to a protracted postoperative clinical course and the development of a subphrenic abscess or a pancreatic pseudocyst.     

选择性血管造影诊断胰腺肿瘤的临床应用价值

目的:探讨血管造影诊断胰腺肿瘤的临床应用价值。材料与方法:临床疑为胰腺良性肿瘤6例和恶性肿瘤5例共11例进行选择性血管造影。结果:血管造影7例阳性,4例阴性,与手术病理结果相符合。结论:选择性血管造影是诊断胰腺良性肿瘤的一种可靠方法。对小胰岛索瘤的定位诊断有独到之处。对胰腺癌手术可切除性的估价有一定帮助。     

Intraductal papillary carcinoma of the pancreas

We report a case of intraductal papillary adenocarcinoma of the distal pancreatic duct. Although a rare subgroup of exocrine pancreatic tumors, their diagnosis is an important one in view of their favorable prognosis with pancreatectomy. Because of the established behavior of villous tumors of the colon, to which they are similar histologically, these tumors should be resected, even if biopsy shows benign disease. Patients should be followed radiologically for recurrence or the development of new adenoma following resection.     

Pancreatic head cancer: accuracy of CT in determination of resectability

Background Pancreatic cancer is a devastating disease whose early detection remains difficult. There is no 100% reliable imaging test to diagnose and stage pancreatic cancer. We assessed the surgical value of contrast-enhanced spiral computed tomography (CT) in predicting the resectability and survival rates of patients who had pancreatic head cancer.Methods Eighty-nine patients who had pancreatic head cancer were investigated with spiral CT. Based on the preoperative CT results, we assigned patients to one of three CT groups based on resectability.Results A correlation between classification of CT resectability and intraoperative finding was found in 83% of patients. The sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of spiral CT in identifying predictive unresectability were 79%, 82%, 91%, 62%, and 81%, respectively. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CT in diagnosis of vascular invasion were 94%, 84.2%, 94%, 84%, and 91.3%, respectively.Conclusion The use of CT in the evaluation of pancreatic tumors provides valuable preoperative assessment of surgical resectability and should be performed for clinical examination. Classifying patients by tumor resectability on CT helps to estimate more precisely the tumor stage and to prognosticate survival rates of these patients.     

Ultrasound in acute pancreatic trauma

The ultrasound findings are reviewed in 4 patients with surgically proven acute pancreatic trauma. Despite technically adequate sonograms, pancreatic injuries were not prospectively diagnosed in any of the patients. Computed tomography (CT) performed shortly after ultrasound demonstrated changes of traumatic pancreatitis in each case. Because of the subtlety of the ultrasound findings, CT appears to be the preferred method for evaluating suspected pancreatic trauma.     

Problems in the diagnosis of pancreatic carcinoma by endoscopic retrograde cholangiopancreatography

Diagnostic problems occurred in five out of 55 patients undergoing endoscopic retrograde cholangiopancreatography who subsequently proved to have carcinoma of the pancreas. In one patient the pancreatic duct was normal, two had non-specific ductal abnormalities, one had pancreas divisum, and one had ductal ectasia. Two patients with non-specific changes on retrograde pancreatography had evidence of tumor on their retrograde cholangiogram. Two patients had ductal obstruction simulating pancreatic cancer, in one due to compression by the thoracic spine, in the other by inflammatory changes.     

Uneven Lipomatosis: A pitfall in pancreatic Sonography

A marked difference in echogenicity between the anterior and posterior parts of the pancreatic head was demonstrated by pancreatic ultrasound in 4 patients. This finding could not be related to local pancreatic or peripancreatic pathology. In all patients the dorsal portion of the head, including the uncinate process, appeared less echogenic than the ventral part of the head, body, and tail. The level of demarcation was identical in all 4 cases, coinciding with the expected fusion line of the embryological dorsal and ventral pancreatic origin. Pathology available in 1 patient showed an uneven lipomatosis as an explanation for this hitherto unreported observation.     

Transection of the pancreas demonstrated by ultrasound and computed tomography

The early occurrence of peritoneal signs and hyperamylasemia in a 14-year-old boy, who had fallen off his horse, urged us to perform a sonographic and computed tomographic study of the upper abdomen. Both examinations showed a complete pancreatic rupture. Distal pancreatectomy led to a rapid and uneventful recovery.     

Pancreatic transplants: secretin-stimulated MR pancreatography

Background

Our study was aimed to evaluate the functional status of pancreatic transplants using dynamic MR pancreatography after secretin stimulation.

Methods

Thirteen asymptomatic patients previously submitted to isolated pancreas (n = 6) or combined kidney–pancreas (n = 7) transplantation, with enteric-portal pancreatic drainage, underwent MR examination at 1.5 T using a phased-array coil. After the acquisition of axial and coronal T1- and T2-weighted sequences, dynamic MR pancreatography was performed using a coronal breath-hold, thick-slab (40–60 mm), single-shot T2-weighted fast spin-echo sequence. After the intravenous administration of secretin (Secrelux^®, Sanochemia; 1 cU/kg body/weight), a single-slice image acquisition was repeated every 30 s up to 15 min. We estimated the calibre changes of the pancreatic ductal system and the filling of the donor’s duodenum on the basis of pancreatic secretion after secretin stimulation, also evaluated by using a mean signal intensity/time histogram in a chosen region of interest including the transplanted pancreas and the connected small bowel.

Results

All patients well tolerated the examination, and no side effects were reported after secretin administration. In 12/13 cases, a significant increase (more than 1 mm) in the diameter of the mean pancreatic duct was observed after secretin stimulation; in all patients, a noticeable filling of the duodenal graft was demonstrated during dynamic MR pancreatography on both qualitative and quantitative analyses.

Conclusions

Dynamic MR imaging after secretin administration allows non-invasive evaluation of exocrine function of the pancreatic transplants and could be used to differentiate patients with graft rejection from those with normal graft function.

     

Ultrasonic characteristics of pancreatic tumors

The ultrasonic features of 40 pancreatic tumors were analyzed. The tumors were categorized by texture, attenuation, shape, size, and location. Secondary effects of pancreatic duct visualization, biliary stasis, splenic vein involvement, metastases, and ascites were reviewed. Thirty of thirty-one adenocarcinomas had a similar ultrasonic texture consisting of a background of faint, low-level echoes with varying amounts of superimposed coarse echoes. Tumors are detectable prior to enlargement or distortion of the pancreas. Secondary features were present in 94% of the adenocarcinomas. Significant information regarding the possibility and complexity of resection can be provided.     

Branch duct IPMTs: value of cross-sectional imaging in the assessment of biological behavior and follow-up

Branch duct intraductal papillary mucinous tumors (IPMTs) are increasingly being described and represent a challenge for the physician. Recent imaging modalities, especially computed tomography and magnetic resonance, allow for a correct diagnosis, but IPMTs can manifest with different degrees of cellular atypia so it is very important to be able to establish the biological behavior of the lesion. Sixty-five patients were included in this study: 29 of them underwent surgery, and the other 36 were followed with cross-sectional imaging. Among patients who underwent surgery, 11 had benign lesions and 18 had malignant lesions. Overall sensitivity, specificity, and accuracy in the diagnosis of malignancy for all the cross-sectional imaging techniques were 61%, 81%, and 69%, respectively. Among patients who were followed and had a magnetic resonance cholangiopancreatographic diagnosis of branch duct IPMT with imaging features indicative of benignity, only two showed modifications over the follow-up period. Even considering some important biases (small number of patients and relatively short follow-up), interesting conclusions can be drawn: the imaging diagnosis of malignancy can be trusted, whereas that of benignity cannot be relied upon, but if the signs of malignancy are absent, the slow growth of the lesions justifies watchful follow-up in the correct clinical setting.     

Magnetic resonance imaging of the pancreas with gadolinium-DTPA

Gadolinium (Gd)-DTPA was evaluated as a contrast agent for magnetic resonance (MR) imaging of the pancreas at 1.5T. Twenty-five patients were imaged with identical gradient-echo (GE) (TR 47, TE 13, 80° pulse angle) and spinecho (SE) (TR 300, TE 15) MR sequences prior to and following an intravenous bolus of 0.1 mmol/kg Gd-DTPA. Marked pancreatic enhancement was demonstrated on dynamic sequential breath-hold GE images obtained immediately following the Gd-DTPA bolus (116% mean enhancement over pre-Gd-DTPA images). Enhancement decreased but persisted on the SE images obtained approximately 5 and 15 min following the Gd-DTPA bolus (65 and 60% mean enhancement, respectively). Five of the patients had a pancreatic mass. In these five patients, the enhancement of pancreatic tissue resulted in improved conspicuity of the mass. These initial results suggest that pancreatic enhancement occurs following an intravenous bolus of Gd-DTPA and has the potential to improve MR visualization of pancreatic masses.     

宽体探测器CT胰腺轴位灌注“一站式”成像的可行性

目的 探讨Revolution CT胰腺轴位灌注"一站式"成像的可行性。方法 收集接受Revolution CT上腹部轴位CT灌注（CTP）扫描的患者13例（CTP组）,测量胰腺的CTP参数,提取最佳时期CTA及3期增强图像,并记录整个灌注期的辐射剂量。收集同期行全腹3期增强及CTA扫描者18例（对照组）,采用螺旋扫描模式。2组患者胰腺均无病变。评价2名观察者测得各CTP参数和对胰十二指肠上动脉（SPDA）图像主观评分的一致性。比较2组SPDA图像的主观评分和CTA图像SPDA以及3期增强图像胰腺的CT值、图像噪声、CNR和SNR。结果 2名观察者测得CTP参数一致性良好（ICC均>0.75）。灌注期有效辐射剂量为（24.52±0.01）mSv。2名观察者对2组CTA图像SPDA的主观评分结果一致性较好（Kappa=0.629、0.769）,2组评分中位数均为5分;CTP组SPDA的CT值、CNR、SNR均高于对照组（P均<0.05）。CTP组静脉期、平衡期的胰腺CT值、CNR、SNR均高于对照组（P均<0.05）。结论 Revolution CT胰腺轴位灌注"一站式"成像,在获得稳定的胰腺CTP定量数据的同时,可提取图像质量相仿甚至更佳的胰腺3期强化图像,并可获得更优质的胰周CTA图像,有很好的临床应用前景。     

P T 螺旋CT对胰周小血管的显示及其临床意义

目的 研究胰周小血管的正常和异常表现,方法 对90例无胰腺及无胰周疾病,无门脉高压的患者和20例胰腺肿瘤的患者行螺旋CT双期扫描,横断面观测胰周小血管包括胰十二指肠后上静脉,胃结肠干,胰十二指肠前上静脉,胃网膜右静脉,胃十二指肠动脉,胰十指肠前上动脉的显示率,并测量其直径,将二者进行比较,结果 （1）两组胰周小血管显示其P＜0．05,两组平均直径比较,胰周小静脉P＜0．05;（2）肿瘤组共显示扩张小静脉13支,结论（1）正常胰周小血管直径有一定的正常值范围。（2）胰周小血管异常改变可帮助对胰腺肿瘤的早期诊断和分期。     

Abnormal intraabdominal gas collections visualized on computed tomography: A clinical and experimental study

Abnormal intraabdominal gas collections visualized on CT scans during a 1-year period were reviewed. There were 34 collections in 29 patients. Sixty-two percent of these abnormalities were noninfectious and iatrogenic in origin, usually a direct result of procedures such as surgery, diagnostic tests, and needle or tube placement. Infections/abscesses (18%), hernias (15%), and gastrointestinal perforations (6%) produced the other abnormal gas collections. In the experimental animal study, gas collections as small as 5cc could be visualized on CT images. Collections of up to 20cc were visible for similar periods of time on both CT scans and conventional radiographs. It is concluded that most abnormally placed gas collections seen on CT are iatrogenic and that CT scans are very sensitive for the detection of such collections.     

Asymptomatic nonspecific serum hyperamylasemia and hyperlipasemia: spectrum of MRCP findings and clinical implications

We assessed the magnetic resonance cholangiopancreatographic (MRCP) findings in patients with asymptomatic, mild elevations of serum amylase and lipase levels to determine whether there might be a pathoanatomic cause for these laboratory abnormalities. MRCP was performed in 633 consecutive patients. Of these, 54 (8.5%) images were obtained in patients with asymptomatic serum hyperamylasemia and hyperlipasemia. MRCP was performed on a 1.0-T MR system; breath-hold gradient-recall, half-Fourier acquisition, and rapid acquisition with relaxation enhancement sequences were obtained. Findings were verified by follow-up, biopsy, or surgery. One-sided, large-sample z tests were used to compare the incidence of abnormalities between the study and control groups (579 patients). The pancreas appeared abnormal on MRCP in 31 patients (57%), including the pancreas divisum in 10 patients (18.5%). Other findings included morphologic changes compatible with chronic pancreatitis in nine patients (16.6%) and a healed pancreatic laceration, juxtapapillary duodenal diverticulum, papillary sclerosis, intraductal pancreatic lithiasis, and hemochromatosis in one patient each (1.9%). Small cystic lesions (< 1 cm) within the pancreas were seen in 15 patients (27.8%). In eight patients, these were associated with other abnormalities (pancreas divisum in three patients, chronic pancreatitis in four, and pancreatic laceration in one). No malignancy was diagnosed. The incidences of normal examination (p = 0.01), pancreas divisum (p < 0.005), and a small cystic lesion (p = 0.01) as solitary findings in this subgroup of patients were significantly higher when compared with the remainder of the studied population. Investigation of asymptomatic patients with nonspecific hyperamylasemia and hyperlipasemia by means of MRCP yielded pancreatic findings in more than 50% of these patients. Pancreas divisum was found more often than expected in the general population.