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Medical Ultrasonography
2010, Vol. 12, no. 1, 62-65

acustic lobul

hepatic stng. Vizualiz area pancrea sului poate fi mbunt it prin administ ra-rea a 500-700 ml ap plat cu 10-15 minute nainte de e amina re. !ent ru a e"ideni

!a ncreati c ultraso und is the #touch stone$ of the ultrasound e amin ation. %heref ore& its e amin ation is a permanen t #stress $ for e"er' beginn er in ultraso nograp h'. ("er time& follo)i ng numer ous e amin ations& perfor med )ith patienc e and perse" erance & the ultraso und e"alua -tion of the pancre as becom es a mome

*edical +ltrasonograph' ,010- 1,.1/0 1,-15

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plorations to be able %he to sa' that e amination the e aminatio methods n of therecommended normal orfor the panare0 pathologica creas gra'scale l pancreas is no longere amination& a difficultharmonic stage ofimaging& as ultrasonic )ell as 8olor e aminatio 9oppler& !o)er or n.

more difficult/.

3t is:pectral imperati"e 9oppler. ; 2.5 that the*<z con"e e amination transducer .or of thea pancreas ismultifre6uenc made on a' transducer/ for abdomen patient fasting for ate amination is least 7-4preferred. 3n hours. %he"er' thin papresence oftients& a 5 linear food in the*<z transducer stomach be ma' pre"entma' needed. a thorough %rans"ers and e and complete longitudinal e amination of theupper organ& or itepigastric can cre-atesections are used to false "isualize the images of pancreatic pancreas& as )ell as tumors. obli6ue in5i6uid ingestion istercostal and permitted& subcostal but not ofsections carbonated .especiall' for fluids .thethe head and %he air in thetail/. pancreas can stomach )ill be e amined ma7e the e amination through of thesections pancreas passing

abo"e the stomach antrum .if the transducer is placed high in the epigastrium/& through transgastric or subgastric sections .the transducer placed appro imatel' half)a' bet)een the umbilicus and iphoid appendi /. %he best ultrasound )indo)s are obtained b' using high epigastric sections .that a"oid the colon/& also b' using transgastric sections and sections that use the left li"er lobe as an acoustic )indo). 3n order to be able to see the pancreas through transgastric sections& the antrum .stomach/ should not contain air or it should be filled )ith fluid& this operating as an #acoustic ultrasound )indo)$ for

the is made in pancreas. dor-sal <ence& thedecubitus. practical %hen )e )ill approach& in"ite the )hen thepatient to sit& pancreas isso that the difficult to)ater )ill "isualize0 thegather into the patient isantrum& )hich in"ited tois the ideal drin7 500-anterior 700 ml of stilllandmar7 of )ater andthe pancreas. e amined 10=' positioning -15 minutesthe patient in after. 3f theright lateral e -amination decubitus& the is performed)ater )ill fill immediatel' the second after )aterpart of the inges-tion& duodenum& the stomachthus better )ill be filleddelineating b' athe head of h'poechoic the pancreas. and not %o transonic highlight the fluid& due to pancreas& )e the small air )ill start b' bubbles& that form during"ie)ing the s)allo)ing. landmar7s0 :o& after 10-posterior > 15 minutes&the portothe air bubsplenic a is bles )ill and disappear and the stomach )ill be filled )ith transonic li6uid& a perfect #acoustic )indo)$ for the pancreas. :ometimes )e might not find )ater into the stomach& most often if the e amination

anterior > the gastric antrum and?or the left li"er lobe .fig1/. =et)een these elements is found a parench'mal structure0 the pancreas. %he splenic "ein forms the dorsal border of the pancreas& from the splenic hilum to its con-fluence )ith the superior mesenteric "ein& at the nec7 of the pancreas. ;t this point& the head and uncinate process of the pancreas actuall' )rap around the "enous confluence )hich forms the portal "ein& and pancreatic tissue is seen both anterior and posterior to the "ein .fig ,/. %he superior mesenteric "essels are considered the mar7ers of di"ision bet)een the head and bod' of the pancreas. %he head of the pancreas is #cuddled$ in

the

second

bod'

of

the

part of

pancreas- % >

Fig 1. @ormal aspect of the pancreas0 !V > portal "ein:V > splenic "ein- ;( > ;orta- 3V8 > inferior "ena ca"a- < > head of the pancreas- = >

tail of the pancreas- +! > uncinate process- 8V > "ertebra.

Fig 2. @ormal pancreas )ith the uncinate process0 !V > portal "ein:*; > superior mesenteric arter'5AB% 5(=A > left

li"er lobe<A;9 > head of the pancreas=(9C > bod' of the pancreas!.+@83@ > uncinate process of the pancreas.

1D Eo

ana Firli et al

Ultrasound examination of the normal pancreas

the duodenum and the tail ma' reach the splenic hilum. ;nother important landmar7 is the celiac trun7& )hich generall' ta7es off the aorta at the superior border of the gland. :o& )hen )e find the celiac trun7 )e angulate the transducer& slightl' do)n)ard& in order to see the pancreas .fig 2/.
%he normal pancreatic parench'ma echogeneit' is similar to that of the li"er .sometimes slightl' h'poe-choic/. 3n obese or elderl' patients& the pancreas can be h'perechoic due to fat load or fibrosis& respecti"el'. :o the echogeneit' of the normal pancreas can "ar'& from h'poechoic to h'perechoic .fig D/. ;ll these aspects are normal& pro"ided that the pancreatic parench'ma struc-ture is fine and homogeneous. %he Girsung duct can be "ie)ed& particularl' in 'oung indi"iduals- its diameter should not be larger than , mm. Fig 3. %he celiac trun70 V! > +suall' onl' a part of the Girsung duct is "isual-ized& onl'portal "ein- ;< > hepatic rarel' throughout its )hole length .fig 5/. arter'- ;: > splenic arter'%he pancreas e amination in trans"erse section )ill highlight %8 > celiac trun7- ;( > much of the pancreas& but almost ne"er the entire pancreas )ill be aorta. seen in the same section. %his is because the pancreas has a slightl' up)ard traHector'. 3n general& )e )ill e amine "arious parts of the pancreas& one b' one. %he use of trans"erse sections allo)s bet-ter e amination of the pancreatic bod' and tail. :agittal sections are preferred for the e amination of the pancre-atic head. Bor the pancreatic tail .especiall' in cases of a #bulbous$ one/& subcostal recurrent left obli6ue sections are used. ; special attention must be paid to the e"alu-ation of the pancreatic tail that sometimes can be "er' long. 3t must be "isualized in its entiret' so that distal pancreatic tail tumors are not #missed$.

Eegarding the normal size of different pancreas seg-ments& opinions "ar'. Ge do not consider them "er' im-portant& because there is great indi"idual "ariabilit'. %he easiest to measure is the bod' of pancreas& in a trans"erse section& the normal antero-posterior diameter of the pan-creatic bod' being 15-,0 mm. %he normal antero-poste-rior diameter of the pancreatic head is 1I-,5 mm& and of the tail is generall' up to ,0-,5 mm& but relati"el' com-mon& the pancreatic tail ma' ha"e a #bulbous$ appear-ance& that ma' ha"e greater dimensions. Ge consider all these pancreatic dimensions purel' orientati"e and )ith relati"e "alue& because on the ultrasound e amination of the pancreas the essential element are the structural changes.

%he e"aluation of the pancreatic head is finished )ith the e"aluation of the main biliar' duct .*=9/. Eight ob-li6ue sections are used to see the *=9 in the hepatic hilum& but also to see the intrapancreatic choledocus. :ometimes& for a better "isualization& the patient should lie in left lateral decubitus .fig 1/.

Fig 4. @ormal aspect of the pancreas .h'perechoic in an elderl' patient/0 !V > portal "ein- :V > splenic "ein- ;( > ;orta- 3V8 > inferior "ena ca"a- ;ntrum > gastric antrum- < > head of the pancreas- = > bod' of the pancreas- % > tail of the pancreas.

Fig 5. @ormal pancreas )ith "isible Girsung duct. !V > portal "ein- :V > splenic "ein- 5<: > left li"er lobe- !; > pancreas9G > Girsung duct.

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:o& e"en if the e amination of the pancreas is a chal-lenge for the beginner& careful and perse"erant e amina-tion )ill allo) pancreas e"aluation in almost all cases. ; correct e"aluation of the pancreas must "isualize all its segments and assess the ecogeneit' and echostructure of the entire organ.

Selective references
Fig 6. @ormal pancreas )ith "izible intrapancreatic main bil-iar' duct. *=9 > main bilar' duct- 555 > left li"er lobe- !V

1. 3oan :porea& 8ristina 8iHe"schi !relipcean. Acogra-fia abdominal n practica clinic& Adiia a 33-a& Aditura *irton&%imiJoara ,00D01,I11,.

> portal "ein- <A;9 > pancreatic head.

2. 3.

Kuenter :chmidt. 9ifferential diagnosis in ultrasound im-aging. %hieme ,00101D1-151 Kuenter :chmidt.%hieme 8linical 8ompanions0 +ltra-sound. %hieme ,0070,I2-200