DAVID SUTTON PICTURES THE PANCREAS ONLY FOR STUDY PURPOSE

1. 26
DAVID SUTTON

2. DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

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

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

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

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

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

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

9. • 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.)

10. • 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.)

11. • 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.)

12. • 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.

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

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

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

16. • Fig. 26.14 Chronic pancreatitis. Extensive
pancreatic calcification.

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

18. • 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.

19. • 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.

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

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

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

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

24. • 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.)

25. • 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.)

26. • 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,

27. • 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,

28. • 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.

29. • 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).

30. • 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).

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

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

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

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

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

36. • 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.

37. • 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.

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

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

40. • 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).

41. • 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.

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

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

44. • 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).

45. • 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).

46. • 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.

47. • 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.

48. • 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.

49. • 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.

50. 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.

51. • 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.

53. • 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.

54. • 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.

55. • 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.

56. • 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.

57. • 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.

58. • 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.

59. • 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.

60. • 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.

61. • 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.

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

63. • 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.

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

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

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

67. • 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.

68. • 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.

69. • 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.

70. • 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.

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

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

73. • 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.

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

75. • Fig. 26.63 Normal pancreatic duct at age 50.

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

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

78. • 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.

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

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

81. • 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.

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

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

84. • 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.

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

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

87. • 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.

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

89. • 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.

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

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

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

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

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

95. • 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.

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

97. • 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.

98. • 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.

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

100. • 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.

101. • 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

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

103. • 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.

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

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

106. • 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).