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THE PANCREAS

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THE PANCREAS * 1. Transparent Pancreas, Ducts, Duodenum (34) * 1. Portal Cir. (13) Duct of Santorini Pancreatic Duct System, continued 3. – PowerPoint PPT presentation

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Title: THE PANCREAS


1
THE PANCREAS
Hastaneciyiz.blogspot.com
2
  • Introduction/General Information
  • A. Located in epigastric left
    hypochondriac regions
  • B. Dimensions
  • 1. 5 - 6 length x
  • 2. 1-1/2 width x
  • 3. 1/2 - 1 thick
  • C. Lies retroperitoneally at T-12/L-1 to
    L-3

3
The Pancreas in situ
Right lobe of liver Falciform ligament Gallbladde
r Pancreas Duodenum
L-3
4
Pancreas, Introduction, continued D.
Head fills concavity of duodenum E. Body
crosses left kidney F. Tail reaches hilus of
the spleen G. Related anteriorly to
transverse colon
5
Pancreas in situ
  • Duodenum
  • Head of Pancreas

6
  • Pancreas, Introduction, continued
  • H. Aorta, IVC lie posterior
  • I. Uncinate process
  • a. Lies posterior to SMA and SMV
  • b. Lies anterior to aorta
  • J. Neck lies anterior to SMV, with pylorus
    just above

7
Venous Drainage of the Pancreas
  • IVC
  • SMV

8
  • Introduction, continued
  • L. Body related posteriorly to left crus, left
    adrenal, left renal vein, and splenic vein
  • Celiac Axis (trunk, artery) lies superior to
    body

9
II. Detailed Anatomy
  • A. Landmark structures
  • 1. Splenic Artery
  • a. Branch of celiac trunk
  • b. passes right to left
  • c. Course is along upper margin of
    body and tail

10
Detailed Anatomy, cont 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
11
Arterial Supply to Pancreas
Proper Hepatic Artery
Common Hepatic Artery
Superior Mesenteric Artery
12
Landmark structures, continued
4. Splenic Vein a. runs parallel to
artery b. on posterior surface of
pancreas c. Terminates in portal vein
13
Landmark structures, continued
5. Superior Inferior Mesenteric Veins a.
pass (inferior to superior) deep
to pancreas b. merge with splenic vein
c. Terminate in portal vein
14
Landmark structures, continued
6. Common Bile Duct a. passes behind
first portion of duodenum b. then
through head of pancreas c. Terminates at
ampulla of vater
15
Detailed Anatomy continued
  • B. Head of Pancreas
  • 1. Important clinically because
  • a. Numerous ducts and vessels traverse it
  • b. Carcinoma usually located here

16
Head of Pancreas, Detailed Anatomy, continued
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
17
Head of Pancreas, Detailed Anatomy, continued
3. Lymphatics from head of pancreas a.
Drain to celiac nodes b. metastases may
follow lymph c. Metastases may spread via
lesser omentum to liver d. Some terminate
in lumbar nodes
18
Head of Pancreas, Detailed Anatomy, continued
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
19
Head of Pancreas, Detailed Anatomy, continued
  • Anterior branch of pancreaticoduodenal artery
  • a. superior branch anterior superior
    pancreaticoduodenal artery
  • b. inferior branch anterior inferior
    pancreaticoduodenal
  • artery

20
Head of Pancreas, Detailed Anatomy, continued
  • 2. Posterior branch of pancreaticoduodenal
    artery
  • a. superior branch posterior superior
    pancreaticoduodenal artery
  • b. inferior branch posterior inferior
    pancreaticoduodenal artery
  • extensive blood supply

21
Anterior Pancreaticoduodenal Artery
  • Branches are continuous with one another
  • Superior branches originate from the GDA
  • Inferior branches originate from the SMA

22
  • Detailed Anatomy, continued
  • Body Tail of Pancreas
  • 1. Supplied by splenic artery 2. Have
    three surfaces
  • a. Anterior surface
  • 1. Concave
  • 2. Deep to stomach
  • 3. Separated from stomach by
    lesser sac of peritoneum
  • (aka omental bursa)

23
Anterior surface of pancreas
Epiploic foramen
Anterior surface of pancreas
24
Lesser sac, continued 4. Lesser sac bounded
by a. Liver, superiorly b. Below, extends to
greater omentum c. Anteriorly lesser
omentum, stomach, greater omentum
25
  • Lesser sac, continued
  • d. Posteriorly greater omentum transverse
    colon, transverse mesocolon
  • e. Laterally
  • Foramen of Winslow on right
  • Spleen on left

26
Detailed Anatomy, continued f. Foramen of
Winslow (AKA Epiploic Foramen)
1. Lies between greater lesser sacs
of peritoneum 2. posterior to free edge of
lesser omentum 3. close to porta
hepatis
27
Three Surfaces, continued 2. Posterior
surface separated from vertebrae by a.
Aorta b. Splenic vein c. Left kidney and
renal vessels d. Left adrenal gland e. Left
Crus of diaphragm f. SMA and SMV
28
Three surfaces, continued 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
29
Detailed Anatomy, continued D. Pancreatic
Duct System 1. Pancreatic Duct (of Wirsung)
a. Course is left to right b. Receives
numerous small ducts c. _at_ neck of pancreas,
duct turns inferior, posterior to the
right d. AKA main pancreatic duct
30
Duct of Wirsung (Main pancreatic duct)
31
  • Pancreatic Duct System, continued
  • 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)

32
Duct of Wirsung
Duct of Wirsung
33
  • Pancreatic Duct System, continued
  • 2. Duct of Santorini
  • a. accessory pancreatic duct
  • b. Not universally identified
  • joins duodenum _at_ minor papilla
  • d. part of duct from dorsal pancreas

34
Duct of Santorini
35
Pancreatic Duct System, continued 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
36
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)
37
Scanning Anatomy, continued 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
38
Scanning Anatomy, continued 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)
39
Scanning Anatomy, continued 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
40
  • Scanning Anatomy, continued
  • D. Further delineation by vascular
    landmarks
  • SMA
  • a. Lies immediately posterior to body,
    points to it!
  • b. Recognized by echogenic fat collar
    surrounding vessel

41
Vascular Landmarks of the Pancreas
  • Pancreatic sonography depends largely on
    identifying surrounding landmark vessels

42
Scanning Anatomy, continued 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
43
Vascular Landmarks of the Pancreas
  • Venous landmarks of the pancreas include the SMV
    and renal veins

44
Scanning Anatomy, continued
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
45
  • Scanning Anatomy, continued
  • 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

46
IV. Pancreatic Disorders A. Pancreatitis
diagnosis depends on clinical evidence
1. Usually secondary to biliary tract
disease 2. Surgery of biliary tract or
stomach, alcoholism are other causes
47
Pancreatitis, Pancreatic Disorders, continued
3. Infrequent causes a. Infectious
diseases b. Trauma d. Drugs e.
Hyperparathyroidism 4. Inflammation may be
diffuse or spotty
48
Pancreatitis, Pancreatic Disorders, continued
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
49
Pancreatitis, Pancreatic Disorders, continued
6. WBCs may increase to 20,000/ml 7.
Increase in pancreatic enzymes a. serum
bilirubinase (by 25) b. serum amylase
c. serum lipase
50
Pancreatic Disorders, continued
B. Pseudocysts 1. False cysts that may
arise a. due to tissue necrosis b. From
enzymatic destruction 2. May persist after
inflammation subsides 3. Usually near or in
pancreas
51
Pancreatic Disorders, continued 4.
Rarely, may be elsewhere a. in abdomen or
pelvis b. Rarely, mediastinum 5. Pseudocyst
appearance a. unilocular or multilocular
b. echoes from pus cellular debris
52
Pancreatic Diseases, continued C. Acute
Pancreatitis 1. Diffuse enlargement 2. Less
echogenic due to edema 3. Echogenicity
usually gt liver parenchyma
53
Pancreatic Diseases, continued D. Chronic
Pancreatitis 1. organ usually appears as small,
atrophic 2. Contains scattered echoes
from calcifications 3. Primary cause is
alcoholism
54
Pancreatic Diseases, continued E. Dilation
of Pancreatic Duct 1. Seen in acute or chronic
pancreatitis 2. Frequently associated
with neoplasm of pancreas 3.
Biliary tract problems
55
Pancreatic Diseases, continued F.
Abscess or Hemorrhagic Pancreatitis 1.
Similar in sonographic appearance 2.
Hemorrhagic a. Mass with inhomogeneous
texture b. Acute hemorrhage sonolucent to
echogenic c. CT scan used for
differentiation
56
Pancreatic Disorders, continued G.
Pancreatic Tumors 1. Malignant tumors usually
arise as adenocarcinomas 2. In head of
Pancreas Sx a. Painless jaundice b.
Anorexia
57
Pancreatic Tumors, In head, continued c.
Nausea d. Weight loss e. Increased plasma
amylase f. Increased alkaline phosphatase g.
May involve compression of pancreatic
duct, CBD
58
Pancreatic Tumors in the Head
  • Tumors in the head may compress biliary ducts or
    pancreatic ducts

59
Pancreatic tumors, continued 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
60
Pancreatic tumors, continued 4. In Tail of
Pancreas Sx a. Often silent until local
metastasis occurs b. May metastasize to
1. para-aortic lymph nodes 2.
spleen
61
Pancreatic tumors, continued 5. Identified
by organ enlargement, subtle echo
changes, irregular outline 6. Metastases to
stomach, liver lungs are
common 7. Often causes dilation of ducts
62
  • Pancreatic Disorders, continued
  • H. Fibrocystic Disease
  • 1. Result of cystic fibrosis
  • 2. Diagnosed by methods other than
    ultrasound

63
Pancreatic Disorders, continued I.
Pancreaticolithiasis 1. Characteristic stone
echoes in pancreatic duct 2. May see atrophied
pancreatic parenchyma 3. Associated with
chronic alcoholic pancreatitis 4. Contours of
body, tail show irregularities
64
Pancreatolithiasis, continued 5.
Incidence slightly higher in head 6.
Associated with occult pancreatic
carcinoma a. Mass lt 2mm diameter b. Seen
with dilation of pancreatic duct or CBD
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