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Pancreas

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Abstract

As clinical signs of pancreatic disease are variable and often non-specific, evaluation of the pancreas should form part of every complete abdominal ultrasonographic examination. Specific indications include: anorexia; weight loss; vomiting; diarrhoea; abdominal pain; palpable abdominal mass; therapy resistant diabetes mellitus; hypoglycaemia; and icterus. This chapter explains the value of ultrasonography compared with radiography and computed tomography. Imaging technique and normal ultrasonographic appearance are covered, together with diffuse disease and focal lesions. This chapter contains five video clips.

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Figures

Image of 12.1
12.1 Pancreas and associated anatomical landmarks. The left lobe of the pancreas (LL) can be found caudal to the stomach (ST) and is intimately associated with the splenic vein. The body of the pancreas (B) is located ventral to the portal vein. The right lobe of the pancreas (RL) follows the descending duodenum (DD). APd = accessory pancreatic duct; Bd = common bile duct; GB = gallbladder; LK = left kidney; Pd = pancreatic duct; RK = right kidney; S = spleen. (Reproduced from the ). Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 12.2
12.2 Ultrasonograms of the normal canine pancreas. Transverse view. The right pancreatic lobe (between arrows) manifests as a triangular structure of intermediate echogenicity, immediately adjacent to the descending duodenum (DD). The centrally located round anechoic structure represents the pancreaticoduodenal vein, which exhibits a flow signal on colour Doppler examination.
Image of 12.3
12.3 Ultrasonogram of the normal pancreas in a cat. The transducer is positioned in transverse orientation to the patient, allowing visualization of the long axis of the pancreatic body (B) and left lobe (LL; between the cursors). Note the associated anatomical landmarks: portal vein (PV); splenic vein (SV); and stomach (ST). The pancreas is of intermediate echogenicity and is readily identified by the centrally located tubular anechoic pancreatic duct.
Image of 12.4
12.4 Acute pancreatitis in a 5-year-old Miniature Schnauzer presented with a 3-day history of vomiting and abdominal pain. Transverse image of the right cranial abdomen showing enlargement and hypoechogenicity of the right lobe of the pancreas (between the cursors) and adjacent strongly hyperechoic fat. Abdominal effusion was also noted in this patient (not shown). DD = duodenum; L = liver.
Image of 12.5
12.5 Chronic pancreatitis in an 8-year-old cat presented with anorexia. The pancreas is hypoechoic, nodular, irregular and more conspicuous than usual. The ultrasonogram of the left cranial abdomen shows the extremity of the left lobe of the pancreas (between the cursors) at the level of the spleen (SP).
Image of 12.6
12.6 Pancreatic lymphoma in a 16-year-old cat. The pancreas (left lobe shown between the arrows) is diffusely enlarged (1.5 cm thickness), hyperechoic and heterogeneous. Fine-needle aspiration of the pancreas was performed and yielded a diagnosis of lymphoma.
Image of 12.7
12.7 Pancreatic oedema in a 6-year-old Cocker Spaniel with chronic hepatopathy and portal hypertension. Longitudinal image of the right lobe of the pancreas (arrowed) showing generalized thickening and a classic ‘tiger stripe’ appearance.
Image of 12.8
12.8 Exocrine pancreatic tumour (adenocarcinoma) in a 16-year-old Scottish Fold presented for lethargy and anorexia. Transverse ultrasonograms of the mid and the left cranial abdomen showing a solid, irregularly marginated, mixed echogenic mass (arrowed), approximately 4 cm in diameter, originating from the extremity of the left lobe of the pancreas (LL). (Courtesy of Dr G. Henry, University of Tennessee)
Image of 12.9
12.9 Endocrine pancreatic tumour (insulinoma) in a 16-year-old West Highland White Terrier presented with a history of trembling, seizures and hypoglycaemia. Transverse image of the right cranial abdomen demonstrating a hypoechoic nodule, approximately 8 mm in diameter, with a few hyperechoic shadowing foci associated with the right lobe of the pancreas (arrowed). DD = descending duodenum.
Image of 12.10
12.10 Incidental finding of pancreatic nodular hyperplasia in a 15-year-old cat with a history of numerous non-pancreatic diseases, including chronic renal failure, hyperthyroidism and hypertrophic cardiomyopathy. The pancreas contained numerous hypoechoic nodules. The largest nodule (arrowed) measured approximately 1 cm in diameter and was associated with the body of the pancreas. LL = left lobe of the pancreas; PV = portal vein; SV = splenic vein.
Image of 12.11
12.11 Pancreatic cyst in an 11-year-old cat with a history of diabetes mellitus and chronic pancreatitis. Ultrasonographic examination revealed a thin-walled structure, approximately 3 cm in diameter, containing anechoic fluid in the right cranial abdomen adjacent to the descending duodenum. Exploratory laparotomy revealed a cystic lesion associated with the right lobe of the pancreas, which was drained and omentalized. An endothelial lining found on histological examination was consistent with a true cyst.
Image of 12.12
12.12 Pancreatic abscess in an 11-year-old Labrador Retriever presented with a 1-month history of vomiting. Sagittal ultrasonogram of the right cranial abdomen showing a thick-walled mass lesion (arrowed), approximately 3 cm in diameter, containing echogenic fluid adjacent to the descending duodenum (DD). FNA cytology yielded a diagnosis of septic suppurative inflammation.

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Normal pancreas (dog).

Clip of the pancreas in a normal dog (4-year-old Miniature Schnauzer). The transducer was placed on the right cranial abdomen in transverse orientation. The right lobe of the pancreas is visualized as a triangular structure of medium echogenicity, immediately adjacent to the duodenum. The pancreaticoduodenal vein appears as circular anechoic structure in the centre of the pancreas. The authors would like to thank Dr George Henry (University of Tennesse) for his assistance with video post-processing and editing.

Normal pancreas (cat).

Clip of the pancreas in a normal cat (12-year-old Burmese). The transducer was placed on the mid-cranial abdomen in transverse orientation. Immediately caudal to the stomach, the left lobe of the pancreas (LL) is indistinctly visible as a homogeneous organ of medium echogenicity, with a centrally located thin anechoic tubular structure representing the pancreatic duct (PD). Vascular landmarks include the portal vein (PV) and splenic vein (SV). The authors would like to thank Dr George Henry (University of Tennesse) for his assistance with video post-processing and editing.

Insulinoma.

Clip of an endocrine pancreatic tumour (insulinoma) in a 16-year-old West Highland White Terrier presented with a history of trembling, seizures and hypoglycaemia (same case as shown in Figure 12.9). The transducer was placed on the right cranial abdomen in transverse orientation. A hypoechoic nodule (‘mass’), approximately 8 mm in diameter, with few hyperechoic shadowing foci is visualized in close proximity to the descending duodenum. The authors would like to thank Dr George Henry (University of Tennesse) for his assistance with video post-processing and editing.

Acute pancreatitis in a dog.

Clip of acute pancreatitis in an 11-year-old Jack Russell Terrier presented with a history of recent onset vomiting and abdominal pain. The transducer was initially placed in transverse orientation on the right cranial abdomen and then turned into a sagittal orientation. The right lobe (RL) of the pancreas seen next to the descending duodenum (DUOD) is thickened, diffusely hypoechoic and surrounded by hyperattenuating fat. Focal abdominal effusion (EFF) is also present. The duodenum contains a small amount of fluid and shows decreased peristalsis during the examination. On sagittal images the pancreas has a ‘tiger stripe’ appearance, consistent with pancreatic oedema secondary to pancreatitis. The authors would like to thank Dr George Henry (University of Tennesse) for his assistance with video post-processing and editing.

Chronic pancreatitis in a cat.

Clip of chronic pancreatitis in a 16-year-old Domestic Shorthaired cat. The transducer was placed on the mid-cranial abdomen in transverse orientation. Vascular landmarks include the portal vein (PV) and splenic vein (SV). The pancreas is more conspicuous than in a normal cat (compare with Normal pancreas (cat) clip). The left lobe (LL) and body (B) of the pancreas are hypoechoic in comparison with the surrounding mesenteric fat and have irregular margins. The left lobe of the pancreas is thickened and the pancreatic duct (PD) is irregularly dilated (up to 0.25 cm). The authors would like to thank Dr George Henry (University of Tennesse) for his assistance with video post-processing and editing.

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