Diagnosing pancreatitis with the help of ultrasound

Ever had a patient with suspected pancreatitis but you wanted to know for sure? In this video, Dr Nikolaus Mayr will take you through the process of using ultrasound to make a definitive diagnosis. By the end of this video, you will recognize the distinguishing features of acute, necrotizing, and chronic pancreatitis, and make an accurate diagnosis based on your patient's ultrasound images.

Want to perform your own kidney ultrasounds? Take our Abdominal Ultrasound Essentials course and you'll become a pro in no time. Your instructor, Dr Nikolaus Mayr–the Chief Resident of Radiology at the Hospital of the Brothers of St. John of God in Salzburg–will guide you through all the ins and outs of abdominal sonography. Boost your medical career with Medmastery today!

Diagnosing acute pancreatitis

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Pancreatitis is inflammation of the pancreas. It has various forms, which can be classified in many ways according to time of onset, etiological agent, or associated pathology. Acute pancreatitis is acute onset of inflammation of the organ. The diagnosis of acute pancreatitis is made by fulfilling two of the following three criteria: acute onset of persistent severe epigastric pain, lipase and amylase elevation three times the upper limit of normal, and characteristic imaging features. Acute pancreatitis can have two different forms of presentation and severity: interstitial edematous pancreatitis and necrotizing pancreatitis. 

Acute pancreatitis on ultrasound

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We will use a cross-section on the epigastrium with its typical 30-degree tilt to the cross-section of the body to get a long-section view of the pancreas organ. In this illustration, we can see the typical findings for acute pancreatitis with thickened pancreas organ and the typical peripancreatic fluid effusion. While we perform ultrasound, the patient can tell us if he feels pain when we press the ultrasound probe onto this region.

Ultrasound findings for acute pancreatitis

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Here, you see the typical ultrasound appearance of a thickened pancreas organ and the peripancreatic fluid effusion. Note the fluid collections in the omental bursa. Take a second to look at these findings. This is a live ultrasound video of a patient with acute interstitial pancreatitis, showing the thickened pancreas organ. We also see hypoechoic fluid streaks along the pancreas body and the fluid collections around the pancreas. We can also see the slim fluid collection within the omental bursa, right behind the stomach. You can see that right here.

Necrotizing pancreatitis on ultrasound

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In this cross-section over the epigastric region, we can see the liver here, the inferior vena cava here, and the pancreas organ as hyperechoic structure right behind the stomach here. We see that the pancreas organ is heterogeneous and there is fluid collection in the omental bursa. We can also see hypoechoic streaks through the pancreas organ, indicating necrotic areas.

Pathology of necrotizing pancreatitis

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Necrotizing pancreatitis is the more severe form of acute pancreatitis. Because of the very extensive inflammation, the vascularity of pancreas tissue is compromised. When pancreatic tissue becomes necrotic, it appears hypoechoic on ultrasound. We can tell this apart from the vital pancreatic tissue because the vital tissue is hyperechoic. When we put on color Doppler, necrotic tissue also shows no vascularity. Take a good look at these different aspects of necrotizing pancreatitis.

Ultrasound findings for necrotizing pancreatitis

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In this video, we see that the pancreas is heterogeneous. We see small fluid collections around the pancreas organ and we see a distended pancreatic duct. This is due to inflammation and swelling of the pancreas head. Here, we can see lots of hypoechoic regions within the pancreas organ, indicating severe inflammation and necrosis. Now, we move laterally in the long section, using the splenic window, where we can see lots of fluid collections running caudally along the left-sided colon.

Pathology of chronic pancreatitis

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Chronic pancreatitis represents the end result of a continuous, prolonged, inflammatory and fibrosing process that affects the pancreas. This results in irreversible morphologic changes and permanent endocrine and exocrine pancreatic dysfunction. The pancreas might appear atrophic, calcified, or fibrotic. 

Ultrasound findings for chronic pancreatitis

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Findings that may present on ultrasound include hypoechogenicity that often indicates fibrotic changes, pseudocysts, pseudoaneurysms of the splenic artery, and presence of ascites. We use our long section of the pancreas to see an atrophic pancreas organ with calcifications. These are typical hyperechogenic reflexes we can find in all of the pancreas organ, depending upon severity of the disease. We can also see a dilated pancreas duct due to the intraluminal pancreatic stones or fibrotic changes that have obstructed the duct.

Pancreatic stones and calcifications on ultrasound

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In [this] ultrasound image, we can see a dilated pancreas duct here due to a pancreas stone occluding the lumen here. We see fibrotic changes and small and larger echogenic reflexes as a result of the pancreas tissue calcifications. Look at these organ changes that are typical for chronic pancreatitis.

In this video, we can see the extremely dilated pancreas duct with multiple intraluminal stones. We can also see that the pancreas body itself is atrophic, which is seen best when we go in the cross-section like this. And the organ itself is composed of almost only calcifications.