THE PANCREAS REVISITED I:

DIAGNOSTIC, CHRONIC PANCREATITIS 0039-6109/01 $15.00 + .OO

PANCREATIC
ULTRASONOGRAPHY
Genevieve L. Bennett, MD, and Lucy E. Ham, MD

Abdominal ultrasonography (US) is used for initial imaging evaluation of

patients with abdominal pain, jaundice, and nonspecific abdominal complaints.
As a screening examination, US often provides the first opportunity to diagnose
pancreatic abnormalities. Diagnostically, US findings may identify pancreatic
abnormalities, differentiate benign pancreatitis from neoplasms, and guide per-
cutaneous interventional procedures and biopsies for definitive diagnosis. Also,
findings on US are useful to determine the need and priority of subsequent
imaging, such as contrast-enhanced CT, MR imaging, and endoscopic or laparo-
scopic US, that may be required to assess extent of disease and to stage pancre-
atic tumors.
This article discusses current techniques for pancreatic US, including the role
of Doppler imaging and harmonic US. The normal and abnormal appearance of
the pancreas are described, with emphasis on characteristic US findings that
may aid diagnosis. This section includes the differential diagnosis of pancreatic
abnormalities detected by US because there is considerable overlap in imaging
appearance of benign and malignant conditions. The role of US-guided biopsy
of the pancreas also is included. Newer applications of US for evaluation of
pancreatic transplants used for the treatment of diabetes also is discussed.

TECHNIQUE

Abdominal US is performed after a minimum fast of 6 hours to allow for

distension of the gallbladder. The fasting state also may improve visualization
of the pancreas because there is less gaseous distention of the stomach and
upper gastrointestinal tract. Scanning is performed with a curved array or

From the Department of Radiology, New York University Medical Center (GLB); the
Department of Radiology, Weill Medical College, Cornell University Medical Center
(LEH); and the Memorial Sloan-Kettering Cancer Center (LEH), New York, New York

SURGICAL CLINICS OF NORTH AMERICA

VOLUME 81 * NUMBER 2 * APRIL 2001 259

260 BENNETT & HANN

sector 3.5- to 5.0-MHz transducer. The patient's position is varied to minimize

intervening bowel gas, and scans may be obtained in the erect, supine, and
shallow left or right decubitus positions.
US offers multiplanar imaging of the pancreas; longitudinal and transverse
images are included in the standard examination, but the orientation of the
images may seem less familiar to the surgeon than CT images that are in the
axial plane. This difference in image display is inherent in US, which is limited
by artifacts from air interfaces; therefore, views are obtained from various projec-
tions using the solid organs, such as the liver, spleen, and kidneys, as an
"acoustic window" to deeper structures, such as the pancreas.

HOW RELIABLE IS ULTRASONOGRAPHY FOR PANCREATIC

DIAGNOSIS?

Some reports have indicated that intervening bowel gas limits US visualiza-
tion of the pancreas, especially of the pancreatic tail.", 36, 47, 56 Other studies have
shown, however, that experienced sonographers and newer equipment increase
the rates of pancreatic visualization to more than 15,39, 43, 67 Campbell and
W i l s ~ n 'used
~ US to evaluate 51 patients with new pancreatic neoplasms. A
technically adequate study was defined as one in which the splenic vein, portal
venous confluence, pancreatic head, neck, body, and tail were all seen. The
pancreatic tail was visualized from the epigastrium and left flank positions. Oral
contrast was not used. All 51 patients had technically adequate pancreatic
studies, and 50 of 51 pancreatic masses were detected by US alone. Similar
findings were reported by Karlson et al,43who performed pancreatic US on 919
patients; 140 of these patients had pancreatic tumors diagnosed within 1 year of
US as reported by the Swedish Death and Cancer Registry. US detected 124 of
140 pancreatic masses, for a sensitivity of 88.6% for all tumors and a sensitivity
of 90% (79 of 88 patients) for detection of exocrine pancreatic cancer.
These two studiesI5* 43 highlight that the diagnostic efficiency of pancreatic
US has improved compared with earlier reports. These differences may be
explained, in part, by advances in US equipment that now provide better
resolution and tissue contrast, but other factors also should be considered. US is
the most operator-dependent cross-sectional imaging technique. Karlson et ale
evaluated interobserver variability for diagnostic accuracy of pancreatic abnor-
malities. The operator's level of US experience was a significant factor in the
diagnostic accuracy of pancreatic abnormalities among three sonographers with
varying experience. The excellent results of pancreatic US diagnosis reported by
Campbell and Wilson15 also may be explained by their meticulous technique
and experience.

TECHNOLOGIC ADVANCES THAT AID ULTRASONOGRAPHY

DIAGNOSIS OF THE PANCREAS

Oral Contrast Agents

Gastrointestinal tract air may significantly limit pancreatic visualization

caused by artifact on US. To eliminate shadowing from intraluminal air, the
stomach can be filled with fluid that acts as an acoustic window through which
the pancreas may be seen. Degassed water is most commonly used. Occasionally,
air may be ingested with the fluid, further exacerbating air artifact, but little air
 PANCREATIC ULTRASONOGRAPHY 261

is swallowed if the patient is instructed to drink slowly and a straw is not used.
By shifting patient position, the fluid in the stomach may be moved to allow for
visualization of each portion of the pancreas.’ Orally administered US contrast
agents, including simethicone and methylcellulose, also have been used to im-
prove visualization of the pan~reas?~, 53 These agents absorb gas bubbles, have
decreased transit time compared with water, and are superior to water for
reduction of gas shadowing. In a phase 2 trial, Lev-Taoff et a149reported that oral
contrast provided better images of the pancreatic head in 61% and pancreatic tail
in 67% of 99 patients who were scanned before and after the administration of
US oral contrast. Optimal results were obtained when imaging was performed
immediately after oral contrast ingestion. Oral contrast also increased diagnostic
confidence for exclusion of pancreatic dis0rders.4~
Other investigators have used a combination of water and simethicone as
an inexpensive alternative for the reduction of gas artifact. This technique was
described by Abu-YouseP in a study of 65 patients who had limited visualization
of the pancreatic tail on standard US. In 74% of patients, the pancreatic tail was
seen in its entirety after the administration of water and simethicone, and in an
additional l8%, visualization of the pancreatic tail was significantly improved.’
These US techniques using oral agents to disperse gas may reduce the need for
additional CT imaging of the pancreas in selected patients.

Harmonic Imaging

Tissue harmonic imaging is a new US technique that provides higher-quality

images, decreased artifact, and improved tissue contra~t?~,As the US beam
@

passes through tissues, it generates higher harmonic frequencies that are multi-
ples of the transmitted frequency. These harmonics are similar in principle to
the harmonics generated with musical instruments. The harmonic US signal is
created within the tissues and is therefore not degraded by artifacts from the
body wall. Harmonic US has increased resolution and improved contrast at
tissue interfaces. Shapiro et a1@used conventional and harmonic US to evaluate
the pancreas in 60 patients. Harmonic US images of the pancreas improved
penetration in 45 patients (75%), provided better detail in 54 (go%), and im-
proved total image quality in 50 patients (83%) as judged by three radiologists
“blinded to the US technique used to generate the image.@Tissue harmonic
imaging is routinely available, and the improvement in image quality has made
it the technique of choice for US evaluation of the abdomen, including the
pan~reas?~, @

NORMAL PANCREATIC ANATOMY ON ULTRASONOGRAPHY

The pancreas usually has uniform texture, and pancreatic echogenicity is

slightly greater than, or the same as, that of the liver. Fatty infiltration of the
pancreas that occurs with advanced age and obesity may increase pancreatic
echogenicity so that it resembles the adjacent retroperitoneal fat. Occasionally, a
texture change may be observed in the uncinate and head of the pancreas caused
by focal fatty sparing within the ventral p a n c r e a ~ .This
~ , ~normal
~ variant can be
differentiated from tumor by the absence of mass effect or vascular or ductal
displacement.
The pancreas is defined by the adjacent vasculature (Fig. 1).On transverse
US images, the body of the pancreas is seen anterior to the splenic vein,
262 BENNElT&HANN

Figure 1. Normal pancreatic anatomy. Transverse ultrasonography (US) reveals a normal

sized pancreas (white arrows), with adjacent peripancreatic vasculature. Aorta and origin
of right renal artery (a), inferior vena cava (i), left renal vein (curved arrow), splenic vein,
and superior mesenteric vein confluence (s), superior mesenteric artery (black arrow).

with the superior mesenteric vein and superior mesenteric artery visualized
posteriorly. The left renal vein courses transversely between the superior mesen-
teric vein and aorta. On sagittal views, the pancreas contacts the inferior vena
cava. This vascular anatomy is well depicted by gray-scale US. When spectral
or color Doppler also is used, vascular patency and flow direction within the
peripancreatic vessels also may be documented on US. The pancreatic duct is
best seen transversely, and it normally is less than 2 mm diameter in the body
of the pancreas and 3 mm in the head34(Fig. 2).

Figure 2. Pancreatic duct. In the body of the pancreas, a 2-mm normal-caliber pancreatic
duct (arrow and calipers) is well visualized. a = aorta; p = portal vein.
 PANCREATIC ULTRASONOGRAPHY 263

ULTRASONOGRAPHY IMAGING IN ACUTE AND CHRONIC

PANCREATITIS

Acute Pancreatitis

US traditionally has a limited role in establishing the diagnosis of acute

pancreatitis. Visualization of the pancreas in patients with pancreatitis often is
limited because of ileus and superimposed bowel gas. Also, the US appearance
of the pancreas may be normal in early pancreatitis. CT is considered to be the
imaging modality of choice for the diagnosis and staging of acute pancreatitis
because of its superb ability to show early inflammatory change, extrapancreatic
fluid collections, and pancreatic necrosis.6,7, CT also has been found to be
helpful in predicting the severity of an attack of acute pancreatitis and the
development of complications and in establishing prognosis?,
US, however, does have a role in the evaluation of patients with acute
pancreatitis. It often is the first examination for the evaluation of patients with
abdominal pain, and it is the best method for the assessment of the gallbladder
and biliary tree. When a patient presents with suspected acute pancreatitis, US
is used to evaluate the gallbladder and biliary tree and to exclude other causes
of abdominal pain, such as cholecystitis. The finding of gallstones provides a
likely etiology for acute pancreatitis, and the identification of choledocholithiasis
and biliary obstruction, with obstructive jaundice or cholangitis, affects immedi-
ate patient management because these patients may be triaged for emergent
endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy.
Whether the mere presence of gallstones in a patient with acute pancreatitis is
an indication for routine presurgical ERCP is contr~versial.'~, 27
The reported sensitivity, specificity, and accuracy of US for the detection of
cholelithiasis are more than 95%.19, 37, 44 CT is less sensitive because many stones
are composed of calcium, bile pigment, and cholesterol and are isoattenuating
to bile? Sensitivity of US for choledocholithiasis ranges from 55% to 85%, with
a specificity of 89% to 91%?0,45, Choledocholithiasis is confidently identified
when there is an echogenic shadowing focus in the common bile duct (CBD)
surrounded by bile (Fig. 3A). The limitations of US for the detection of CBD
stones include stones in nondilated ducts, nonshadowing stones, and stones
present in the distal CBD, which often is obscured by bowel gas. Helical CT
has proven to be a useful adjunctive imaging technique for the detection of
choledocholithiasis, with a reported sensitivity and specificity of 88% and 97%
relative to ERCP (Fig. 3B). Magnetic resonance cholangiopancreatography
(MRCP) also has offered sensitivities in the range of 92% to 93%, and diagnostic
accuracy of as much as 97%.'O~~~
US findings related to the pancreas vary depending on the severity of
pancreatitis, timing of imaging, and ability to achieve an adequate US window.
This latter issue is improved with optimized imaging t e c h n i q ~ e s Scans
. ~ ~ ob-
tained in the semiupright and right posterior oblique position can facilitate
visualization of the pancreatic head and distal CBD with fluid accumulation in
the gastric antrum and proximal duodenum, and displacement of air to the
region of the gastric fundus. The left lobe of the liver serves as an acoustic
window for evaluation of the pancreatic body and lesser sac, while the spleen
can serve as a window for evaluation of the pancreatic tail and anterior para-
renal space.
In early pancreatitis, the pancreas shows normal size and US echotexture.
Eventually, there will be a change in echotexture of the gland, becoming more
hypoechoic and heterogeneous relative to the healthy pancreas. Subsequently,
264 BENNETT & HANN

Figure 3. Choledocholithiasis. A, Common bile duct stone (s)appears as echogenic focus

in the distal common bile duct (CBD), with associated posterior acoustic shadowing (arrow).
B, Helical CT image reconstructed in the coronal plane shows stone (arrow) in distal
CBD (d).

the gland will enlarge and develop an irregular contour (Fig. 4). The margins of
the pancreas become indistinct, secondary to peripancreatic inflammatory
changes and edema within the peripancreatic fat. Dilatation of the pancreatic
duct may be observed. A focal intrapancreatic abnormality may be secondary
to complications such as fluid collection, hemorrhage, or necrosis. US cannot
differentiate between necrotic and non-necrotic pancreatic tissue, and CT is
considered the study of choice for identifying pancreatic necrosis." 42 Necrosis
appears on CT as an area of nonenhancing parenchyma. MR imaging can be
used for the evaluation of patients who cannot receive intravenous contrast. If
the gland shows significantly altered echotexture on US, or if no normal defin-
able pancreatic tissue is present, CT evaluation should be performed (Fig. 5 ) .
Occasionally, pancreatitis may be a focal process, with involvement of one
segment of the gland, usually the head. On US, this appears as a focal enlarge-
ment with altered echotexture. On occasion, this is difficult to distinguish from
a pancreatic Clinical correlation is important, as is a history of pancreati-
tis. The presence of calcification is reassuring; however, CT or MR evaluation
may be necessary. Also, ERCP may be helpful to show changes within the
pancreatic duct.
In addition to the evaluation of the gland, US can be used to identify
extrapancreatic spread of inflammation. Fluid collections are commonly seen
within the lesser sac, anterior pararenal spaces, transverse mesocolon, and small
 PANCREATIC ULTRASONOGRAPHY 265

Figure 4. Acute pancreatitis related to recent endoscopic retrograde cholangiopancreatog-

raphy (ERCP). A, US reveals diffuse enlargement of the pancreas (p), with overall de-
creased echogenicity and irregular contour. 6, CT scan performed with intravenous contrast
demonstrates enlarged, heterogeneously enhancing pancreas (p). There is contrast present
in the distal CBD (d) caused by recent ERCP. g = gallbladder; s = splenic vein.
266 BENNETT & HANN

Figure 5. Severe acute pancreatitis with pancreatic necrosis. A, Transverse US demon-

strates enlarged hypoechoic, heterogeneous pancreas (p). B, CT scan performed with
intravenous contrast demonstrates only a small amount of enhancing pancreatic tissue in
the region of the head (h). The remainder of the gland is nonenhancing, consistent with
necrosis (n).

bowel mesentery and peripancreatic spaces.4O This fluid can have a spectrum of
US appearances, from simple anechoic fluid to complex fluid with septations.
Other extrapancreatic findings include ascites, bowel wall thickening, and thick-
ening of the gallbladder wall.
US also may have an important role in the identification of complications
related to pancreatitis. A pseudocyst is a well-defined, walled-off fluid collection
that persists on serial examinations for at least 4 weeks after the onset of
inflamrnati0n.2~Pseudocysts develop in 10% to 20% of patients with acute
pancreatitis and usually require 4 to 6 weeks to form.62Diagnosis can be sug-
gested based on clinical and laboratory parameters but can be confirmed with a
variety of imaging techniques. Typically, a pseudocyst appears on US as a well-
defined fluid collection that is anechoic with posterior acoustic enhancement
(Fig. 6). These may have a more complex appearance if infected or complicated
by hemorrhage4*(Fig. 7). Other complications include rupture, biliary tract
obstruction, and involvement of the gastrointestinal tract, liver, or spleen.
Color and spectral Doppler US have a crucial role in the identification of
 PANCREATIC ULTRASONOGRAPHY 267

Figure 6. Pseudocyst. A, Pseudocyst appears on US as well-circumscribed anechoic fluid

collection (c) anterior to the tail of the pancreas (p). 6, CT with intravenous contrast
demonstrates well circumscribed fluid collection (c) anterior to the pancreas.

vascular complications of acute pancreatitis. These include venous thrombosis

and pseudoaneurysm formation. Venous thrombosis can involve the portal or
splenic veins and can manifest as complete thrombosis with lack of flow or as
an echogenic filling defect within the vein. If thrombosis is chronic, cavernous
transformation of the portal vein results. Pseudoaneurysms most commonly
involve the splenic artery, gastroduodenal arteries, pancreaticoduodenal arcade,
or occasionally the hepatic artery and result from severe necrotizing pancreatitis
or erosion by a pseudocyst. These are readily identified with color Doppler and
show characteristic findings with spectral Doppler.
US cannot distinguish an uninfected peripancreatic fluid collection or pseu-
docyst from an infected one. The presence of echogenic foci corresponding to
gas bubbles is suggestive; however, air also may be present secondary to fistula
with bowel. If there is any clinical suspicion, US can provide image guidance
for fluid aspiration or drainage and for nonsurgical decompression of a pseu-
docyst!
268 BENNE’IT & HA”

Figure 7. Complex pseudocyst (c) with debris and septations. Needle aspiration demon-
strated evidence for hemorrhage.

Chronic Pancreatitis

US findings in patients with chronic pancreatitis include alterations in the

size and echotexture of the gland, calcifications, pancreatic duct dilatation and
irregularity, bile duct dilatation secondary to stricture, and chronic p~eudocysts.~
The gland generally atrophies and becomes heterogeneous in echotexture sec-
ondary to fibrosis and calcification. Calcifications appear as hyperechoic foci
with associated posterior acoustic shadowing, which may be focal or distributed
throughout the gland (Fig. 8). They usually are intraductal, resulting from
deposition of calcium carbonate on intraductal protein plugs. The pancreatic
duct may be dilated and often is irregular in appearance, with dilatation of side
branches. This may be difficult to distinguish from other causes of pancreatic
duct dilatation, such as cancer. A history of pancreatitis and presence of calcifi-
cations without definite focal mass are reassuring; however, further evaluation
with helical CT, MR, or ERCP may be necessary.

DIFFERENTIAL DIAGNOSIS OF PANCREATIC

ABNORMALITIES

Because US often is the initial imaging study for evaluation of the pancreas,
it is useful to differentiate the appearance of pancreatitis on US from neoplasms
to appropriately triage patients.

Pancreatic Duct Dilation

The intraductal papillary mucinous tumor (IPMT) may mimic pancreatic

duct dilation of chronic pan~reatitis?~, 66 This pancreatic cystic neoplasm
spreads in the pancreatic ducts and secretes thick mucin that fills the main or
branch ducts and causes ductal dilatation (Fig. 9). Many of the radiologic
 PANCREATIC ULTRASONOGRAPHY 269

Figure 8. Chronic pancreatitis with calcification. A, Prominent pancreatic duct (pd) contains
echogenic foci with posterior acoustic shadowing within the pancreas, consistent with
calcification (arrows) from pancreatitis. 6, CT scan performed with intravenous contrast
demonstrates calcifications within the pancreas (p).

features mimic the main duct dilatation seen in patients with chronic pancreati-
tis. When IPMT involves the entire length of the duct with associated parenchy-
mal atrophy, differentiation from chronic pancreatitis may be impossible. Mark-
edly dilated branch ducts may mimic pseudocysts. CT, MR, endoscopic US
(EUS), and ERCP may allow for further characterization. The presence of mural
nodules, much globs, or a solid mass identified by any of these modalities is
important in making the correct diagnosis. A virtually pathognomonic finding
is dilatation of the major or minor papilla, or both, with bulging into the
duodenal lumen. Diagnosis of IPMT with ERCP is certain when much is
observed leaking from the papilla.

Solid Mass

Adenocarcinorna
A focal mass, observed in as many as 40% of patients with chronic pancreati-
tis, may appear hyper- or hypoechoic and may be difficult to distinguish from
270 BENNETT & HANN

Figure 9. Dilated pancreatic duct with intraductal papillary tumor. Transverse US image of
the body of the pancreas reveals a dilated pancreatic duct (d) and polypoid intraductal
mass (arrow). v = superior mesenteric vein.

cancer2,54(Figs. 10 and 11).The presence of calcifications favors the diagnosis of

chronic pancreatitis because calcification in cancer is unusual. Correlation with
helical CT, with thin-section imaging of the pancreas during the dynamic bolus
infusion of intravenous contrast or MR imaging, is recommended to further
characterize and assess for spread of disease. These procedures also may be
inconclusive, and image-directed biopsy or close follow-up to assess for interval
change may be necessary. The utility of endoscopic US for the diagnosis of early
changes of chronic pancreatitis and for characterizing focal abnormalities is the
subject of current investigation.16
Vascular invasion is an early hallmark of pancreatic cancer. Color Doppler
US is useful for determining the patency of peripancreatic vessels and can be
used to determine resectability of pancreatic cancer. Although pancreatitis may
be associated with venous thrombosis, frank encasement of the celiac axis,
superior mesenteric vessels, and splenoportal confluence are more common in
pancreatic cancer (Fig. 12). Color Doppler US is useful for determining the
patency of peripancreatic vessels and can be used to determine resectability of
pancreatic cancer?', 72* 74 Ralls et a161 reported on color Doppler findings in 51
patients with pancreatic cancer, 49 of whom had technically complete examina-
tions with visualization of all index vessels. The lesions of all 30 patients who
were considered to have unresectable disease by color Doppler were unresect-
able at surgery. The lesions of 6 of 15 patients (40%) that were considered
resectable on US were unresectable for cure.
Atrophy of the gland and pancreatic duct dilation may be present in pancre-
atitis and pancreatic cancer, but when these findings are present only distal to a
mass, the diagnosis of pancreatic cancer is favored. Bile duct obstruction also
may be present in pancreatitis and pancreatic cancer, but abrupt cutoff of the
duct and the double duct sign are more common in pancreatic cancer than in
pancreatitis. Hepatic metastases detected on US may confirm the diagnosis of
malignancy. Metastases are more common at presentation of pancreatic body
and tail tumors because these usually become symptomatic at a later stage than
pancreatic head tumors that cause biliary obstruction.
 PANCREATIC ULTRASONOGRAPHY 271

Figure 10. Focal chronic pancreatitis. A, Transverse US image of an enlarged head of

pancreas (p) with calcifications. 6,MR image correlation demonstrates enlarged head of
pancreas (p).

Other Solid Masses

Neuroendocrine tumors of the pancreas derived from the amine precursor
uptake and decarboxylation (APUD) system may be functioning or nonfunction-
ing and may be associated with multiple endocrine neoplasia (MEN) syn-
drome?, 22 Patients with functioning tumors, such as insulinomas and gastrino-
mas, usually present with clinical symptoms related to excessive insulin, gastrin,
or other hormones, but approximately one third of neuroendocrine tumors are
nonfunctioning. Ninety percent of insulinomas are benign, but the prevalence of
malignancy is higher for gastrinomas and other functioning islet cell tumors.
Nonfunctioning tumors are more likely malignant.
Helical CT and MR imaging are preferred for presurgical imaging of neuro-
endocrine tumors.3,52, 68 Using arterial and venous phase helical CT, Van Hoe et
a P reported accurate presurgical identification of 9 of 11 pancreatic neuroendo-
crine tumors, one of which measured only 4 mm in diameter. The rate of
transabdominal US detection of islet cell tumors is relatively low, in the range
of 60%, because of the small size of these tumors.3,32, 33, 50,52* 63, 68 Neuroendocrine
272 BENNETT & HANN

Figure 11. Bile-duct obstruction from carcinoma in the head of the pancreas. Longitudinal,
left lateral decubitus US image reveals a pancreatic head carcinoma (calipers and curved
arrow) obstructing a dilated CBD (bd).

tumors less than 2 cm in diameter usually are hypoechoic or isoechoic to the

pancreas. Large islet cell tumors may be seen on US as echogenic, irregular
masses with calcification or cystic areas from hemorrhage: Although transab-
dominal US is of limited value, intraoperative US (IOUS) of the pancreas is
extremely accurate for the identification of islet cell tumors. IOUS has a true
positive detection rate of 98'3'0, and tumors as small as 3 mm in diameter may
be detected by IOUS.31,32 Also, IOUS may be useful to identify unsuspected
multiple tumors, which are present in 10% of insulinomas and 20% to 40% of
gastrin~mas.~~
Non-Hodgkin's lymphoma may involve the pancreas diffusely or as a focal
mass (Fig. 13). It is hypoechoic on US, and the appearance may mimic pancreati-
tis if the patient presents with abdominal pain. The presence of bulky adenopa-
thy, or adenopathy below the level of the renal veins, may be useful in establish-
ing the diagnosis of lymphoma.51Lack of pancreatic duct dilation and patent
vessels on Doppler imaging also are characteristic US findings in pancreatic
lymphoma.51

Cystic Neoplasms

Cystic neoplasms are relatively uncommon, representing approximately 10%

to 15% of pancreatic cysts and 1% of pancreatic cancers.41US provides excellent
characterization of cystic lesions and easily depicts mural nodules, septations,
and internal debris. Cystic neoplasms often have discriminating features on US
imaging that may be useful for differentiation from pseudocysts of pancreatitis.
Serous microcystic adenomas are benign neoplasms with multiple cysts
ranging in size from 1 mm to 2 cm. Although microcystic adenomas are cystic
neoplasms, they have a variable appearance on US depending on the size of the
CyStS.13. 29. 30, 41 Microcystic adenomas with 1- to 2-mm cysts may appear solid
because of the numerous interfaces produced by the walls of the small cysts.
Microcystic adenomas with larger cysts have anechoic areas on US and, charac-
 PANCREATIC ULTRASONOGRAPHY 273

Figure 12. Pancreatic adenocarcinoma involving the splenoportal venous confluence. A,

Transverse US image at the level of the pancreatic neck reveals an irregular hypoechoic
2-cm mass (calipers and arrow). The mass compromises the splenic vein (SV). B, An
oblique sonogram of the portal vein reveals focal nodularity (arrows)that narrows the lumen
of the portal vein (pv). Tumor involvement of the portal vein was confirmed by histopathol-
ogy. A = aorta.

teristically, these cysts are distributed in a peripheral location within the tumor
(Fig. 14).Central stellate scars, shown on US as central linear echogenic areas,
are present in approximately 13% of cases, and calcification may be present
within the scar.41Tumors are well defined on US, with smooth margins. They
occur more commonly in the pancreatic head, but because the tumors are
relatively soft, there is no obstruction of the pancreatic duct or compromise of
the peripancreatic vessels. Doppler imaging of microcystic adenomas aids in
diagnosis. The lack of vascular encasement may be useful to differentiate these
benign neoplasms from adenocarcinomas that typically involve the peripancrea-
tic vessels. Color or power Doppler also may be used to show internal vascu-
larity within microcystic adenomas, which are very vascular neoplasms that
have numerous vessels within the pseudocapsule and ~eptations.'~, 29
In contrast to microcystic adenomas, macrocystic mucinous tumors of the
274 BENNETT & HANN

Figure 13. Lymphoma of the pancreatic body and tail. A, Transverse sonogram shows an
enlarged hypoechoic pancreatic body and tail (arrows). Appearance is consistent with
neoplasm or inflammation. B, CT image shows low-attenuation mass (arrows) infiltrating
the pancreatic tail. CT-guided biopsy revealed lymphoma. a = aorta; i = inferior vena cava.

pancreas are malignant or potentially malignant. Macrocystic mucinous cystade-

noma and cystadenocarcinoma have larger cysts (>2 cm in diameter). Character-
istic features of macrocystic tumors are thick septations, cysts with solid mural
nodules, or cysts with echogenic f l ~ i d ~(Fig.
, ~ l 15).Calcifications may be present,
often are coarse, and are peripheral in distribution.4l Johnson et a14' reported
that 78% of microcystic tumors and 95% of macrocystic adenomas or adenocarci-
nomas were correctly classified on US in a retrospective analysis. It is not
possible to definitively distinguish between benign and malignant macrocystic
tumors, but, in general, as solid components increase, there is a greater risk for
malignan~y.~, 30
Another neoplasm that appears cystic on US is solid and papillary epithelial
neoplasm (SPEN) of the pancreas. This tumor is uncommon, has low-grade
malignant potential, and is seen in young women.I4 SPEN is characterized by
areas of internal hemorrhage and cystic degeneration with fluid-debris levels
and posterior enhancement on US.14Calcification may be present and is more
 PANCREATIC ULTRASONOGRAPHY 275

Figure 14. Microcystic adenorna. A, Sagittal sonogram shows a large echogenic pancreatic
head mass (rn, open arrows) with small peripheral cystic areas (curved arrows). The mass
obstructs the CBD (CD). 6,T-2 weighted MR image shows the cysts within the pancreatic
head mass (open arrows). gb = gallbladder; v = superior mesenteric vein.

readily identified on CT. MR imaging may provide specific diagnosis by demon-

strating blood products. Mucinous cystic neoplasms may have similar features,
but SPEN lacks internal septations and multiple loculations that are present in
microcystic and macrocystic adenoma~.'~

OTHER APPLICATIONS OF ULTRASONOGRAPHY

Ultrasonography-GuidedPercutaneous Biopsy of the

Pancreas

US-guided fine-needle aspiration (FNA) biopsy provides definitive diagno-

sis of pancreatic abnormalities. Biopsy positive for malignancy has a reported
specificity of 23, 57, 73 Di Stasi et alZ3
reported on US-guided percutaneous
276 BENNETT & HA"

Figure 15. Macrocystic adenoma. A, Transverse sonogram reveals a cystic mass (calipers)
with multiple thick septations in the tail of the pancreas. The splenic artery (s)contacts the
mass (arrows) but is not involved. B, CT image shows mass (arrows) that contains
septations and calcification (open arrow).

FNA biopsy results in 519 patients. For cytology, histology, and cytology plus
histology, retrieval rates were 94%, 967'0, and 97%; sensitivity was 8770, 94%, and
94%; and diagnostic accuracy was 9170, 90%, and %YO,respecti~ely.~~
Brandt et all2 compared US- and CT-guided biopsy of the pancreas and
found an accuracy of 95% for US and 86% for CT. The rate of false-negative
results, including unsatisfactory specimens, was lower with US biopsies (3 of 58
procedures, 5%) compared with CT (30 of 211 procedures, 12%). Accuracy was
higher with masses larger than 3 cm and larger needle size. Results also were
better for masses located in the pancreatic body or tail rather than the head.
The rate of major complications caused by percutaneous pancreatic biopsy
is rare, at less than 1%.l2,65 Pancreatitis is the most common complication of
percutaneous biopsy and is unrelated to the method of imaging guidance or
type of needle used for the procedure. US-guided biopsies, using 18-gauge
needles with automated, spring-loaded sampling devices, have reported sensitiv-
ity of 92% to 94%, with no increase in complication rate.", 65 Tumor seeding
 PANCREATIC ULTRASONOGRAPHY 277

along the needle tract is rare (0.003%-0.009%) but is more common with pancre-
atic tumors than with other rnalignancie~.~~

Pancreatic Transplant Evaluation

Simultaneous pancreas and kidney transplantation is a therapeutic option

for end-stage renal disease in patients with type 1 diabetes mellitus, and various
complications may be identified with imagingz6Several techniques may be used
for transplantation, and physicians should understand the surgical anatomy
when assessing for potential complications. The transplanted pancreas is one of
the most difficult organs to evaluate, and findings usually are not evident until
there is extreme compromise of the transplant?* Complications include abscess
or pseudocyst formation, vascular thrombosis, leak, or compromise of adjacent
structures. The role of US is limited because the transplanted pancreas often is
obscured by adjacent bowel. If the pancreatic duct is visualized, it can serve as
a useful landmark. Also, differentiating between pancreatitis, rejection, and
vascular compromise is difficult because these problems may result in a similar
sonographic picture, with an enlarged heterogeneous, hypoechoic, edematous
gland. US may identify peripancreatic fluid collections, such as abscess or hema-
toma, although CT usually provides better delineation of size and extent of
these abnormalities and evaluation of the gland.21
Vascular complications are the second most common cause of pancreatic
graft failure, after graft rejection. The most important role for US is in the
evaluation of the transplant vasculature using color and spectral Doppler. Vascu-
lar complications, such as graft thrombosis (arterial or venous), stenosis, or
pseudoaneurysm formation, can be identified and subsequently confirmed with
conventional angiography or MR angiographyZ6The ability to use resistive index
elevation as a positive predictor of transplant rejection has not proven useful
because many rejecting transplants have a normal resistive index (RI), and
elevation of the RI is nonspecific and can be seen with vascular compromise,
such as venous t h r o m b ~ s i s ~
however,
~; in a series of 11 patients with venous
thrombosis evaluated with duplex US, Foshager et alZ8found that reversal of
diastolic flow in pancreatic transplant arteries was highly specific for the detec-
tion of graft venous thrombosis during the first 12 days after transplantation.
Also, they found that an RI greater than or equal to 1.00 and absence of venous
flow, in combination, are highly sensitive and specific for the diagnosis of
pancreatic graft venous thrombosis.

SUMMARY

Pancreatic abnormalities usually are detected on US when it is used for

screening patients with abdominal pain and for assessment of the gallbladder
and bile ducts. Pancreatic visualization is limited by bowel gas, but with experi-
enced sonographers and newer techniques, including harmonic imaging and oral
contrast US, diagnosis of pancreatic abnormalities has significantly improved
compared with earlier reports. Appropriate initial diagnosis by US can tailor
further investigation, and US-guided biopsy may establish definitive diagnosis.
278 BENNETT & HANN

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Address reprint requests to

Lucy E. Hann, MD
Department of Radiology
Memorial Sloan-Kettering Cancer Center
1275 York Avenue
New York, NY 10021

e-mail: hand@mskcc.org