胰腺分离影像学诊断

Hilary Hochberg Gillian Lieberman, MD Pancreas Divisum: Patient Presentation and Discussion Hilary Hochberg Advanced Radiology Clerkship Beth Israel Deaconess Medical Center Dr. Gillian Lieberman September 2001 2 Hilary Hochberg Gillian Lieberman, MD Patient JC •44 yo male •Abdominal pain, epigastric, radiating to back x 1d •Nausea, vomiting, diaphoresis, low-grade fevers, chills •PMHx: 4 m ago, EU abdominal pain  Normal CT 3 Hilary Hochberg Gillian Lieberman, MD Physical Exam Vitals: T 100.3 P70 RR20 BP 150/90 • Abd: Distended, tenderness to palpation diffusely, mostly periumbilical • -Rebound +Voluntary guarding • BS markedly depressed • No Cullen/Grey Turner sign 4 Hilary Hochberg Gillian Lieberman, MD Labs CBC: WBC 13.4 Hct 42 Plets 257 Amylase 2302 Lipase 1940 LFTs: ALT/AST 47/23 LDH 199 Alk Phos 83 TG 264 E’lytes: 143 | 104 | 23 / 4.3 | 25 | 0.9 \ 150 Ca 9.3 / Ph 4.1/ Mg 2.0 5 Hilary Hochberg Gillian Lieberman, MD Indistinctive pancreatic margins Fat stranding (misty appearance) of peripancreatic fat Thickening of pararenal fascia and pararenal fluid accumulation Our Patient JC: Abdomenal CT Findings consistent with pancreatitis 6 Hilary Hochberg Gillian Lieberman, MD Illustration at http://www.hopkins-gi.org/subspecialties/chronic/introduction/anatomy.htm Anatomy of the Pancreas 7 Hilary Hochberg Gillian Lieberman, MD JC:Endoscopic Retrograde Cholangiopancreatography (ERCP) What a mouthful! Cannulation of patient JC’s major ampulla CBD Cystic duct (corkscrew) and gall bladder Illustration at http://www.aafp.org/afp/990501ap/2507.html 8 Hilary Hochberg Gillian Lieberman, MD Normal intrahepatic ductal system Our Patient JC: ERCP 9 Hilary Hochberg Gillian Lieberman, MD Small ventral duct Dominant dorsal duct connecting to main pancreatic duct JC: ERCP Major papilla cannulation Minor papilla cannulation 10 Hilary Hochberg Gillian Lieberman, MD Ductal Variations Major Minor Major Minor Major Minor 11 Hilary Hochberg Gillian Lieberman, MD Ductal Variation Type 3 Pancreas Divisum The most common congenital variant of pancreatic anatomy. 12 Hilary Hochberg Gillian Lieberman, MD Magnetic Resonance Cholangiopancreatography Stomach Gall Bladder •Fluid filled bile and pancreatic ducts are very bright on T2 images •Accessory duct drains majority of pancreas Pancreas Divisum Anomaly 13 Hilary Hochberg Gillian Lieberman, MD He returned to EU with nausea, vomiting, and periumbilical pain, similar to prior admission. •CT: Pancreatitis and large pancreatic pseudocyst extending into lesser sac and compressing stomach J.C. clinically improved, and he was discharged home. 2 weeks later: stomach Our Patient JC: 2 Weeks later Hilary Hochberg Gillian Lieberman, MD What happened? So… 15 Hilary Hochberg Gillian Lieberman, MD Pancreas Divisum: Embryology Picture: http://anatomy.med.unsw.edu.au/cbl/embryo/sysnote.htm 16 Hilary Hochberg Gillian Lieberman, MD Week 4: Dorsal pancreatic bud Week 5: Ventral bud appears between GB and duodenum. Bile duct moves to right, apposing the pancreatic buds as duodenal wall differentially grows. Dorsal duct (Santorini) and ventral duct (Wirsung) FUSE. The ventral duct is the main duct for pancreatic secretions into the duodenum. If the dorsal duct persists, it is called the minor papilla. Illustrations: www.vesalius.com Normal Embryological Development of Pancreas 17 Hilary Hochberg Gillian Lieberman, MD Pancreas Divisum • NO FUSION of ventral and dorsal pancreatic buds • Ventral bud only drains ventral pancreas • Dorsal bud (through minor papilla) must drain majority of pancreas. • Minor papilla is often stenotic and inhibits flow of pancreatic juice Pancreatitis • Other features: – Stenosis of minor papilla – Signs of chronic pancreatitis – Dilated dorsal duct – Santorinicele 18 Hilary Hochberg Gillian Lieberman, MD Diagnosis of Pancreas Divisum: ERCP • Absent or small ventral duct • Confirm by cannulation of minor duct lack of communication between dorsal and ventral and dorsal ducts. 19 Hilary Hochberg Gillian Lieberman, MD Complications of Pancreatitis Phlegmon Loculated fluid collection Pseudocyst Abscess Pancreatic necrosis Pancreatic hemorrhage Pseudoaneurysm Pancreatic ascites Acute Subacute 20 Hilary Hochberg Gillian Lieberman, MD Treatment of Pancreas Divisum Standard Medical Therapy: Low fat diet Analgesics Pancreatic enzymes Anticholinergics Minor Papilla Treatment: Endoscopic •Dilatation •Stenting •Papillotomy Open surgical •Minor sphincteroplasty •Pancreatico-jejunostomy with Roux-en-Y limb 21 Hilary Hochberg Gillian Lieberman, MD Pros Cons ERCP •Best visualization of ductal anatomy •Access for biopsy or therapeutic intervention (sphincterotomy) •Technically difficult. •Radiation •Expensive •Invasive: Complications (4% ERCPpancreatitis) MRCP •Noninvasive •Better imaging of parenchyma •Worse resolution than fluoroscopy so less sensitive than ERCP •Screening Examination In Patients With Low or Intermediate Probability Of choledocholithiasis •Failed or Incomplete ERCP •Post-operative Anatomy •Primary Sclerosing Cholangitis (PSC) •Complications of Chronic Pancreatitis •Variant Ductal Anatomy! MRCP growing in use…. Hilary Hochberg Gillian Lieberman, MD 22 Articles of interest: Ertan A. Long-term results after endoscopic pancreatic stent placement without pancreatic papillotomy in acute recurrent pancreatitis due to pancreas divisum. Gastrointestinal Endoscopy 2000; 52(1): 9-12. Freeman M, et al. Risk factors for post-ERCP pancreatitis: A prospective, multicenter study. Gastrointestinal Endoscopy 2001; 54(4) 425-434. Varshney S, Johnson CD. Pancreas Divisum. International Journal of Pancreatology 1999; 25 (2): 135-141. 23 Hilary Hochberg Gillian Lieberman, MD The End Acknowledgments Pamela Lepkowski Larry Barbaras & Cara Lyn D’amour Pancreas Divisum: �Patient Presentation and Discussion Patient JC Physical Exam Labs Slide Number 5 Anatomy of the Pancreas JC:Endoscopic Retrograde Cholangiopancreatography �(ERCP) Slide Number 8 Slide Number 9 Ductal Variations Ductal �Variation Magnetic Resonance Cholangiopancreatography Slide Number 13 What happened? Pancreas Divisum: Embryology Slide Number 16 Pancreas Divisum Diagnosis of Pancreas Divisum: ERCP Slide Number 19 Treatment of Pancreas Divisum Slide Number 21 Slide Number 22 Slide Number 23