Take Care of Your Pancreas!

During exacerbation of chronic recurrent pancreatitis there were various changes of sonographic picture which generally were a result of diffuse or local spread of the acute inflammatory process. The volume of the pancreas was enlarged, mainly due to the head, less often the tail. In case of aparent exacerbation of pancreatitis indistinct differentiation of contours of the organ was observed.

To determine the condition of the blood flow in the pancreatic area and specify the localization the necrosis zone patients were examined with the use of colour doppler mapping and energy dopplerography.

During the interstitial edematic form of AP intensifying vascularization of the pancreas parenchyma was intensified what was evident from the increase in the number of coloue singnals in a separate section of the parenchyma. As the edema was intensified the resistance index and the pulsatory index in parenchymatous arterias rose more than 0,86 and 2,15. However in case of the intensive edema of the pancreas the parenchymatous blood flow was slowed down but the blood flow in efferent vessels remained the same. Deformation of the parenchymatous vascular pattern in the zone of the apparent inflammation and venous-arterial shunting were typical of the necrotic form of AP. As the pathological process increased the linear indices of intrapancreatic vessels gradually came down. During the reactive phase the linear speed of the blood flow in intrapancreatic vessels was not determined and reduced in adjacent vessels. The change of the resistance index and the pulsatory index were badly determined in adjacent vascular structures and were not determined in the parenchyma. The comparative analysis of doppler signals in the thickness of the pancreas and on its surface showed that hemodynamics decreases or disappears in case of necrotic fusion of tissues. In case of purulo-necrotic complications absolute and relative indices of hemodynamics are determined only in vessels adjacent to the pancreas. The dopplerographic picture of the pseudocyst of the pancreas was characterized by visualization of the avascular and hypoechoic zone with deformation of fine vessels at the periphery of the nidus. In adjacent vascular structures linear blood flow indices rose, indices in intraparenchymatous vessents could be determined indistinctly. Exacerbation of the chronic recurrent form was characterized by the decrease of the linear blood flow speed inside the pancreas, as well as in adjacent vascular structures. The resistance index and the pulsatory index tended to rise in adjacent vessels.

Purulent fusion of tissues of pancreatic infiltration is accompanied by a large number of fine irregularly placed echo-free structures with indistinct contours. During dynamic observation we can mark their fusion into larger inclusions of non-uniform density. Purulent fusion of tissues with formation of a cavity is traced approximately within 5-7 days. During formation of an abscess the augmentation of infiltration with an echo-free rim at the periphery is marked due to the gathering of liquid in the omental bursa. Diffusion of the process on adjacent tissues is accompanied with the loss of sharpness of their structure and illegibility of vessel contours.

During abscesses of the abdominal cavity and retroperitoneal space the common nidus of irregular shape and lowered echogenicity is determined. The internal structure of the abscess is non-uniform with individual regular or irregular fine echogenic inclusions. A strip of intensive reflections is marked behind the nidus. Echoginicity is reduced in the parts of the pancreas adjacent to the nidus.

The size of the pancreas is moderately enlarged or normal in case of cystous lumps. Cystous lumps with homogeneous hypoechoic structure up to 20-25 cm in diameter are determined in the parenchyma. During visualization the duct of the pancreac is crimped. The parenchyma surrounding the cyst had an apparent non-uniform structure. Some patients can have caval organs pushed off - the stomach, the duodenal with signs of gastro- and duodenostasis.

Echography shows that empyema of the cyst is heterogenic. On the homogeneous echo-free background the structures are more dense; they are suspended and look like flakes. Alongside with it the capsule is thickened and its internal border is loosened. The reactive process simultaneously develops in adjacent tissues.

In case of the necrotic form of acute pancreatitis (AP) the pancreas size exceeded the norm. Depending on the degree of affection there is the increase in size of different parts of the pancreas. The pancreas changes its shape when local affection is considerable. The contours are uneven, usurious, vague. Echogenicity of the parenchyma is reduced and the apparent heterogeneity of the acoustic structure with chaotic alternation of large parts of increased and decreased echogenicity is determined. The duct system is visualized unsatisfactorily and the liquid in the omental bursa is determined as echo-free lumps in different parts of the bursa.

Patients with infiltrative necrotic form of acute pancreatitis have a large pancreatogenic of irregular shape, uneven contours, increased echogenicity, heterogeneous structure, usually located in the projection of the greater omentum and the transverse colon. The sizes of the infiltration usually vary from 5 to 15-20 cm. In case of extension of infiltration in the retroperitoneal space, the length of massive affections located much lower than the pancreas is from 10 to 20 cm and even more. Adjecent vascular structures are hardly visualized.

All patients with the aseptic form of AP have vague contours of the pancreas all the parts of which are enlarged. The patients of this group have the following typical features: the heterogeneity of the internal pancreas structure, various echogenicity, unchanged sound conduction. Vascular structure and duct system of the pancreas in most cases are not determined. We can observe pathological foci as anechoic or hypoechoic formations with clear-cut or indistinct, more often uneven contours, irregular shape, often with heterogeneous structure and thickness of walls of about 0,2-0,4 cm.

Patients have various clinical forms of acute destructive pancreatitis (AP). Intensity and type of the clinical presentation depend on the phase of the pathological process. Thus, at early phases of acute destructive pancreatitis the signs of enzymatic toxemia prevail. Purulo-septic complications are typical of late phases of the desease.

The changes in blood properties during laboratory research (red blood colour, developed leukocytic formula, leucocytosis, increase in ESR) are auxiliary signs of the disease. The disfunction of the pancreas and liver at different phases of the desease is determined during biochemical investigation.

Ultasonic tomography (UST) is a fast, high-quality non-invasive method of direct diagnostics of acute pancreatitis. We’ve observed a number of sonographic variants of AP.

The enlargement of the pancreas proportionally to the edema is typical of the edematic form of AP. The visible contours of the pancreas are even and clear-cut. Echogenicity of the pancreas is educed diffusely and irregularly in different parts. The local decrease in echogenicity corresponding to the place of the maximum edema is typical of the segmental and local variants of affection. In most cases the echostructure of the parenchyma is homogeneous and the structure of stromal tissue elements was preserved. In case of diffusive affection we usually observe heterogeneity in all parts depending on the degree of the edema. When liquid gathers in the omental bursa we observe an echo-free area of different size as the distance between the back wall of the stomach and the forward surface of the pancreas increased.