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.

Exploratory puncture under ultrasonic guidance is of extensive current use in the diagnosis of aseptic and septic pancreatonecrosis types at the early stage.

Our aim is to determine the role of ultrasonic tomography, including puncture biopsy of the pancreas under ultrasonic guidance, in the diagnosis and treatment of acute destructive pancreatitis.

We held one-day puncture biopsy examinations under ultrasonic guidance of 50 hospitalized patients suspected of destructive pancreatitis. The biopsy examination was multifocal: with the signs of the spare fluid the 4 spot intake was made from at least 2 parts of the pancreas and the omental bursa zone with the needle of the Chiba and Angiomed G 22-21 type. In order to intake cellular material from the pancreas zone without contamination by gastric flora, аn original method of step change of intaking multiplicity, duration and rate was applied.

The analysis for infection of the pancreas and parapancreatic structures disclosed negative results with 44 patients. The results of the microbiological investigation of 10 patients were positive. Bacterial flora was presented by conditionally pathogenic gram-negative enterobacteria (E.coli, K.pneumoniae, B.cepacia, P.mirabilis) in 60 per cent of cases. The cases of infection by gram-positive agents (S.epidermidis, S.saprophyticus) covered 40 per cent. Sensitivity of the method used attained 91,7 per cent, specificity – 86,5 per cent, accuracy – 89,4 per cent.

Thus, the microbiological and cytological analysis of the aspirate taken by fine-needle aspiration under ultrasonic guidance allowed to determine the state of the pancreas objectively, to specify the pathologic process and its evolution, to verify the mode of tissue involvement in case of pancreatonecrosis.