Imaging of the pancreas: Part 1

Keith Quencer, MD, Avinash Kambadakone, MD, FRCR, Dushyant Sahani, MD,
and Alexander S. R. Guimaraes, MD, PhD

T
he pancreas is a retroperitoneal affecting the pancreas as they relate to superior pancreatico-duodenal branches
organ situated deep within the specific types of pancreatitis, pancreatic and the SMA-inferior pancreatico-
abdomen and not easily acces- neoplasms, and tumors. duodenal branches. These form an
sible by physical examination. Pan- extensive arterial network around the
creatic pathologies have a variety of Normal anatomy and physiology pancreatic head. The body and tail of
presentations, which make their diagno- The pancreas is a retroperitoneal the pancreas are supplied by branches
sis challenging to physicians.1 Imaging organ located in the anterior parare- of the splenic artery, including the dor-
plays a critical role in the evaluation of nal space posterior to the stomach and sal pancreatic artery.2
pancreatic diseases and provides valu- bounded by the c-loop of duodenum The pancreas has two distinct func-
able information to clinicians, thereby on the right side. The pancreas is di- tions, endocrine and exocrine. Eighty
dictating crucial management decisions. vided into the head, uncinate process, to 95% of the pancreatic parenchyma
Technological advancements in multide- neck, body, and tail. The head is situ- is composed of acinar cells, which are
tector computed tomography (MDCT) ated within the duodenal c-loop, while dedicated to the exocrine functions of
and magnetic resonance imaging (MRI), the tail lies in the splenic hilum slightly producing and secreting digestive en-
coupled with innovations in 3-dimen- superior to the head. Since the pancreas zymes, such as trypsinogen, lipase.
sional (3D) imaging capabilities, have is unencapsulated, there is uninhibited and amylase.3 It is curious to note that
revolutionized the role of imaging in spread of tumor and inflammation to while the overwhelming majority of the
managing patients with pancreatic dis- surrounding structures. The spleno- pancreatic parenchyma is composed
orders. Imaging is most often performed portal vein confluence lies just poste- of acinar cells, acinar cell carcinoma is
to manage patients with pancreatitis and rior to the pancreatic neck and anterior an extremely rare subtype of pancre-
suspected pancreatic mass lesions. to the uncinate process. The splenic atic carcinoma (< 1% of all pancreatic
In Part 2 of this article, available on vein courses along the posterior aspect tumors).4 Only 5% to 20% of the pan-
www.appliedradiology.com, the dis- of the pancreatic body and tail, while creatic parenchyma is responsible for
cussion continues regarding imaging the celiac artery is related cranially to the endocrine function, composed of
manifestations of various abnormalities the neck of the pancreas. The superior cells clustered into Islets of Langerhans,
mesenteric artery (SMA) arises from which produce hormones, such as insu-
Dr. Quencer, Dr. Kambadakone, Dr. the aorta at the level of the pancreatic lin, glucagon, and somatostatin.
Sahani, and Dr. Guimaraes are at the neck. The head receives arterial blood
Division of Abdominal Imaging and supply from the common hepatic ar- Development and variants
Intervention, Massachusetts General tery via gastroduodenal artery (GDA) Embryologically, the pancreas arises
Hospital, Boston, MA. branches—the anterior and posterior from a dorsal and ventral pancreatic bud.

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 IMAGING OF THE PANCREAS: PART 1

A B

C D FIGURE 2. Axial CECT images in a

37-year-old man with annular pancreas.
Axial CECT image shows pancreatic tissue
(white arrow) completely encircling the sec-
ond portion of the duodenum (black arrow)
consistent with an annular pancreas.

times depict parenchymal calcifications,

which helps in the detection of chronic
pancreatitis. However, punctate calci-
fications near the pancreas can be con-
FIGURE 1. Colored schematic diagram showing normal and variant pancreatic ductal anat-
omy. (A) Normal pancreatic ductal anatomy with the main pancreatic duct of Wirsung (thin
fused with splenic artery calcifications.
arrows) emptying into the major duodenal papilla at the ampulla of Vater (thick arrow). (B) In patients with pancreatitis, several
Normal variant where an accessory pancreatic duct (thin arrow) empties into the minor papilla plain radiographic features have been
(thick arrow). (C) Dorsal-dominant drainage where the main pancreatic duct (thin arrow) emp- described, including the so-called ‘colon
ties into the minor papilla and the accessory pancreatic duct (thick arrow) empties into the cutoff sign,’ characterized by abrupt ter-
major papilla. (D) Pancreas divisum with complete separation of the major (thin arrows) and
minor pancreatic ducts (thick arrow).
mination of colonic gas shadow at the
splenic flexure.
The larger dorsal bud is the precursor of ventral pancreatic ducts.5 An associa-
the anterior portion of head as well as tion between the pancreas divisum and Ultrasound
body and the tail, while the smaller ven- pancreatitis is described and is believed Ultrasound (US) also has a lim-
tral bud develops into the posterior head to be due to the relative obstruction of ited role in pancreatic evaluation as
and uncinate process. The dorsal and the dorsal pancreatic duct, which carries the overlying gas from the transverse
ventral ducts fuse into one major duct, digestive enzymes from the majority of colon and stomach makes visualiz-
the duct of Wirsung, which empties the gland and empties through smaller ing pancreatic parenchyma difficult
into the duodenum along with the com- minor papilla.6 This, however, is con- or even impossible. However, US can
mon bile duct at the ampulla of Vater.1 troversial and other authors believe help identify gallstones as an etiology
Variations in the pancreatic ductal that pancreas divisum is not causative in patients with pancreatitis and biliary
branching pattern are common (Figure in pancreatitis, but rather only associ- ductal dilation in patients with a pan-
1). One common variant is the presence ated with other known genetic causes of creatic head mass. Most focal pancre-
of an accessory pancreatic duct, known acute and chronic pancreatitis, such as atic lesions are hypoechoic compared
as the duct of Santorini, which empties CTFR, SPINK1, and PRSS1 associated to normal parenchyma. The advent of
into the duodenum separately from the mutations.7 Annular pancreas can result endoscopic US (EUS), has added a new
main pancreatic duct via the minor pa- during rotation of the ventral pancreatic dimension as it provides ultra-high res-
pilla, which is superior to the ampulla. bud as it fuses with the dorsal bud, re- olution images and exquisite details of
Another variant is the so-called dorsal sulting in a ring of pancreatic tissue en- pancreatic tumors, particularly in cys-
dominant drainage, where the duct of circling the duodenum, causing gastric tic lesions. Additionally, EUS allows
Wirsung empties into the minor pa- outlet obstruction in infants and pancre- simultaneous tissue sampling of pan-
pilla and the duct of Santorini empties atitis in adults (Figure 2). creatic lesions with EUS-guided fine
into the major papilla. This is similar to needle aspiration (FNA). However, the
pancreas divisum, which is present in Imaging evaluation acquisition and interpretation of these
about 10% of normal individuals. How- Plain radiograph images are usually performed by inter-
ever, in the pancreas divisum, there is Radiography has a limited role in im- ventional gastroenterologists and are
complete separation of the dorsal and aging of the pancreas, but it can some- not within the scope of this article.

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IMAGING OF THE PANCREAS: PART 1

which there is maximal differentiation

Table 1. Scanning parameters for CT using 16- and 64-slice MDCT between the normal parenchyma and
hypodense pancreatic tumors like ad-
16-MDCT 64-MDCT enocarcinoma. This phase also provides
optimal arterial and mesenteric venous
Detector Configuration 16 x 1.25 64 x 0.625
opacification, which allows assessment
Rotation time (s) 0.5 0.5 of vascular involvement, thereby per-
Pitch 0.9-1.375 0.9-1 mitting surgical planning by evaluating
Table speed (mm/rotation) 27.5 40 potential tumor resectability. Arterial
opacification in this phase limits the need
kVp 120-140 120-140 for a separate dedicated arterial phase.
MA ATCM ATCM Accurate contrast timing for image ac-
Reconstruction Algorithm Standard Standard quisition during various phases can be
achieved using the test bolus or the auto-
Slice thickness
matic bolus triggering technique.
1. Arterial phase 2.5 2.5
2. Pancreatic phase 2.5 2.5
3. Porto venous 5 5 MRI
Magnetic resonance imaging (MRI)
IV contrast (mg/ml) 370 370
with cholangiopancreatography (MRCP)
IV contrast volume 100-150 100-150 has emerged as a reliable tool for ac-
Contrast injection rate (cc/s) 4 4 curately characterizing pancreatic pa-
thologies. The superior soft-tissue and
Oral contrast Neutral oral contrast Neutral oral contrast
contrast resolution inherent to MRI
Scan delay (fixed) 40s (PP), 60s (PVP) 45s, 65s (PVP) makes it a superior test for assessing the
Reconstructions 1. Sagittal and coronal reformations morphologic features of pancreatic tu-
2. MIP reconstruction of arterial and venous phase mors particularly in pancreatic cysts.
3. CT pancreatography for abnormal pancreas MRCP provides excellent 2-dimensional
(2D) and 3-dimensional (3D) depiction
MIP=maximum intensity projection, ATCM=automatic tube current modulation. PP= pancreatic of the pancreatic duct anatomy and its
phase, PVP=portal venous phase
abnormalities in patients with pancreati-
tis as well as neoplasms.
Multidetector CT be answered. A typical MDCT protocol
MDCT is the modality of choice for pancreatic evaluation involves ad- Technique
for the evaluation of both inflamma- ministration of oral and intravenous con- Typical imaging sequences used in-
tory and neoplastic conditions of the trast (Table 1). For routine indications, clude axial T1-weighted images, with
pancreas. 2 In inflammatory condi- including pancreatitis, a portal venous- and without fat saturation, using breath-
tions, MDCT not only provides excel- phase abdominal CT with positive oral hold or gated respirations. A complete
lent visualization of the parenchymal contrast medium (POCM) provides the evaluation of the pancreatic paren-
abnormalities, but clearly depicts the most information. However, for a dedi- chyma and pancreatico-biliary ductal
extrapancreatic spread of disease. In cated pancreatic protocol CT, neutral system can be performed with the fol-
pancreatic neoplasms, MDCT accu- oral contrast media (NOCM) like water lowing sequences: T1-weighted gradi-
rately depicts the tumor morphology, are preferred, as they allow superior ent echo, T2-weighted (T2W) axial, and
ductal anatomy, and its relationship to image reconstruction.8 In patients with coronal sequences, either fast spin echo
surrounding organs and vascular struc- suspected pancreatic mass, a focused (FSE) or turbo spin echo (TSE), 2D and
tures. Thin-section MDCT in combina- pancreatic protocol CT is performed, 3D MRCP; and T1-weighted 3D gradi-
tion with image-processing techniques which includes a pancreatic, portal ve- ent-echo before and after gadolinium.
(multiplanar reconstructions and nous, and a delayed phase through the To adequately visualize the gallbladder
curved reformations) can provide ad- liver to assess for hepatic metastases. An and to assess the exocrine response to
ditional imaging details and can define arterial phase may be performed in place secretin, the patient should ideally be
the pancreatic ductal anatomy. of a pancreatic phase if a hypervascular fasting for 4 hours. Negative oral con-
pancreatic lesion like a neuroendocrine trast is administered to reduce the signal
Technique tumor is suspected. Pancreatic phase re- from the overlying stomach and duo-
The specific MDCT imaging proto- fers to the late arterial phase (typically denum. Axial and coronal T2 images
col depends on the clinical question to 40-45 sec after contrast injection) during with and without fat saturation should

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 IMAGING OF THE PANCREAS: PART 1

Table 2. CT grading of acute pancreatitis proposed by Balthazar.9

CT grade Points Necrosis percentage Points
A: Normal Appearing Pancreas 0 0 0
B: Pancreatic Enlargement 1 0 0
C: Pancreatic/Peripancreatic 2 < 30 2
fat inflammation
D: Single peripancreatic 3 30-50 4
fluid collection
E: Two of more fluid collections, 4 > 50 6
retroperitoneal air

FIGURE 3. Axial noncontrast CT shows

complete fatty replacement of the pancreas homogenous appearance. On MDCT, by premature activation of digestive
in a 24-year-old man with cystic fibrosis. the normal pancreas has slightly higher enzymes within the pancreatic paren-
No pancreatic parenchyma is visible in its attenuation than the paraspinal muscles chyma, leading to digestion of pancre-
expected location (white outline). and has a lobulated contour. On con- atic and peripancreatic tissues. The
also be obtained. Dynamic postcontrast trast administration, it enhances fairly etiology for acute pancreatitis includes
images should be obtained 25, 70, and homogenously (up to 100-150 HU) gallstones (40%), alcohol abuse (30%-
120 sec after the gadolinium contrast in- with slight attenuation differences (< 30 35%), and idiopathic causes (20%).
jection. Ideally, field strength should be HU) between the head and tail, which Other etiologies include mechanical
≥ 1.0 Tesla with fast imaging sequences. can be a normal variant.9 Fatty infil- (post ERCP, trauma), metabolic (hyper-
A standard pancreatic protocol also in- tration of the pancreas can occur with calcemia, hypertriglyceridemia, cystic
cludes MRCP images for further evalu- normal aging, but is also seen in patho- fibrosis, and hereditary pancreatitis)
ation of pancreatic ductal abnormalities. logic conditions, such as obesity, cystic and toxic (drugs like HCTZ and aspari-
The MRCP sequence can be obtained as fibrosis, and rarer conditions, such as ginase).1 The overall mortality rate
2-dimensional (2D) or a 3-dimensional Schwachman-Diamond syndrome and for pancreatitis is 2% to 10%, but most
(3D) acquisition. 3D MRCP produces Johnson-Blizzard syndrome (Figure 3).2 (70%-80%) patients experience mild
high-resolution images of the pancreato- The normal pancreas has the high- oredematouspancreatitis,whichistypically
biliary ductal anatomy as the thin sec- est intrinsic T1 signal of all abdominal a self-limiting disease with a mortality of
tions without slice gap of a 3D technique organs and therefore precontrast T1- < 1%. On the other hand, approximately
allows better assessment of small stones, weighted images are the most sensitive 25% of patients experience severe pan-
side branches of the main pancreatic sequence to detect focal lesions, which creatitis, which is associated with high
duct, and intrahepatic bile ducts. The are often hypointense relative to normal morbidity and a mortality rate between
2D MRCP is acquired either as a thick- parenchyma and for detection of hemor- 10% and 23%. The dichotomy between
slab, single-shot, fast spin echo T2W rhage within inflammatory collections. these two outcomes is highly correlated
sequence or a multisection, thin-slab, On T2-weighted images, the pancreas with the presence or absence of pancre-
single shot FSE T2W sequence. The 3D is slightly hyperintense compared to the atic necrosis, which is seen in nearly
fast spin echo sequence can either be ac- adjacent muscle, and they are optimally 20% of all cases.11 Pancreatic necrosis
quired as a series of breath holds or dur- suited for depicting the ductal anatomy, is caused by disruption of the microcir-
ing free breathing. Secretin MRCP is a cystic lesions, and islet cell tumors, culation via necrotizing vasculitis and
modified MRCP sequence, which entails which are hyperintense compared to thrombosis and is an important prog-
administration of secretin to stimulate normal pancreas.5 nostic indicator. Mortality rises with
the exocrine function of the pancreas. Se- the degree of pancreatic necrosis and
cretin MRCP is useful in assessment of Inflammatory disorders mortality rates of > 50% are seen when
complex ductal anomalies and to quan- Acute pancreatitis necrosis involves > 30% of pancreatic
titatively or semiquantitatively assess the Acute pancreatitis refers to acute parenchyma.12 The necrotic tissue can
exocrine function of the pancreas. reversible inflammation of pancreatic get secondarily infected due to transloca-
parenchyma. Approximately 200,000 tion of gut flora and is nearly always fatal
Normal appearance patients with this condition are ad- if untreated.13 The treatment typically en-
On US, the pancreas is slightly echo- mitted to the hospital each year in the tails surgical debridement or percutane-
genic compared to the liver and has a United States (U.S.).10 It is triggered ous drainage.

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IMAGING OF THE PANCREAS: PART 1

cases, but arterial phase scanning is

A B imperative when pseudoaneurym is
suspected. The range of pancreatic
findings and the CT grading is depicted
in Table 2. Mild or early pancreati-
tis (Grade A) is occult on CT and the
imaging findings lag behind the clini-
cal and laboratory findings. Grade B
pancreatitis is characterized by diffuse
or focal pancreatic enlargement, while
peripancreatic inflammatory changes,
including blurring of the pancreatic
margin, stranding of adjacent fat, and
mild decrease in parenchymal density
from edema occur in Grade C pancre-
FIGURE 4. Two axial CECT scans (A and B) of a 30-year-old man with acute pancreatitis atitis (Figure 4). Thickening of the an-
show an edematous pancreas with peripancreatic fat stranding (white arrows) and thicken- terior renal fascia (Gerota’s fascia) is
ing of the anterior pararenal fascia (black arrows). There are no focal fluid collections and the also seen and is an early and sensitive
entire gland enhances normally without evidence of necrosis. This is consistent with CT grade
C pancreatitis.
indicator of peripancreatic inflamma-
tion. MRI is typically performed for
evaluation of etiologies, such as gall-
A B stones or pancreas divisum. The im-
aging findings include loss of normal
T1 hyperintensity with heterogeneous
hypointense areas. T2 fat-suppressed
images may show small amounts of
peripancreatic fluid.

Complications
Necrosis
Accurately detecting pancreatic ne-
crosis is of paramount importance in
imaging pancreatitis. On both MDCT
and MRI, pancreatic necrosis appears
FIGURE 5. Axial (A) and coronal (B) CT as diffuse or focal parenchymal areas
scans demonstrate lack of enhancement without enhancement (Figure 5). Ad-
of the pancreatic neck (white arrow, white ditionally, MRI depicts areas of hemor-
circle) consistent with pancreatic necrosis
rhage within necrotic foci as ill-defined
in this 33-year-old man. This led to focal
duct disruption. Note the peripancreatic fat areas of high T1 and low T2 signal.
stranding (black arrows). On MDCT, false positive diagnosis
can result from areas of decreased at-
Imaging in acute pancreatitis pancreatitis, or groove pancreatitis.2,9 tenuation due to focal fatty replacement,
The diagnosis of acute pancreatitis Additionally, CT has been shown to edema, or intrapancreatic fluid collec-
is often based on clinical and labora- be a better predictor of complications, tions. False negative scans occasionally
tory evidence. Imaging is therefore mortality, and length of hospital stay occur when imaging is performed early
performed in patients with pancreatitis than either the Ranson or APACHE II in the phase of pancreatic inflamma-
not for diagnosis but for the following criteria.14 tion (first 12-24 hours after symptom
reasons: (i) to identify the possible eti- MDCT is the preferred imaging mo- onset). Although necrosis occurs early,
ology (such as gallstones or neoplasm), dality and contrast administration is es- the false negative rate can be reduced if
(ii) to grade the severity, (iii) to evalu- sential to detect complications, such as CT is performed 72 hours after symp-
ate complications, and (iv) to identify parenchymal necrosis, venous throm- tom onset. Overall, MDCT has been re-
possible distinctive imaging features bosis, and arterial pseudo-aneurysm. ported to have 87% accuracy and 100%
in special types of pancreatitis, such A single portal venous phase abdomi- specificity in the detection of necrosis
as tropical pancreatitis, autoimmune nal MDCT is performed for routine involving > 30% of the gland.9

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 IMAGING OF THE PANCREAS: PART 1

A B

FIGURE 6. Axial CECT (A) shows fluid collection with peripheral rim enhancement (white FIGURE 7. CECT shows multiple peripan-
arrows) which has mass effect on the gastric antrum (black arrows), seen on the barium swal- creatic fluid collections (black arrows) some
low examination (B) consistent with a pancreatic pseudocyst in this 52-year-old man. This of which contained foci of air (white arrows).
patient was treated with cyst gastrostomy for decompression of the pseudocyst. After this 76-year-old male patient under-
went surgical debridement, polymicrobial
infection was confirmed. Other causes of air
A B within peripancreatic fluid collections include
enteric fistula and recent intervention.

Fluid collection/Pseudocyst
Acute fluid collections often occur
in patients with pancreatitis, and the
presence of fluid collections increases
the CT pancreatitis grade. Pseudocysts
are the most common inflammatory
cystic pancreatic lesions and contain
necrotic debris from digested retro-
peritoneal fat. While their definitive
diagnosis requires aspiration of con-
tents to show a high amylase level, a
FIGURE 8. Axial MIP image from the arterial phase of a CECT (A) and a single digital sub-
traction angiography image (B) show a large pseudoaneurysm (curved white arrow) from the
preceding history of pancreatitis with
splenic artery which enhances similar to adjacent aorta (thin white arrow) in this 60-year-old the typical imaging features, such a
man with acute pancreatitis. (CA=celiac artery). fluid collection with a distinct fibrous
capsule persisting for > 4 weeks allows
A B for a confident presumptive diagnosis.
Pseudocysts can have myriad imaging
appearances ranging from unilocular
to multilocular morphology. Enhance-
ment of the cyst wall is commonly seen
on MDCT. On MRI, they typically
show variable but low signal on T1-
weighted images and high signal on
T2-weighted images. Hemorrhage and
debris can cause an atypical appear-
ance leading to an increased T1 signal
and decreased T2 signal compared to
simple appearing pseudocysts. Many
FIGURE 9. Axial CECT (A) shows pancreatic head calcifications (black arrows). The coronal pseudocysts demonstrate communi-
3D MIP image from an MRCP (B) shows irregular ductal dilation in this 60-year-old man with cation with the main pancreatic duct,
chronic pancreatitis. best seen with either ERCP or MRCP.2

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IMAGING OF THE PANCREAS: PART 1

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