Ultrasound imaging of the pediatric pancreas

Poster No.: C-741

Congress: ECR 2009
Type: Educational Exhibit
Topic: Pediatric
Authors: 1 1 2 1
M. G. Papadaki , H. Moschouris , C. Hadjigeorgi , M. Khalili , D.
1 1 2
Matsaidonis ; Piraeus/GR, Athens/GR
Keywords: Acute pancreatitis, pediatric pancreas, chronic pancreatitis,
increased reflectivity of the pancreas
DOI: 10.1594/ecr2009/C-741

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Learning objectives

To present normal appearances and congenital abnormalities of the pancreas in children.

To highlight the role of ultrasonography (US) in the evaluation of pancreatic disorders.

To emphasize the importance of clinical grounds and follow-up studies.

Background

The pancreas is easily visualised during US examination in most children, especially

the thin ones. Low body fat content and a large left hepatic lobe provide an excellent
acoustic window. The use of high frequency, even linear transducers, usually result in
detailed images of all pancreatic areas. However, imaging of the tail may be difficult
and in such patients scanning through the spleen provides the information needed.
Children are not necessarily examined in the fasting state. A drink of water and
scanning in the upright position may significantly improve visualization in problematic
cases. Pancreatic diseases are relatively uncommon during childhood.

Acute pancreatitis is rare. Pancreatic duct obstruction or nonspecific parenchymal

inflammation result in tissue injury from activated pancreatic enzymes and
autodigestion of the pancreatic parenchyma. Infectious agents, drugs, gallstones,
shock, cystic fibrosis, gallstones, biliary sludge, hypertriglyceridemia, hypercalcemia,
pancreas divisum, trauma, renal failure, familial disease and vasculitis are possible
causes of acute pancreatitis though its etiology remains unknown in a significant
number of patients (25%). When relapsing, especially in very young patients, a
congenital abnormality (e.g. pancreas divisum) should be suspected. Trauma
is the most common case of acute pancreatitis in childhood. The classic bicycle
handle-bar injury lap seatbelts or non-accidental trauma may result in a variable
pancreatic damage. Clinical manifestations are usually intense and include epigastric
pain, nausea and vomiting. Laboratory findings include elevated serum amylase
and lipase levels. Complications include pseudocyst and abscess formation and
pseudoaneurysm, the splenic artery being most frequently affected.

Chronic pancreatitis is the result of recurrent episodes of acute pancreatitis that cause
progressively pancreatic parenchymal destruction. Fibrous or fatty degeneration of the

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organ occurs and sometimes calcium deposition is observed. Hereditary and idiopathic
forms exist. Other causes include malnutrition, hyperparathyroidism, cystic fibrosis,
obstruction of the pancreatic duct and pancreas divisum. Clinical manifestations
and laboratory findings are usually less pronounced than in the acute disease.
Complications include pseudocyst formation, splenic and portal vein thrombosis and
biliary obstruction.

Pancreatic exocrine insufficiency is extremely rare and may be part of a genetic or

systemic illness e.g. Swachman (pancreatic insufficiency, neutropenia and chest wall
deformities) and Pearson (bone marrow and pancreatic insufficiency) syndromes.

Increased echogenicity of the pancreas, due to hemosiderosis, is a frequent finding in

children and adolescents with beta-thalassemia. There are laboratory findings suggesting
that increased echogenicity of the pancreas is associated with disturbance of its function
and an increased risk for developing diabetes mellitus in this group of patients.

Congenital cysts of the pancreas are extremely rare and usually solitary. Multiple
pancreatic cysts may occur in patients withautosomal dominant polycystic kidney
disease and in patients with von Hippel-Lindau syndrome. Parasitic cysts may also
be observed. Cystic lesions of the pancreas, single or multiple, have beendescribed
in patients with cystic fibrosis. A duplication cyst of the foregut in this area may
communicate with the pancreatic duct. Pancreaticoblastoma is a rare benign tumor that
may presentcystic. Hemangiomas, hamartomas and lymphangiomas have also rarely
been described. Primary pancreatic malignancies in the pediatric population are rarely
reported in the literature. Metastaticdeposits may be associated with lymphoma and
neuroblastoma.

Imaging findings OR Procedure details

The normal pediatric pancreas has usually a bulky appearance with a prominent tail
(fig.1). Its size and reflectivity increases with age. In neonates it may present significantly
hypoechoic or isoechoic compared with the adjacent liver (fig.2). An erroneous diagnosis
of acute pancreatitis should be avoided in this age group. Low echogenicity of the
pancreas in children is probably the result of the low fat content in pancreatic lobules.
The pancreatic duct is visualised in the center of the gland as a smooth tubular structure
with hyperechoic walls (fig.3). A lumen diameter greater than 1,5 mm is abnormal.

An annular pancreas is often associated with duodenal atresia or web. This condition is difficult
to confirm by US but a rounded pancreatic head and a proximal duodenum running through the
head should raise suspition. MR imaging easily confirms and is the method of choice for the
evaluation of both the pancreas and the ducts.

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Pancreatic exocrine insufficiency is extremely rare and may be part of a genetic
or systemic illness e.g. Swachman and Pearson syndromes. The gland presents
increased echogenicity, a discrease of its dimentions while multiple calculi may be
detected in the pancreatic duct (fig.4).

Acute pancreatitis presents a broad spectrum of US features. In a significant proportion of

patients the pancreas presents normal. The classic features include diffuse or focal
enlargement and reduced reflectivity of the organ (fig.5). These changes may be difficult
to assess correctly because the pediatric pancreas is normally bulky and echo-poor.
Dilatation of the pancreatic duct is a useful sign. In patients with vasculitis, acute
pancreatitis may present more pronounced imaging features (fig.6). A search for the
presence of intra-pancreatic or peri-pancreatic fluid collections is mandatory. The lesser
sac and the anterior pararenal space are more prone to these collections. An increase in
reflectivity or the pararenal space may be demonstrated due to the release of pancreatic
enzymes and lipolysis of the pararenal fat. Ascites and pleural effusions are commonly
noted.

An underlying cause is sometimes demonstrated. Cholelithiasis and biliary sludge are potential
causes and their incidence increase in patients receiving drugs for various pathologic conditions.
Small calculi may easily cause obstruction. In patients with a history of trauma findings depend
on gravity and mechanism. An heterogeneous, mostly hypoechoic appearance of any part of the
pancreas is suggestive of oedema. A fractured pancreas may be directly visualized as heterogeneity
in the whole thickness of the organ. Disruption of the duct is suggested by peritoneal fluid and
lesser sac collections (fig.7). A fracture is generally more easily identified in CT studies while
MRCP has a major role in the diagnosis of duct trauma.

Chronic pancreatitis present with shrinkage and increased reflectivity of the pancreas. Pancreatic
duct dilatation and calcifications are commonly seen. Associated abnormalities, e.g. signs of
cirrhosis, should be looked for in patients with cystic fibrosis and haemosiderosis (fig.8).

Pseudocyst formation is the major complication of acute pancreatitis in childhood, especially in

cases of trauma. They are commonly found anterior to the body and tail of the pancreas but other
location is possible (pararenal space, left lobe of the liver, juxtrasplenic area, retroperitoneum
and mediastinum) and may reach several centimeter of dia. Formation requires a few weeks (4
or more) from the onset of symptoms. Pseudocysts are round or oval in shape surrounded by
a thick capsule composed of fibrous or granulation tissue and they contain sterile pancreatic
enzymes (fig.9). About half will resolve spontaneously. Percutaneous drainage under US guidance
is a useful method of treatment for those that have not resolved. Possible complications include
rupture, haemorrhage and infection.

A pancreatic abscess may also complicate acute pancreatitis. They develop in close proximity to
the pancreas and contain purulent material (fig.10). They are often complex and multilocular. CT
is generally performed and percutaneous drainage plays a major role for diagnosis and treatment.
Differentiation from pancreatic necrosis is essential and can only be assessed by CT.

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Vascular complications of acute pancreatitis may be assessed by US. Erosion of arterial walls,
especially the splenic and branches of the pancreaticoduodenal artery, may result in haemorrhage
that can be suspected in US if there is an hyperechoic collection of fluid. A complex mass with a
turbulent arterial flow is indicative of pseudoaneurysm.

Pancreaticoblastoma occurs usually in children under the age of 7 years. It is usually a large (up
to 10 cm), well defined mass with or without necrosis. A dilated pancreatic or biliary dust may be
observed while vascular encasement, hepatic and nodal metastases may occur.

Papillary cystic tumor (fig.11) has a low malignancy potential and it mainly affect adolescents.
It usually presents as a large well-defined cystic mass. Solid areas represent papillary projections.

Secondary involvement by lymphoma may present intraparenchymal echo-poor lesions

and associated lymphadenopathy. Neuroblastoma may involve pancreas by direct
infiltration.

Images for this section:

Fig. 1: The normal pediatric pancreas has usually a bulky appearance with a prominent
tail.

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Fig. 2: The pancreas is isoechoic compared to the adjacent liver parenchyma in this 30
days old baby.

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Fig. 3: The pancreatic duct is visualised in the center of the gland as a smooth tubular
structure with hyperechoic walls.

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Fig. 4: The gland presents increased echogenicity and a discrease of its dimentions.
Multiple calculi are detected in the pancreatic duct.

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Fig. 5: Diffuse enlargement and reduced reflectivity of the gland are noted in this 10 years
old patient with acute pancreatitis. No other findings were demonstrated.

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Fig. 6: Significant enlargement of the gland is demonstrated. The increase in pancreatic
reflectivity and in peripancreatic space is noted and this may be attributed to the release
of pancreatic enzymes and lipolysis of the peripancreatic fat.

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Fig. 7: A fractured pancreas with a collection extending to the lesser sac. Disruption of
the duct was demonstrated in MRCP.

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Fig. 8: Shrinkage and increased reflectivity of the pancreas are usually demonstrated in
patiens with haemosiderosis due to multiple blood transfusions.

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Fig. 9: An oval cystic collection, surrounded by a thick capsule, was formed behind the
hepatic artery 5 weeks after the appearance of symptoms.

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Fig. 10: A pancreatic abscess complicating acute pancreatitis. It developed in the
peripancreatic space, containing echogenic material.

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Fig. 11: A large well-defined cystic mass adjacent to the tail of the pancreas. Solid areas
represent papillary projections.

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Conclusion

US is a valuable tool in the evaluation of the pediatric pancreas.

Normal appearance varies with age and radiologists should be aware to avoid erroneous
diagnosis.

It can be used confidently as the first imaging approach in cases of acute pancreatitis of
various etiologies. Classic US features existe but a normal appearance does not exclude
inflammation. An underlying cause may be demonstrated.

In cases of trauma, a fractured pancreas may be visualized, but MR imaging is essential

in establishing disruption of the duct.

Complications of acute pancreatitis may be demonstrated, the most common being

pseudocyst formation. US is a safe procedure to monitor involution and guide drainage.

CT and MR imaging still the method of choice and should be performed at a certain stage
of the disease or in cases of disagreement between US and clinical findings.

Pancreatic tumors are rare. Lymphoma and neuroblastoma may involve pancreas.

Personal Information

Marina G. Papadaki

Iroon Polytechniou 131-135

16122 Athens, Greece

Tel.:+302107218115

e-mail: papadaki1@yahoo.com

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