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Journal of Feline Medicine and Surgery (2020) 22, 241–259
FELINE ABDOMINAL
ULTRASONOGRAPHY: WHAT’S
NORMAL? WHAT’S ABNORMAL?
The pancreas
Sally Griffin
Scanning the pancreas
B-mode ultrasonography is the modality of choice to image the feline
pancreas and is widely available to most practitioners. It provides
information regarding the size, echotexture and echogenicity of the
pancreas, while permitting concurrent evaluation of the peripancreatic
fat and regional lymph nodes. Aspiration of the
The main pancreas, regional lymph nodes and suspected
metastatic disease is also facilitated using ultra-
indications for sound guidance.1 Abdominal radiographs are
ultrasonography of very insensitive in the evaluation of the pancreas.
Ultrasound is superior to radiography, particu-
the feline pancreas larly in cats in poor body condition or those
are suspected that have an abdominal effusion, both of which
decrease serosal detail and reduce the clinician’s
pancreatitis and ability to assess the pancreas radiographically.
The main indications for ultrasonography of
pancreatic the feline pancreas are suspected pancreatitis
neoplasia or for and pancreatic neoplasia; ultrasonography may
also be conducted as part of an investigation
investigation into into extrahepatic biliary obstruction.2 As men-
tioned in previous articles in this series, the
extrahepatic biliary principal disadvantage of ultrasonography is that
obstruction. its use as a diagnostic tool is largely dependent
upon clinician experience, which is very variable.
Preparation
Where possible, animals waiting for an elective
examination should be fasted for 12 h prior to
ultrasound. Any abdominal hair in the region to
be scanned should be clipped and acoustic coupling gel applied to
remove the air gap between the transducer surface and the skin. Sedation
is preferable wherever possible to immobilise the patient and achieve
maximum relaxation of the abdominal wall muscles. Owing to the
inherently small size of the feline pancreas, the use of a high frequency
(around 11–15 MHz) linear transducer is advisable to provide optimum
image resolution, thereby allowing the pancreas to be assessed in detail.
Readers are referred to the articles on the liver and normal gastroin-
testinal tract in this series (see the box on page 255) for a more detailed
discussion pertaining to patient preparation and transducer choice.
Sally Griffin
BVSc, CertAVP, DipECVDI
Radiology Department,
Willows Veterinary Centre and Referral Service,
Highlands Road, Shirley,
Solihull B90 4NH, UK
Email: sally.griffin@willows.uk.net
DOI: 10.1177/1098612X20903599
© The Author(s) 2020
CLINICAL REVIEW
Practical relevance:  Abdominal
ultrasound plays a vital role in the
diagnostic work-up of many cats
presenting to general and specialist
practitioners. Ultrasound examination
of the pancreas is a vital part of the
investigation into feline pancreatic disease.
Clinical challenges: Despite ultrasonography
being a commonly used modality, many
practitioners are not comfortable performing an
ultrasound examination or interpreting the resulting
images. Even for the experienced ultrasonographer,
differentiating between incidental findings such as
nodular hyperplasia and pathological changes such
as neoplasia can be challenging.
Aim: This review, part of an occasional series on
feline abdominal ultrasonography, discusses the
ultrasonographic examination and appearance
of the normal and diseased pancreas. Aimed at
general practitioners who wish to improve their
knowledge of and confidence in feline abdominal
ultrasound, this review is accompanied by high-
resolution images and videos available online
as supplementary material.
Equipment: Ultrasound facilities are readily
available to most practitioners, although use
of ultrasonography as a diagnostic tool is highly
dependent on operator experience.
Evidence base: Information provided in this article
is drawn from the published literature and the
author’s own clinical experience.
Keywords: Ultrasound; pancreatitis; neoplasia;
pancreatic; cyst; abscess
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a b

Figure 1 Transducer positioning for the left (a) and right (b) lobes of the pancreas

Scanning technique
The pancreas can be scanned with the cat The author’s preference is to scan
in left or right lateral, dorsal or ventral
recumbency.1 The author’s preference is
the left and right pancreatic lobes
to scan the left lobe while the animal is in while the cat is in right and left lateral
right lateral recumbency and the right lobe
with the animal in left lateral recumbency recumbency, respectively.
(Figure 1).

Anatomy and ultrasonographic identification of the pancreas

The pancreas is divided into two lobes that are
united at the body of the pancreas, which is sit-
uated ventral to the portal vein. The close proxim-
ity of these two structures makes the portal vein an
excellent landmark for the identification of the
pancreatic body (Figure 2). It should be noted that Colon
the pancreatic body in the cat is much closer to the Liver
midline than in the dog, and the angle between left Stomach
and right pancreatic lobes is also much smaller.3
Recognition of adjacent landmarks is key to the
successful identification of the pancreas. The left
pancreatic lobe is sandwiched between the stom-
ach cranially and the transverse colon caudally Portal vein
(Figure 3). The tip often extends medially to the
head and body of the spleen, which acts as an
acoustic window, and the splenic vein usually runs
caudally and dorsally to the left pancreatic lobe.
The right lobe of the pancreas is located medially
or dorsomedially to the descending limb of the
duodenum (Figure 4).1 Unlike the dog, the distal
portion of the right pancreatic lobe in the cat
turns back on itself, creating a hook-like shape Figure 2 Ultrasonographic landmarks for the pancreatic body (arrows)
(Figure 4c).4 The left lobe of the pancreas is larger
(5–9 mm thickness) in the cat than the right lobe
In all ultrasound images, unless stated otherwise,
(3–6 mm thickness) and usually, therefore, more
cranial is to the left and caudal is to the right of
easily identified.5,6 This is in contrast to the dog, in
the image.
which the right lobe of the pancreas is normally
easier to locate with ultrasound.

Recognition of adjacent landmarks is key to the successful

identification of the pancreas.
Continued on page 243

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R E V I E W / Feline abdominal ultrasonography – the pancreas

Continued from page 242

a b

Spleen

Colon

Stomach

c d

Figure 3 Ultrasound images of the normal left pancreatic lobe (arrows) in transverse (a,b) and sagittal (c,d) planes in healthy cats. In (d) the thin-walled colon
(*) is visible just caudal to the pancreas

a b

Figure 4 (a,b) Ultrasound images from two cats to show the normal
c appearance and location of the right pancreatic lobe (arrowheads). The
descending limb of the duodenum (arrow) is visible in transverse in (b).
(c) The white line indicates the margins of the distal right pancreatic lobe
where it forms a hook-like shape

In contrast to the dog,

the left pancreatic lobe is usually
more easily identified than
the right in the cat.

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Normal appearance of the

pancreas

The feline pancreas is a well-defined organ

when imaged with a good quality ultrasound
machine and a high frequency transducer,
although it can initially appear somewhat
inconspicuous to the untrained eye. It is
isoechoic to slightly hypoechoic relative to the
surrounding fat and has a similar echogenici-
ty to the liver.1,6,7
Most dogs have two larger pancreatic ducts
into which the smaller ducts that link the
pancreatic acini drain.8 In contrast, there is
usually just one pancreatic duct in the cat,
known as the major pancreatic duct. This duct
is consistently visible on ultrasound as an
anechoic tubular structure, flanked by thin
hyperechoic walls, running within the central
Figure 5 Ultrasound image of the normal major pancreatic duct (arrows) within the left lobe of
portion of the left lobe from the tip towards the pancreas of a 6-year-old male neutered domestic longhair cat. A video showing the normal
the body (Figure 5).1,9 It can be differentiated pancreatic duct within the left lobe of the pancreas is available as supplementary material

There is usually just one pancreatic duct in the cat,

known as the major pancreatic duct, but a second minor
or accessory duct is also present in around 20% of cats.

from a blood vessel by the absence of flow

signal when interrogated with colour Doppler.
This is because flow within a pancreatic duct
is considerably slower than blood flow and, as
such, does not generate a Doppler signal.
The diameter of the major pancreatic duct
has been reported in 20 healthy cats <10 years
of age. In these cats, the mean diameter was
determined to be 0.8 ± 0.25 mm (range 0.5–1.3
mm).7 In a separate study involving a group
of cats >10 years of age, the mean diameter of
the pancreatic duct was recorded as 1.3 ± 0.4
mm (range 0.6–2.4 mm).5 Dilation of the duct
up to 2.5 mm diameter has been shown to
a occur as an incidental ageing change in older
cats with no signs of pancreatic disease
(Figure 6).5–7 A satisfactory explanation for
this phenomenon has yet to be found. One
suggested hypothesis for the same change in
humans is that widening of the pancreatic
duct with age occurs as a result of atrophy of
the pancreas.5,10

The major pancreatic duct

can be differentiated from a
blood vessel by the absence
of flow signal when interrogated
b
with colour Doppler.
Figure 6 (a) Mild dilation of the pancreatic duct (arrows) within the left pancreatic lobe of
an 11-year-old male neutered domestic shorthair cat. This was presumed to be an incidental
age-related change. (b) Note the absence of colour within the pancreatic duct when a colour
Doppler window is applied over the pancreas

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Abnormalities of the pancreas

Pancreatitis
Pancreatitis is the most commonly diagnosed
disorder of the feline exocrine pancreas14 and
yet, despite this, an underlying cause is not
identified in the majority of cases and the con-
dition is often considered to be idiopathic.15–17
Cats of all ages may be affected, with reports
in animals from 3 weeks to 20 years.16,18 While
any breed may be affected, Siamese are
thought to be over-represented.18 The left lobe
and body are usually more commonly affect-
ed by inflammation, in contrast to the situa-
tion in dogs in which the right lobe is more
commonly affected, although any portion
may be affected in either species.3
The clinical signs and results of clinico-
pathological tests in cats with pancreatitis are
often vague and non-specific, making the
diagnosis challenging.19 Furthermore, since
Figure 7 Ultrasound image of a normal duodenal papilla (arrows). A video showing the the disease can affect the pancreas multifocal-
pancreatic and common bile ducts fusing before entering the duodenal papilla is available ly, histopathology may fail to detect evidence
as supplementary material
of inflammation in biopsy specimens.15
Fortunately, the clinician’s ability to detect
Abnormalities of the pancreaticoduodenal, pancreatitis has improved over the years,
thanks to the development of a feline-specific
jejunal, hepatic and splenic lymph nodes are not pancreatic lipase assay. One potential draw-
necessarily indicative of pancreatic disease. back of this assay, however, is that it may be
less well suited to the diagnosis of mild and
chronic forms of the disease.15 Consequently,
diagnostic imaging still has an important role
The major pancreatic duct merges with the to play in the diagnosis of pancreatitis.
common bile duct at the ampulla of Vater Anticipated radiographic changes include a
immediately prior to its entry into the mass effect in the region of the pancreas, loss
duodenum at the major duodenal papilla.11 of serosal detail due to peripancreatic effusion
The major duodenal papilla is located along and the presence of dilated bowel loops due
the dorsal wall of the duodenum, approxi- to ileus.20–23 Nevertheless, in spite of these
mately 3 cm distal to the pylorus (Figure 7).12 potential abnormalities, abdominal radiogra-
In a minority of cats, the major pancreatic duct phy is neither sensitive nor specific for feline
and common bile duct open into the duode- pancreatitis. Ultrasound, on the other hand,
num separately, but immediately adjacent to provides much more comprehensive informa-
each other.13 In around 20% of cats, a second tion relating to the health of the pancreas and
minor or accessory duct is present that drains surrounding tissue, and is recommended in
into the duodenum via the minor duodenal cats with suspected pancreatitis.
papilla, which is located approximately 2 cm The sensitivity of ultrasound for the detec-
distal to the major duodenal papilla.12 tion of pancreatitis in the cat has traditionally
Lymphatic drainage from the pancreas is been regarded as relatively low, with three
supplied by the pancreaticoduodenal, jejunal, studies between 2000 and 2002 reporting
hepatic and splenic lymph nodes. Each node values of 11%, 24% and 35%.22,24,25 In 2004, a
also supplies other organs and hence abnor- further study reported a much higher sensi-
malities of these lymph nodes are not neces- tivity of 80% for cats with moderate to severe
sarily indicative of pancreatic disease. pancreatitis and 62% for those with mild

Compared with radiography, ultrasound provides much more

comprehensive information relating to the health of the pancreas and
surrounding tissue, and is recommended in cats with suspected pancreatitis.

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Due to the link between pancreatitis and intestinal tract

and hepatic disease, the liver and gastrointestinal tract should be evaluated
ultrasonographically at the same time as the pancreas.

pancreatitis.26 Two potential explanations Acute pancreatitis

were offered by the authors for this dramatic
difference in sensitivity relative to the earlier
studies. The first was an inherent bias towards
a diagnosis of pancreatitis such that the radi-
ologist, being aware of the nature of the study,
would have evaluated the pancreas more
extensively than in previous ultrasound stud-
ies, which were of a retrospective nature. In
these earlier studies, the pancreas was evalu-
ated during a routine ultrasound examination
and hence was not the focus of the study.
Secondly, there have been, and continue to be,
significant advances in ultrasound technology
and markedly improved radiologist skill lev-
els that are likely to contribute to greater sen-
sitivity levels.26 Interestingly, an even higher
sensitivity of 84% and a specificity of 75% for
diagnosing pancreatitis were reported in a
much more recent study.27 However, in this
study elevated serum feline pancreatic lipase
immunoreactivity (fPLI) was used as the stan-
dard for diagnosis of pancreatitis, which has
been shown to have only fair agreement with
ultrasonography in cats with a suspicion of
pancreatitis.28 Of the 35 cats included in the
study, only six cats had histopathological eval-
uation of the pancreas;27 therefore, this figure
for sensitivity should be interpreted with cau-
tion. It should also be noted that all of these
studies were conducted at university teaching
hospitals and most ultrasound examinations
would have been performed by board-
certified radiologists using high-end equip-
ment. Hence, it is reasonable to assume that
sensitivity is liable to be reduced when scans
are performed by clinicians less experienced
in ultrasound using lower quality equipment.14
Concurrent inflammatory bowel disease,
cholangitis/cholangiohepatitis and hepatic
lipidosis have been reported in 50–56% of cats
diagnosed with pancreatitis.24,26,29,30 In a study
of 23 cats with inflammatory bowel disease,
16 cats had elevated serum fPLI concentra-
tions (>6.9 μg/l).31 Therefore, due to the link
between pancreatitis and intestinal tract and
hepatic disease, the liver and gastrointestinal
tract should be evaluated ultrasonographical-
ly at the same time as the pancreas.
In contrast to the situation in dogs, chronic
pancreatitis has traditionally been considered
to be more common than acute necrotic
pancreatitis in the cat, although both may be
relatively under-diagnosed.3,15,23,32,33 Several
studies have, however, resulted in increased
recognition of the acute form of the disease in
this species.18,24,34,35 Acute pancreatitis can
be mild, moderate or severe and affect the
pancreas focally, or as a multifocal or diffuse
disease. When ultrasonographic abnormali-
ties suggestive of acute pancreatitis are identi-
fied, they are often more subtle than those
seen in the dog; furthermore, and in the light
of the sensitivities discussed above,3,24 the
absence of changes on ultrasound is not suffi-
cient to rule out the possibility of pancreatitis.
In those cases where the ultrasonographic
appearance of the pancreas is unremarkable
but the clinical suspicion of pancreatitis
remains high, ultrasound can be repeated
after 2–4 days, which may allow sufficient
time for ultrasonographic changes to appear.36
The ultrasonographic features of acute
pancreatitis in cats are reasonably specific and
mirror those described in dogs. Typical abnor-
malities include enlargement of the pancreas
(which if sufficiently substantial can result in
a mass effect), a reduction in echogenicity of
pancreatic tissue (owing to necrosis and/or
oedema), severely irregular pancreatic mar-
gins, hyperechogenicity and hyperattenuation
of peripancreatic mesenteric fat (due to
saponification following the release of pancre-
atic enzymes) and localised peritoneal effu-
sion (Figure 8).20,25,27,29,35 When inflammation
of peripancreatic fat is severe, it can become
hazy in appearance and pancreatic margins
may appear ill-defined.
Hyperechoic peripancreatic fat may be one
of the most sensitive indicators of pancreatitis;
it was identified in 68% of cats (n = 35) that
had concurrently elevated serum fPLI in one
study27 and was the most frequently identi-
fied ultrasonographic abnormality in 55% of
cats with raised fPLI in another study.37
Accordingly, this would suggest that there is a
moderate probability of cats with pancreatitis

When ultrasonographic abnormalities suggestive of acute pancreatitis are identified,

they are often more subtle than those seen in the dog. Furthermore, the absence of
changes on ultrasound is not sufficient to rule out pancreatitis.

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a b

* **

Figure 8 Acute pancreatitis. (a) Left lobe of the pancreas (transverse plane)
c of a 14-year-old female neutered Birman presenting with a 10-day history of
lethargy and inappetence, and severe weight loss over a longer period of time.
* The pancreas (arrows) is enlarged and hypoechoic and surrounded by markedly
hyperechoic peripancreatic fat. The spleen (*) is to the left of the pancreas and
the transverse colon (**) is to the right. (b) The right pancreatic lobe in the same
cat is also affected. Note the hyperechoic fat (arrowheads) adjacent to the
pancreas. The duodenum (arrow) is seen in the transverse plane to the left of
the pancreas. Videos showing the left and right pancreatic lobes in this cat are
available in the supplementary material. (c) Pancreatitis affecting the left lobe
of the pancreas (longitudinal plane) of a 4-year-old female neutered domestic
shorthair cat referred for further investigation of icterus that had developed
following a period of reduced appetite and weight loss. The pancreas is diffusely
hypoechoic and surrounded by hyperechoic fat. The anechoic tubular structure
(arrows) running through the centre of the left lobe is the pancreatic duct.
The spleen (*) is visible in the top right of the image. (d,e) Pancreatic changes
affecting the caudal tip of the left pancreatic lobe of an 11-year-old female
neutered domestic shorthair cat presenting with a recent history of weight loss
and inappetence. (d) The left lobe (being measured between the calipers) is
predominantly normal in appearance, although the pancreatic duct is mildly
dilated. (e) In contrast, the caudal tip (arrows) is enlarged, hypoechoic and
irregularly marginated and surrounded by hyperechoic fat

d e

The presence of a thick left pancreatic limb, severely irregular

pancreatic margins and hyperechoic peripancreatic fat in cats with appropriate
clinical signs and raised serum feline pancreatic lipase immunoreactivity
concentrations is highly supportive of pancreatitis.

having this abnormality on ultrasonographic in addition to hyperechoic pancreatic fat,

examination, although it is important to
note that the authors of these studies do not
differentiate between cats with acute and
chronic pancreatitis.27,37 The authors of the
earlier of these two studies report that,
the presence of a thick left pancreatic limb
and severely irregular pancreatic margins
in cats with appropriate clinical signs and
raised serum fPLI concentrations is highly
supportive of pancreatitis.27

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* *
*

a b

Figure 9 Pancreatic oedema in two cats. (a) Ultrasound image from a 5-year-old female neutered domestic shorthair cat presenting for further investigation of
acute renal failure. Pleural and peritoneal effusion developed as a result of poor urine output. The pancreas is enlarged (arrows) and multiple anechoic striations
(asterisks) dissect between pancreatic lobules giving rise to a ‘tiger stripe’ appearance, indicative of pancreatic oedema. (b) Ultrasound image from a 4-year-old
male neutered domestic shorthair cat presenting with marked hypoalbuminaemia, ascites and peripheral oedema secondary to protein-losing nephropathy.
The arrows indicate the margins of the pancreas, and the asterisks indicate the anechoic striations within the pancreas. Videos showing pancreatic oedema,
including in a cat with severe hypoalbuminaemia, are available in the supplementary material

Pancreatic oedema results in pancreatic Chronic pancreatitis

enlargement and fluid accumulation within
the interlobular septae. This gives rise to
multiple hypoechoic striations dispersed
throughout the parenchyma – the so-called
‘tiger stripe’ appearance.38 Although this
finding is reported specifically in dogs, the
author has also observed this change in cats
(Figure 9). It can be seen in cases of pancreati-
tis but can also occur as a result of portal
hypertension and hypoalbuminaemia and
hence is not considered to be pathognomonic
for inflammation.38
Dilation of the biliary tree owing to
compression of the common bile duct by
an inflamed pancreas and mesenteric
lymphadenopathy are further changes that
have also been reported in association with
pancreatitis.11,22,39,40 On ultrasound, the nor-
mal common bile duct should measure no
greater than 4 mm in diameter, whereas
a diameter >5 mm is suggestive of extra-
hepatic biliary obstruction (EHBO).11 It
should, of course, be remembered that
there are several other differentials for EHBO
aside from pancreatitis, such as cholelith-
iasis.11 The ultrasonographic appearance of
EHBO was discussed in more detail in the
article on the biliary tree in this series (see box
on page 255).
Further changes that may be appreciated
on ultrasound in cats with acute pancreatitis
include thickening and/or altered layering of
the gastric or duodenal wall and a mildly
dilated, hypomotile descending duodenum,
possibly with concurrent corrugation (due to
paralytic ileus).1,25,41 In some cats, these may
be the only abnormalities present.
Recurrent episodes of inflammation over
months or years can lead to the development
of chronic pancreatitis. Whereas acute pancre-
atitis is typically associated with neutrophilic
inflammation, necrosis and oedema, chronic
pancreatitis leads to irreversible acinar loss
and fibrosis,9 and resembles the process seen in Ultrasonographic
humans where fibrosis is more pronounced than changes
inflammation.32 The condition is often mild and
asymptomatic and has a high prevalence in observed in cats
apparently healthy cats, causing some to
question its clinical significance.15 Histological
with chronic
evidence of chronic pancreatitis was identified pancreatitis
in 67/115 cats undergoing necropsy in one
study; in comparison, 18 cats showed histo- tend to vary
logical evidence of acute pancreatitis.32 between
Despite this, there is relatively little in the
literature regarding the ultrasonographic individuals.
appearance of feline chronic pancreatitis.
As for acute pancreatitis, a normal ultra- In addition,
sound examination does not exclude the a normal
possibility of chronic pancreatitis, since the
disease processes present may be insufficient ultrasound does
to induce an alteration in the appearance of
the pancreas on ultrasound.14 Similarly, the not exclude the
ultrasonographic changes observed have a possibility of
tendency to be somewhat variable between
individuals, thus complicating the diagnosis chronic
further.1 In the dog, reported abnormalities
include an increase or decrease in the size
pancreatitis.
of the pancreas, increased (possibly due
to fibrosis), decreased or mixed echogenicity
of the pancreatic parenchyma and normal or
mildly hyperechoic peripancreatic mesentery,
although any increases in mesenteric
echogenicity are usually less pronounced
than those seen with acute pancreatitis.1,42–44

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a
However, a further separate study found no
correlation between pancreatic duct width
and clinically significant pancreatic disease.5
Furthermore, since dilation of the pancreatic
duct can occur as a normal ageing change, it
should not be used as the sole indicator of
pancreatitis in the geriatric cat.
As with most diagnostic tests, ultrasound
has its limitations. As mentioned above, results
suggest that it may not be possible to distin-
guish between acute necrotising and chronic
non-suppurative pancreatitis with ultrasound,
even when the history, physical examination
findings, results of clinicopathological testing
b
and any radiographic abnormalities present
are taken into account.20 Furthermore, the
authors of a recent retrospective study of 42
cats presenting with at least two clinical signs
of pancreatitis and raised fPLI values were
unable to identify any significant correlation
between ultrasonographic changes and out-
come;37 thus the use of ultrasound for prognos-
tic purposes appears limited.
In view of the fact that the ultrasonographic
diagnosis of chronic pancreatitis is not always
straightforward, attempts have been made to
discover alternative means of obtaining a
more definitive diagnosis using ultrasound in
combination with a hormone called secretin.
In healthy individuals, secretin stimulates
Figure 10 (a,b) Chronic pancreatitis in a 5-year-old male neutered domestic the pancreas to secrete bicarbonate, resulting
shorthair cat presenting with a history of lethargy, inappetence and occasional
vomiting of 1 week’s duration. The left lobe of the pancreas (arrows) is enlarged, in dilation of the pancreatic duct, which is iden-
diffusely hypoechoic and surrounded by abnormally hyperechoic fat suggestive
of a localised steatitis. Exploratory coeliotomy was performed to acquire biopsies
tifiable ultrasonographically.46,47 It has been
of the liver, small intestine and pancreas. Final diagnoses based on histopathology shown that in humans with chronic pancreati-
were cholangiohepatitis, inflammatory bowel disease and marked chronic tis, the duct fails to dilate and it is thought that
pancreatitis with accompanying fibrosis and nodular regeneration. A video
showing chronic pancreatitis affecting the left lobe of the pancreas in the this occurs as a result of periductal fibrosis.47,48
same cat with triaditis is available in the supplementary material To investigate the potential use of this hormone
as a diagnostic tool for chronic pancreatitis in
Abnormal pancreatic thickness, an irregular cats, the effect of exogenous administration of
pancreatic margin, nodularity and hypo- secretin on the diameter of the pancreatic duct
echogenicity of the pancreas, hyperechoic in healthy cats was recorded.49 Mean pancreat-
mesentery and abdominal effusion have all ic duct diameter increased from 0.77 ± 0.33 mm
been reported in cats with chronic pancreatitis to 1.42 ± 0.40 mm following secretin administra-
confirmed by histopathology (Figure 10).5,20,27 tion and the mean percentage increase in pan-
Thus, it appears that there is a degree of over- creatic duct diameter over basal diameter up to
lap in the ultrasonographic appearance of 15 mins after secretin administration was 101.9
acute and chronic pancreatitis in the cat. There is a ± 58.8%.49 To date, the relationship between
Fibrosis and calcification of the pancreas as secretin administration and ductal diameter
a result of chronic pancreatitis can lead to the degree of in the diseased feline pancreas has not been
presence of shadowing hyperechoic foci. evaluated and, therefore, the ability of this
As with acute pancreatitis, dilation of the overlap in the diagnostic procedure to identify cats with
common bile duct may also be recognised ultrasonographic chronic pancreatitis has yet to be determined.
and, if adhesions form secondarily to chronic
inflammation, the duodenum and/or part of appearance of
Detection and differentiation of pancreatitis
the stomach can become displaced from their
normal position within the abdomen.1
acute and Differentiating acute from chronic pancreatitis
in the cat is challenging, and in some cases
In humans with chronic pancreatitis, irregu- chronic may not be possible without histopathology.
lar widening of the pancreatic ducts has been
reported and is believed to be due to periduc- pancreatitis Combining the results of tests such as fPLI and
ultrasound findings, rather than relying solely on
tal fibrosis.10 Dilation of the pancreatic duct in the cat. any one test, is likely to improve the detection of
has also been reported in cats with chronic
pancreatitis in cats.26
pancreatitis by the authors of one study.45

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Exocrine pancreatic insufficiency
Chronic pancreatitis is the most common
cause of exocrine pancreatic insufficiency
(EPI), a condition seen only rarely in the
cat.36,50 Pancreatic nodularity and inhomo-
geneity have been reported in two cats with
EPI based on feline trypsin-like immunoreac-
tivity assay results.5 Hyperechogenicity and a
reduced volume of the pancreatic parenchy-
ma, in association with dilation of the pancre-
atic duct with or without pancreatic calculi,
have also been reported with this condition.3
Hypermotility and distension of the intestinal
tract may be observed concurrently due to
EPI-related malabsorption.3
Cystic pancreatic abnormalities
Cystic pancreatic abnormalities include pan-
creatic cysts and pseudocysts, abscesses and
pancreatic bladder. Neoplasia is discussed in
a separate section below, alongside nodular
hyperplasia.
Pancreatic cysts
Pancreatic cysts are occasionally identified
in cats1 and can be classified as true cysts,
pseudocysts or retention cysts. True cysts
have an epithelial lining, do not communicate
with the pancreatic duct and are usually inci-
dental.51,52 To date, they have only been
reported in a handful of cases.53–55 A peduncu-
lated true cyst attached to the body of the pan-
creas, which was presumed to be congenital in
origin, has been reported in a 5-year-old cat.53
On ultrasound examination, the cyst was
3.91 cm in length, multilocular and had a thick
wall with anechoic contents and occasional
septations. Histopathological examination of
the cyst confirmed the presence of a lining
comprising a single layer of cuboidal to
columnar epithelial cells.53 Multiple recurrent
true pancreatic cysts of unknown aetiology,
associated with pancreatic inflammation,
atrophy and diabetes mellitus, have also been
reported in a 14-year-old domestic shorthair
cat.54 Similar ultrasonographic findings are
described in the most recent report: a well-
defined multilobulated cystic structure locat-
ed craniomedial to the left kidney was
described on ultrasound in a 15-year-old
female neutered domestic shorthair cat.
At laparoscopy, a 7 cm diameter cyst was con-
firmed originating from the left pancreatic
limb and subsequently omentalised.55
Pseudocysts form as a result of pancreatitis
and pancreatic duct rupture. They have a non-
epithelialised fibrous capsule and are filled
with fluid rich in pancreatic enzymes and
debris.56,57 It is postulated that focal pancreatic
necrosis and pancreatic duct rupture occur
as a result of pancreatitis. Pancreatic juices
leak into the area of necrotic tissue and an
250 JFMS CLINICAL PRACTICE
inflammatory exudate forms, eventually
becoming enclosed within a fibrous connec-
tive tissue capsule. The term ‘pseudocyst’ is
appropriate because they lack a true epithelial
lining. Identification of a pancreatic cystic
lesion in a patient with a clinical history of
pancreatitis should raise the suspicion of a
pseudocyst.58
There are occasional descriptions in the
veterinary literature detailing the ultrasono-
graphic appearance of pancreatic pseudocysts
in cats.59,60 The wall of a pseudocyst is typical-
ly much thicker and more irregular than that
of a true cyst and the lumen may be septated
and contain internal echoes.59,61 An accompa-
nying distal acoustic enhancement artefact is
Identification often present owing to the fluid component of
the cyst. Complications arising from larger
of a pancreatic pseudocysts, such as compression of the
cystic lesion in common bile duct causing EHBO, have been
reported in humans.62 Furthermore, pseudo-
a patient with a cysts that become infected may form abscess-
es and ruptured pseudocyts in humans have
clinical history been reported to cause severe peritonitis.63
of pancreatitis Spontaneous regression of human pancreatic
pseudocysts has also been reported.64
should raise Aspiration of luminal contents from a
pseudocyst under ultrasound guidance is con-
the suspicion sidered to be a safe procedure and will typi-
of a cally reveal high levels of amylase and/or
lipase.59,65 This can be invaluable in helping to
pseudocyst. differentiate pseudocysts from abscesses
and cystic neoplasms, all of which can appear
similar ultrasonographically.59,65
The third type of cyst described in the pan-
creas, the retention cyst, forms due to the
blockage of a pancreatic duct followed by the
accumulation of glandular secretions. In
humans, retention cysts are reported to be
incidental findings and have no clinical signif-
icance.58 They are usually small and have an
epithelial lining and are more likely to contain
anechoic rather than echogenic fluid, in con-
trast to inflammatory pseudocysts.1,58 To the
author’s knowledge, retention cysts associat-
ed with the pancreas have not been reported
in the cat.
Cats with polycystic kidney disease develop
numerous cysts throughout the kidneys but
can also develop cysts concurrently within the
liver and pancreas (Figure 11).66 Consequently,
it is prudent to scan both the liver and pan-
creas in cats presenting with this condition.
Aspiration of luminal contents from a
pseudocyst under ultrasound guidance can be
invaluable in helping to differentiate pseudocysts
from abscesses and cystic neoplasms, all of which
can appear similar ultrasonographically.
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R E V I E W / Feline abdominal ultrasonography – the pancreas

Figure 11 Ultrasound images from a 14-year-old male neutered Persian cat with
polycystic kidney disease. (a) Large (approximately 8 cm diameter) thin-walled cyst
containing mildly echogenic fluid associated with the pancreas. (b) Multiple, variably
a sized, smaller cysts are visible throughout the entire pancreas (arrows). Concurrent
cysts were also present throughout both kidneys and the liver (not shown)

Pancreatic abscesses can be highly

variable in appearance but usually present
as thick-walled cavitary lesions with
hyperechoic or flocculent contents.
a variable in appearance but usually present as
Pancreatic abscessation
Pancreatic abscesses are uncommon in cats but
may develop as a consequence of pancreatitis
or an infected pseudocyst.67 Pancreatic absces-
sation has also been identified in a cat with
diabetes mellitus.68 Abscesses can be highly
thick-walled cavitary lesions with hyper-
echoic or flocculent contents (Figure 12).67,68
Occasionally gas is also present and recognised
on ultrasound by the presence of hyperechoic
foci associated with a reverberation artefact.1

Figure 12 Pancreatic abscessation in two cats. (a,b) Ultrasound images from

an 11-year-old male neutered Norwegian Forest Cat presenting for investigation
of weight loss. Abdominal ultrasound revealed the presence of multiple, variably
sized cavitary lesions throughout the pancreas. Most lesions had a thick wall
and contained gravity-dependent sediment (arrows). Hyperechoic fat is also
visible adjacent to the lesions. Aspiration of the fluid from the largest of these
yielded a non-septic, neutrophilic exudate consistent with abscessation.
(c) Ultrasound image from an 8-year-old female neutered diabetic Bengal cat.
Multiple thick-walled cavitary lesions (arrows) are present within the right lobe
of the pancreas. Lesion contents varied from anechoic to echogenic. Note the
marked hyperechogenicity of the peripancreatic fat, reflecting adjacent
steatitis. Lesion aspiration was consistent with abscessation. Three videos
showing pancreatic abscessation are available in the supplementary material

b c

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R E V I E W / Feline abdominal ultrasonography – the pancreas
Pancreatic bladder
A pancreatic bladder refers to cystic dilation
of the pancreatic duct, a rare condition in the
cat.50,69,70 Some prefer the term pancreatic
pseudobladder since there is no true bladder
associated with the pancreas, unlike the uri-
nary and biliary systems.1 On ultrasound,
pancreatic bladders are fluid-filled structures
associated with the pancreas that can be con-
fused with a bipartite gall bladder or a pancre-
atic cyst.69,70 Identifying a connection between
the cystic structure and the ductal system of
the pancreas confirms the true nature of the
lesion.70 While they may be incidental, they
can reach a size sufficient to obstruct the com-
mon bile duct, thereby causing icterus.69 The
presence of marked saccular dilation of the
pancreatic duct in the absence of an obstruc-
tive process has also been described in cats.3
Concurrent thickening of the pancreatic duct
wall and the presence of anechoic to echo-
genic fluid within the duct lumen were addi-
tional findings reported in these cases.3
The cause of the severe ductal distension
could not be determined.
Pancreatic bladder has also been reported
in association with pancreaticolithiasis. The
latter is a rare condition that describes the
presence of one or more calculi within the
ductal system or parenchyma of the pancreas.
Calculi are usually easily recognised by their
characteristic strongly hyperechoic interface
and distal acoustic shadowing (Figure 13).
Obstruction of the pancreatic duct by a stone
(pancreatolith) has been reported in a 14-year-
Calculi associated with pancreaticolithiasis
can usually be easily recognised by their characteristic strongly
hyperechoic interface and distal acoustic shadowing.
a b
Figure 13 Pancreaticolithiasis in an 8-year-old female neutered domestic shorthair cat. (a) Two calculi (arrows) are visible within the dilated pancreatic duct of the
left lobe. (b) Marked dilation of the pancreatic duct within the right lobe (arrows) in association with further calculi (arrowheads)
252 JFMS CLINICAL PRACTICE
old Maine Coon with chronic pancreatitis.70
It was thought that the obstruction of the
duct resulted in pancreatic duct dilation and
subsequent pancreatitis. In the same cat an
anomalous cystic structure containing calculi
that communicated with the pancreatic ductal
system was also identified and found to repre-
sent a pancreatic pseudobladder following
exploratory surgery. Migration of a calculus
from the pseudobladder into the pancreatic
duct was considered to be the most likely
explanation for the pancreaticolithiasis.70
Nodular hyperplasia and pancreatic
neoplasia
Nodular hyperplasia of the pancreas is a com-
mon incidental finding in older cats.71 The
ultrasonographic appearance of nodular hyper-
plasia in five cats has been described as multi-
ple hypoechoic nodules within the pancreas
varying in size from 3 mm to 10 mm in diame-
ter.72 Small pancreatic cysts have the potential to
appear similar on ultrasound, although a distal
acoustic enhancement artefact is expected with
cysts due to their fluid content, thus allowing
them to be distinguished from solid nodules.3
Exocrine pancreatic neoplasia, of which
adenocarcinoma is the most frequently
encountered type, is rare in the cat, partic-
ularly when compared with pancreatitis, with
incidences of 0.013% and 0.05% being report-
ed in large cohorts of cats.73,74 Pancreatic
adenocarcinoma usually affects older cats;
in two studies comprising a total of 48 cats
with malignant pancreatic tumours, the
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R E V I E W / Feline abdominal ultrasonography – the pancreas

approximate mean age was 12 years.72,75 cytology and/or histopathology remains

Any part of the pancreas may be affected75
and cases of pancreatic adenocarcinoma have
been reported in association with paraneo-
plastic alopecia.76–78 On ultrasound examina-
tion, pancreatic neoplasia typically presents as
a hypoechoic nodule or mass in the region of
the pancreas, although diffuse infiltration or
even a normal-appearing pancreas is also pos-
sible (Figure 14).1,72,75,79 Solitary masses exceed-
ing 2 cm diameter in at least one dimension
are reported to be more likely to be neoplas-
tic.72 The presence of multiple pancreatic nod-
ules measuring 1.5 cm to 6 cm in diameter has
also been reported in cats with pancreatic
adenocarcinoma.75 Although hyperplastic nod-
ules tend to be smaller than this, there is still
considerable overlap in the ultrasonographic
appearance of both conditions and hence
necessary for definitive differentiation.
Ancillary findings in cases of pancreatic
neoplasia include evidence of pancreatic
mineralisation,72 invasion of the duodenal
wall, free abdominal fluid, hyperechogenicity
of peripancreatic fat, lymphadenopathy and
obstruction of the common bile duct.72,75 The
presence or absence of abdominal effusion can
also be used as a prognostic indicator. In one
report of 34 cats with pancreatic adeno-
carcinoma, the median survival of those cats
with abdominal effusion at diagnosis (16 in
total) was 30 days compared with 165 days for
cats with no effusion.79 Unfortunately, feline
pancreatic adenocarcinoma has a poor prog-
nosis and has often metastasised by the time
of diagnosis, particularly to the liver, lung and
small intestine.73,75

On ultrasound, pancreatic neoplasia typically presents

as a hypoechoic nodule or mass in the region of the pancreas, although diffuse
infiltration or even a normal-appearing pancreas is also possible.

Figure 14 Pancreatic adenocarcinoma in three cats. (a) Ultrasound image of

the pancreas of a 10-year-old male neutered domestic shorthair cat presenting
with a 2-month history of progressive lethargy, intermittent diarrhoea and, more
recently, vomiting. The pancreas is moderately and diffusely enlarged up to
2.4 cm in thickness, with a mass in the right lobe (arrows). Pancreatic borders
are irregular and the parenchyma is heterogeneous throughout. Cytology
from ultrasound-guided fine-needle aspiration (FNA) was most consistent with
pancreatic adenocarcinoma. (b) A 1.5 cm x 2.5 cm mixed echogenicity mass
(arrows) within the right lobe of the pancreas of an 8-year-old male neutered
domestic shorthair cat presenting for further investigation of inappetence
and weight loss. Histopathology results were consistent with tubular
adenocarcinoma of the exocrine pancreas and concurrent nodular hyperplasia.
(c) Ultrasound image of a poorly circumscribed hypoechoic mass (arrowheads)
associated with the left lobe of the pancreas in a 14-year-old British Shorthair
presenting with lethargy, inappetence and ascites. The spleen is visible in the
near field of the image. Multiple poorly defined hypoechoic nodules (arrows)
are visible throughout the hyperechoic mesentery and a moderate volume of
a slightly echogenic peritoneal fluid is also present. FNA results were consistent
with pancreatic adenocarcinoma and widespread carcinomatosis

b c

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R E V I E W / Feline abdominal ultrasonography – the pancreas

Lymphoma of the pancreas is also recog- Neoplasia of the endocrine pancreas

nised in the cat but may represent pancreatic Neoplasia of the endocrine pancreas is
involvement in multicentric disease rather extremely rare in the cat and, as a result,
than a primary tumour of the pancreas.72 descriptions of the ultrasonographic findings
It has been reported to result in irregular are scarce. An insulinoma has been described
margination, diffuse enlargement and hypo- in a 15-year-old female neutered domestic
echogenicity of the pancreas (Figure 15).3 shorthair cat in which it presented as a 9 mm
Pancreatic adenomas have likewise been diameter, mildly hyperechoic, spherical
described in the cat and can present nodule within the left pancreatic lobe.80 The
as smoothly defined nodules with an tumour was considered to be a benign islet
echogenicity similar to that of adjacent cell adenoma based on well-differentiated cell
pancreatic tissue.3,73 However, the concurrent morphology and lack of invasive growth.80
ancillary changes described above, including Another report documents the presence of a
lymphadenopathy, would not usually be 1 cm diameter nodule in the body of the pan-
expected. creas of a 17-year-old male neutered Siamese
cat, confirmed to be an islet cell carcinoma fol-
lowing histopathology.81 In this cat, metas-
tases were identified in the liver and regional
lymph nodes.81 The ultrasonographic findings
from both of these reports in cats are similar to
those in dogs; canine endocrine pancreatic
tumours are also typically small nodules (usu-
ally <2.5 cm diameter) that can be challenging
to detect on ultrasound.1,82 These descriptions
are further supported by the most recent
report of insulinoma, in a 14-year-old male
neutered domestic shorthair cat, which
describes the presence of a focal, well-defined
hypoechoic pancreatic mass measuring 16
mm x 23 mm diameter.83

Metastatic neoplasia
There are only occasional reports of metastatic
disease occurring within the pancreas in cats.
a
Pancreatic metastases were identified in 2/26
cats with visceral haemangiosarcoma in one
study,84 and in an 11-year-old cat secondarily
to a prostatic adenocarcinoma,85 although the
specific ultrasonographic features were not
described.

Rupture of the pancreas

Pancreatic rupture is a very rare event that
has been documented in cats with high-rise
syndrome.86 Leakage of pancreatic enzymes
into the abdominal cavity ensues, resulting in
pancreatic autodigestion and saponification of

Lymphoma of the
pancreas has been reported to
result in irregular margination,
diffuse enlargement and
hypoechogenicity of
b
the pancreas.
Figure 15 (a,b) Pancreatic lymphoma in a 16-year-old male neutered domestic shorthair cat
referred for assessment of an abdominal mass. The pancreas is markedly enlarged and contains
multiple well-circumscribed hypoechoic masses throughout. Fat surrounding the pancreas is
mildly hyperechoic. Concurrent hepatosplenomegaly and a gastric mass were noted at the time
of abdominal ultrasound in addition to marked enlargement of hepatic, gastric and jejunal
lymph nodes

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241_259_Griffin_pancreas2.qxp_FAB 03/02/2020 12:53 Page 255
adjacent fat. Without the correct diagnosis and
treatment, the condition can lead to multi-
organ failure and death. On ultrasound, the
pancreas in four affected cats appeared hyper-
echoic and was surrounded by hyperechoic
peripancreatic mesenteric fat.86 Additional
findings in all affected cats included ascites
and hypomotility of the gastrointestinal tract.
It is thought that the left pancreatic lobe may
be particularly vulnerable to rupture and,
in the four cases described, the diagnosis of
pancreatic rupture was confirmed either at
surgery or at post-mortem examination.
Traumatic pancreatitis has also been report-
ed in association with high-rise syndrome.87
Abdominal ultrasonography of affected cats
may reveal any combination of pancreatic
enlargement, decreased or heterogeneous
pancreatic echogenicity, hyperechoic mesen-
tery and peritoneal effusion.87
Contrast-enhanced Doppler
ultrasound
Contrast-enhanced Doppler techniques have
been used in the human field to differentiate
between pancreatitis and neoplasia, to detect
parenchymal necrosis in individuals with
acute severe pancreatitis and to assess pancre-
atic tumours.88–90 Accordingly, the feasibility
of using contrast-enhanced Doppler ultra-
sound to evaluate the feline pancreas has also
been investigated.91,92 The perfusion pattern of
Interventional procedures: sampling considerations
There is significant overlap in the ultrasonographic appearance
of pancreatic neoplasia, nodular hyperplasia and pancreatitis,
and hence it is often not possible to discriminate between these
conditions on the basis of ultrasound appearance alone.79
Tissue sampling via either biopsy or fine-needle aspiration (FNA)
is usually required to make a definitive diagnosis and is diagnos-
tic in a high proportion of cases.79
Pancreatic FNA has been performed in several studies and no
complications were reported.59,73,79 The safety of percutaneous
ultrasound-guided pancreatic FNA in the cat has also been
specifically evaluated.93 In that study, there was no difference in
the complication rate between cats undergoing ultrasound-
guided FNA of the pancreas and those in which sampling was
not performed, and many of the complications reported, such as
hypotension and respiratory distress, were considered unlikely
to have been caused by the aspiration procedure.93 Cytology
samples were of diagnostic quality in 67% of cases and agreed
with histopathology in 6/7 cases in which histopathology was
also available.93
The author’s preference is to use a 23 G hypodermic needle
attached to a 5 ml syringe with either a suction or non-suction
technique. Where possible, three aspirates are collected to
increase diagnostic yield. Cavitary lesions such as abscesses
and pseudocysts can be drained safely, although as much fluid
as possible should be aspirated to reduce the risk of subsequent
R E V I E W / Feline abdominal ultrasonography – the pancreas
the normal pancreatic parenchyma has been
described in detail in 10 clinically healthy cats
using a second-generation contrast medium
containing sulfur hexafluoride (SonoVue;
Bracco UK).92 Additionally, significantly high-
er pancreatic blood volumes and vascularity
are present in cats with pancreatic disease
compared with normal cats, regardless of
the Doppler method used (ie, pre-contrast
vs post-contrast, colour vs power Doppler).91
As expected, power Doppler yields higher
Doppler values than colour Doppler and is
thus superior. Contrast-enhanced ultrasonog-
raphy has also been used in the diagnosis of
pancreatic insulinoma in a cat.83 Further
research is required to determine whether this
technique can be used in cats that are suspect-
ed of having pancreatic pathology but have
normal B-mode scans, and to determine the
accuracy of Doppler with regard to differenti-
ating the various disorders of the pancreas.
Earlier articles in the series
✜ The liver (2019; 21: 12–24)
✜ The biliary tree (2019; 21: 429–441)
✜ Hepatic vascular anomalies (2019; 21:
645–654)
✜ The normal gastrointestinal tract (2019; 21:
1039–1046)
✜ The diseased gastrointestinal tract (2019; 21:
1047–1060)
leakage. Where abdominal fluid is present, it may be possible to
achieve a diagnosis based on cytology of a sample of fluid,
although the success rate is typically higher when using tissue
aspiration.79 This is thought to be due to difficulty in differentiat-
ing carcinoma cells from reactive mesothelial cells.79 It should
be noted that a negative FNA cytology result does not necessar-
ily exclude a diagnosis of pancreatitis due to the potential for the
disease to be focal or multifocal in nature.14 Samples may also
be poorly cellular in cases of chronic pancreatitis, most likely
due to fibrotic replacement of normal pancreatic tissue.94
There is significant overlap in the
ultrasonographic appearance of
pancreatic neoplasia, nodular hyperplasia
and pancreatitis, and so tissue sampling
via either biopsy or fine-needle aspiration
is usually required to make a
definitive diagnosis.
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R E V I E W / Feline abdominal ultrasonography – the pancreas

Case notes
Charlie, a 16-year-old male neutered domestic
shorthair cat, was referred for further investigation
of anorexia and jaundice.

Recent history For the previous 6 weeks, Charlie’s

appetite had been significantly reduced and he had been
vomiting intermittently, usually food but sometimes just froth
with a small volume of fluid. He became moderately jaundiced
during this period, although this had improved slightly
immediately prior to referral.

Long-term history Charlie had been with his current owners

for 14 years and was rescued as a stray, at which time he was
estimated to be about 2 years old. He had generally been a well
cat until 2 years prior to referral when he was diagnosed with
hyperthyroidism. This was treated with methimazole until he
developed icterus, at which point his medication was stopped.
Figure A Dilation of an intrahepatic bile duct (arrowheads). Note the typical
Physical examination and laboratory findings On tortuosity of the duct and free peritoneal fluid surrounding the liver lobe
physical examination, Charlie was quiet, alert and responsive
with a body condition score of 2/9 and rectal temperature of
38.2ºC. His mucous membranes were pink with a capillary
refill time of 1 s. Heart rate was 180 beats per minute and
no murmur was detected. His skin and sclerae were noted
to be icteric and he had a non-painful pendulous abdomen
suspected to be due to a peritoneal effusion. Peripheral
lymph nodes were unremarkable on palpation.
Abnormal laboratory findings are shown in the table.

Abnormal laboratory findings

Parameter Result Reference interval
Albumin (g/l) 23.8 25.0–45.0
Alanine aminotransferase (U/l) 391.4 5.0–60.0
Alkaline phosphatase (U/l) 717.0 ⩽60.0
Aspartate transaminase (U/l) 175.0 10.0–50.0 Figure B Several dilated extrahepatic bile ducts

Total bilirubin (µmol/l) 193.1 0.1–5.1

Bile acids (fasting; µmol/l)) 359.6 0.1–5.0
Glucose (mmol/l) 10.2 3.9–8.0
Thyroxine (nmol/l) 102.2 10.0–60.0

Imaging Abdominal ultrasound revealed the presence of

marked distension of the intra- and extrahepatic portions
of the biliary tract (Figures A and B). The gall bladder was
subjectively enlarged and contained a moderate amount
of non-shadowing echogenic sediment. A 3 cm diameter,
irregularly marginated, hypoechoic mass was identified in
the region of the junction between the right lobe and body
of the pancreas (Figure C). The mass partially enveloped and
invaded the adjacent segment of duodenum, causing loss of
wall layering (Figure D). A small volume of anechoic peritoneal
fluid was also visible throughout the abdomen. Findings
were consistent with a pancreatic mass causing extrahepatic
biliary obstruction. The primary differential for the mass was
neoplasia. Fine-needle aspirates of the pancreatic mass were
Figure C Large pancreatic mass (arrowheads) adjacent to the duodenum
acquired under ultrasound guidance at the time of the scan. in transverse (arrow)
As anticipated, cytology results confirmed the mass to be
pancreatic adenocarcinoma. Continued on page 257

256 JFMS CLINICAL PRACTICE

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R E V I E W / Feline abdominal ultrasonography – the pancreas

Continued from page 256

Treatment and follow-up Due to the poor prognosis, the
owners opted for euthanasia at the referring veterinary practice.

✜ What this case demonstrates: Strictly speaking,

Figure D Close-up view showing invasion of the duodenal wall (arrow) by
the pancreatic mass
it is not normally possible to differentiate between pancreatic
neoplasia and pancreatitis based on ultrasonographic
appearance alone. Although pancreatitis is much more
common than neoplasia, most ultrasonographic features
are common to both conditions. Evidence of invasion of
the duodenal wall is a characteristic of an aggressive
lesion and one of the few imaging features that is much
more suggestive of pancreatic neoplasia than pancreatitis.
In rare cases where this is identified, and in the light of
the poor prognosis, sampling of the pancreas/pancreatic
mass is recommended to allow expedient confirmation
of the suspected diagnosis.

Conflict of interest Ethical approval

The author declared no potential
conflicts of interest with respect to
the research, authorship, and/or
publication of this article.
Funding
The author received no financial
support for the research, authorship
and/or publication of this article.
SUPPLEMENTARY
MATERIAL This work did not involve the use of animals and
Videos to accompany the still therefore ethical approval was not required.
figures within this article – see legends
to Figures 5, 7–10 and 12 for more
information – are available as
Informed consent
supplementary material at: jfms.com
DOI: 10.1177/1098612X20903599 This work did not involve the use of animals and
therefore informed consent was not required.
No animals or humans are identifiable within
this publication, and therefore additional informed
consent for publication was not required.

KEY POINTS
✜ The left lobe of the pancreas is larger than the right in the cat and easier to identify on ultrasound examination.
The pancreatic duct within the left lobe is usually clearly visible on ultrasound.
✜ The landmarks that facilitate identification of the left pancreatic lobe are the stomach cranially, colon caudally
and spleen laterally.
✜ The landmark for the right lobe of the pancreas is the descending limb of the duodenum.
✜ The feline pancreas is well-defined and isoechoic to slightly hypoechoic relative to surrounding fat.
✜ Key ultrasonographic abnormalities suggestive of acute pancreatitis include enlargement and reduced echogenicity
of the pancreas, and increased echogenicity of peripancreatic fat.
✜ Ultrasonographic findings suggestive of chronic pancreatitis include abnormal echogenicity and/or size of the
pancreas, irregularity of pancreatic margins, a nodular appearance and mild hyperechogenicity of peripancreatic fat.
✜ As a minimum, the liver and small intestine should also be examined with ultrasound if features indicative of
pancreatitis are identified.
✜ Multiple pancreatic nodules <1 cm diameter are more likely to represent nodular hyperplasia, whereas a solitary
mass >2 cm diameter is more likely to be neoplastic.
✜ Potential consequences of pancreatitis include extrahepatic biliary obstruction and the formation of pancreatic
pseudocysts or abscesses. Pseudocysts and abscesses typically have thick walls and may contain echogenic
contents and, as such, it may not be possible to distinguish between them ultrasonographically. Differentiation
may be possible through aspiration of contents and determination of amylase and lipase levels.
✜ Since pancreatitis can appear mass-like on ultrasound and neoplasia can produce diffuse pancreatic
changes, FNA of the pancreas may be warranted and is considered to be a safe and minimally
invasive technique.

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