Abdominal Radiology

https://doi.org/10.1007/s00261-019-02364-x

SPECIAL SECTION: PANCREATITIS

Utility of ultrasound in acute pancreatitis

David P. Burrowes1   · Hailey H. Choi2 · Shuchi K. Rodgers3,4 · David T. Fetzer5 · Aya Kamaya6

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Ultrasound plays an essential role in the initial evaluation of patients with suspected or confirmed acute pancreatitis. In
addition to evaluation of the pancreatic parenchyma, ultrasound is used for assessment of the gallbladder, biliary tree, peri-
pancreatic tissues, and regional vascular structures. While enlarged and edematous pancreas are classic sonographic features
of acute pancreatitis, the pancreas may appear sonographically normal in the setting of acute pancreatitis. Nonetheless, sono-
graphic evaluation in this setting is valuable because assessment for etiologic factors such as gallstones or evidence of biliary
obstruction are best performed with ultrasound. Complications of pancreatitis such as peripancreatic fluid collections, venous
thrombosis, or arterial pseudoaneurysm can be identified with careful and focused ultrasound examination. Knowledge of
various scanning techniques can help to mitigate some of the commonly encountered barriers to sonographic visualization
of the pancreas and right upper quadrant structures. Ultrasound can also be used for guidance of percutaneous treatment
such as drainage of fluid collections or pseudoaneurysm thrombosis. Difficulty in differentiating edematous from necrotizing
pancreatitis can be mitigated with the use of contrast-enhanced ultrasound to assess pancreatic parenchymal enhancement.

Keywords  Pancreatitis · Gallstones · Ultrasound · Sonographic technique · Bile duct

* David P. Burrowes
Introduction
david.burrowes@ahs.ca
In patients known or suspected to have pancreatitis, imaging plays
Hailey H. Choi
hailey.choi@ucsf.edu an essential role in assessing extent of disease, identifying etiolo-
gies, and managing potential complications. Imaging findings of
Shuchi K. Rodgers
rodgerss@einstein.edu pancreatitis are typically characterized by CT or MRI; however,
the workup of patients with initial presentation with epigastric
David T. Fetzer
David.Fetzer@UTSouthwestern.edu pain often begins with ultrasound [1–4]. Current ACR appropri-
ateness criteria list ultrasound as the only ‘usually recommended’
Aya Kamaya
kamaya@stanford.edu imaging study in patients with suspected acute pancreatitis in the
first 48–72 h [5]. Thus, findings of acute pancreatitis should be
1
University of Calgary Cumming School of Medicine, 1403 recognized in this setting to avoid delays in diagnosis and treat-
29 St NW, Calgary, AB T2N 2T9, Canada ment. On the other hand, in patients with an established diagnosis
2
UCSF, 1001 Potrero Ave, San Francisco, CA 94110, USA of pancreatitis, ultrasound is often performed to identify potential
3
Department of Radiology, Einstein Medical Center, 5501 Old etiologies such as gallstones and/or choledocholithiasis (i.e., gall-
York Rd, Philadelphia, PA 19141, USA stone pancreatitis) [4, 6, 7]. Additional sonographic indications
4
Sidney Kimmel Medical College, Thomas Jefferson include detection of pancreatic parenchymal abnormalities and/
University, Philadelphia, USA or masses, retroperitoneal fluid collections, or adenopathy, and
5
UT Southwestern Medical Center, Department of Radiology, guidance during aspiration or drainage of fluid collections. It is
5323 Harry Hines Blvd E6‑230, Dallas, TX 75390‑9316, important to note that ultrasound does not replace CT or MRI in
USA the evaluation of patients with atypical presentations of pancreati-
6
Stanford University Department of Radiology, 300 Pasteur tis, critically ill patients, or patients with suspected complications
Drive H1307, Stanford, CA 94305, USA of acute pancreatitis [5].

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 Abdominal Radiology

Pancreas Fig. 3  Three patients with acute interstitial pancreatitis. a 64-year-old ▸

female presenting with epigastric pain and increase lipase. Sonogram
of the pancreas in the transverse plane demonstrates markedly hypo-
In early or mild cases of acute pancreatitis, the pancreas echoic and enlarged pancreas (*) with adjacent echogenic inflam-
may appear normal on ultrasound [8]. Normal appearance matory fat (arrows). b 14-year-old female undergoing evaluation for
of the pancreas is described as having equal or slightly acute on chronic pancreatitis. Transverse ultrasound of the pancreas
demonstrates diffusely heterogeneous and hypoechoic pancreas as
increased echogenicity relative to the liver (Fig. 1) [8]. If well as peripancreatic fluid (arrowheads) and perivascular cloak-
the echogenicity cannot be assessed relative to the liver, the ing (curved arrow) along the splenic vein c 25-year-old female with
echogenicity of the renal cortex or spleen can be used as epigastric pain and elevated lipase found to have acute pancreatitis.
reference; the pancreas should be isoechoic to the renal cor- Sonogram of the pancreas in transverse plane demonstrates diffuse
heterogeneous enlargement of the pancreas with small-volume peri-
tex [9] and spleen [10]. Parenchymal echogenicity, however, pancreatic fluid along the ventral aspect (arrowheads) and “perivascu-
varies and tends to increase with age due to atrophy and lar cloaking” near the portosplenic confluence (curved arrow)
fatty replacement [8]. In some patients, the posterior half
of the pancreatic head, or the ventral embryologic anlage,
may appear focally hypoechoic relative to the dorsal anlage 2.5 cm [8]. 3 mm is considered the upper limit of normal
secondary to variation in fatty atrophy; unlike a pancreatic for the diameter of the main pancreatic duct in the head
mass or focal pancreatitis, however, the margins are linear, and 2 mm is considered the upper limit of normal for the
and there is no mass effect on adjacent vasculature [8] or
common bile duct (Fig. 2). The normal pancreas demon-
strates smooth or slightly lobular margins.
Abnormal ultrasound findings can be seen in 33-90% of
patients with acute pancreatitis. Sonographic findings of
acute pancreatitis can be subtle and can include changes in
pancreatic echogenicity, glandular enlargement, pancreatic
duct dilation, and peripancreatic fluid [11]. Enlargement
of the pancreas as well as hypoechoic or heterogeneous
echotexture [8] is caused by associated interstitial edema
(Fig. 3a) [11, 12].
The glandular size can vary depending on the pancre-
atic region: the pancreatic head can measure up to 3 cm in
thickness; the pancreatic body and tail can measure up to

Fig. 1  43-year-old female who presented with epigastric pain, found
to have elevated pancreatic enzyme levels (lipase > 400 U/L), referred
for abdominal ultrasound. Transverse grayscale image demonstrates
normal sonographic appearance of the pancreas (curved arrow) ante-
rior to the splenic vein (arrowheads), which is slightly hyperechoic
relative to the adjacent left hepatic lobe (*)
Fig. 2  59 year-old-female with normal pancreas and relative lack of
fatty atrophy in the ventral pancreas. a Transverse ultrasound image
shows a hypoechoic ventral pancreas (arrows) and hyperechoic dorsal
pancreas (*). Note the linear margins and lack of mass effect on adja-
cent vasculature. b Sagittal ultrasound image shows the hypoechoic
ventral pancreas and a normal common bile duct (arrows)

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Abdominal Radiology
diameter of the main pancreatic duct in the body and tail
of the pancreas. While these numbers are used as a general
rule of thumb, it has been observed that the pancreatic
duct can distend with age [8, 13, 14].
Peripancreatic fluid is another finding often seen with
acute pancreatitis [8]. Fluid may also dissect along vessels
and along the portosplenic confluence and superior mes-
enteric vein, leading to a sonographic finding termed
“perivascular cloaking” (Fig. 3b, c). As the pancreas is a
retroperitoneal organ, peripancreatic fluid may accumu-
late in the right and left anterior pararenal and perirenal
spaces.
While ultrasound may be useful in depicting morpho-
logic changes of acute inflammation, conventional grayscale
and color Doppler imaging techniques are less sensitive in
detecting parenchymal necrosis [12, 15, 16] without the
benefit of intravenous contrast. Moreover, focal pancreatitis,
which frequently involves the pancreatic head and neck, can
be difficult to distinguish from pancreatic adenocarcinoma
and may require additional workup (Fig. 4) [17]. Commonly,
short-term follow-up imaging is required to evaluate for
improvement/resolution of focal pancreatitis as differentia-
tion from adenocarcinoma can be challenging on all imaging
modalities [18].
Scanning technique of the pancreas
and retroperitoneum
In the setting of pancreatitis, sonography of the pancreas can
be challenging because pancreatitis itself often incites an
associated ileus and excessive bowel gas which can obscure
visualization of the pancreas. In addition, associated abdom-
inal tenderness may limit the amount of transducer compres-
sion one can apply. Finally, pancreatic visualization with
ultrasound is significantly impacted by patient body habi-
tus and can be challenging in overweight or obese patients
who may be more prone to development of gallstones, a risk
factor for pancreatitis. Pancreatic imaging with ultrasound
can be optimized by utilizing the following tips and general
technical considerations, as outlined in Table 1.
The pancreas is an unencapsulated retroperitoneal organ
located in the anterior pararenal space between the duode-
num and splenic hilum. Typically, the pancreatic body can
be imaged from the subxiphoid approach using the left lobe
of the liver as an acoustic window and the splenic vein and
portal-splenic confluence as vascular landmarks. Inspira-
tion and having the patient “push his/her belly out” can aid
in visualization, noting that the pancreas location varies
with respiration and can shift 2–8 cm in the cranial–cau-
dal dimension [19]. Keeping the probe in the same position
and using sagittal subxiphoid ‘side tilting’ is more effective
at visualizing the pancreas than sliding the probe side to
side [20]. Erect imaging displaces the gas-filled stomach or
colon away from the pancreas and brings the liver anterior
to the pancreas, allowing the liver to be used as an acoustic
window. To visualize the pancreatic head, the transducer is
placed in a right subcostal space and angled slightly medi-
ally. Changing the patient’s position to left posterior oblique
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 Abdominal Radiology

◂
Fig. 5  Improved pancreatic visualization using varied scanning tech-
nique. a 39-year-old female with abnormal liver enzymes, transverse
ultrasound image taken with the patient in the supine position shows
poor visualization of the pancreatic head. b Repeat transverse ultra-
sound image taken with the patient in erect positioning demonstrates
improved visualization of the pancreas (arrowheads). c, d 50-year-old
male patient, transverse ultrasound image in supine position with the
abdomen relaxed shows poor visualization of the pancreatic head,
body, and tail (arrow). e, f Repeat transverse ultrasound image taken
in the supine position with the patient instructed to “push his belly
out” shows improved visualization of the pancreatic head, body, and
tail (arrowheads)

may aid in visualization as the gallbladder can move ante-

Fig. 4  67-year-old female who presented with abdominal pain and
elevated liver function tests following endoscopic retrograde cholan-
giopancreatography. a Transverse ultrasound image shows increased
thickness of the pancreatic head (arrowheads) with focal hypoechoic
region in the pancreatic head(*). b Abdominal MRI/MRCP per-
formed 3 days later. Axial T2-weighted, fat-suppressed image dem-
onstrates acute interstitial edematous pancreatitis, with more focal
edema centered in the pancreatic head (*) which corresponds to
hypoechoic areas seen on ultrasound. In addition, edema in the right
retroperitoneum is seen (arrowheads)
rior to the pancreatic head and be utilized as an acoustic
window. A number of techniques have been described to
image the tail of the pancreas. Scanning the patient in an
upright position allows for use of the upper pole of the left
kidney as an acoustic window through a left coronal view
[20]. Alternatively, one can use the spleen as an acoustic
window in thin patients via a left lateral intercostal approach
using a coronal plane [20]. Finally, having the patient ingest
water and scanning in a semi-reclined position allows for
use of the fluid-filled stomach as an acoustic window via an
anterior approach [8].
The purpose of imaging the entire retroperitoneum is to
show sequelae of pancreatic pathology including collec-
tions, adenopathy, or masses. Sonographic images should
include the left and right anterior pararenal space, left and
right perinephric space, para-aortic region, transverse meso-
colon, and lesser sac.
In general, we find that taking the time to perform
some of the above described maneuvers is beneficial and
greatly enhances the ability to visualize the pancreas
(Fig. 5). In patients with particularly challenging pan-
creatic visualization, it is important to weigh the rela-
tive benefit of added scanning time. Many patients with
acute pancreatitis will have subsequent imaging with CT
or MRI, decreasing the necessity of complete gland visu-
alizing with ultrasound.

Table 1  General technical considerations for ultrasound in acute pancreatitis [39]

Use a standardized protocol and compare to relevant prior studies

To limit interference from bowel gas and allow physiologic distention of the gallbladder, ideally patient should fast for 6–8 h (often not practical
in the acute setting)
Use curvilinear transducers (2–9 MHz) with tissue harmonic imaging in various patient positions
Use graded compression to displace gas, best performed during quiet breathing when abdominal muscles are relaxed
Acquire representative transverse and longitudinal grayscale images of the pancreas, retroperitoneum, gallbladder, and biliary tree. Use cine
loops as required
Use color Doppler to assess patency of vasculature (identify vessel thrombosis and pseudoaneurysms), differentiate phlegmon from collections,
and differentiate bile ducts from blood vessels

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Abdominal Radiology

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Fig. 6  61-year-old obese female presenting with right upper quadrant
pain, diagnosed with cholangitis and mild acute pancreatitis (lipase
131; T Bili 6.6, D Bili 5.6, Alk Phos 790). a Ultrasound image of
the right portal vein branch shows central intrahepatic biliary ductal
dilatation (arrowheads). b Ultrasound image through the left lobe also
shows “tram-track sign; or double tube sign”, consistent with intrahe-
patic biliary ductal dilatation (arrowheads). c Ultrasound image of the
Gallbladder and biliary tree
In the setting of known or suspected acute pancreatitis, a
“right upper quadrant” ultrasound examination helps to
evaluate for cholelithiasis and biliary ductal dilatation that
may indicate choledocholithiasis as the inciting etiology
(gallstone pancreatitis) [4, 6, 7]. Of all imaging modalities,
ultrasound has a highest sensitivity for detection of chole-
lithiasis, reported as over 95%; however, the sensitivity
decreases when taking into account ileus and bowel disten-
tion often seen in acute pancreatitis, potentially decreasing
sensitivity to 67–78% [21]. Interestingly, the risk of gall-
stone pancreatitis has been reported as over 2% in patients
with asymptomatic cholelithiasis [22].
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Abdominal Radiology
distal common bile duct reveals two echogenic intraluminal foci with
posterior acoustic shadowing (white arrows), consistent with chole-
docholithiasis. d Fluoroscopic image from a subsequent intraopera-
tive cholangiogram reveals two round filling defects in the distal CBD
(arrowheads) corresponding to choledocholithiasis, the distal most
stone resulting in a meniscus sign
Often associated with a distended fluid-filled bile duct,
choledocholithiasis can be diagnosed when an echogenic
intraluminal focus with posterior acoustic shadowing is
visualized [23] (Fig. 6). Ultrasound has a relatively high
specificity for choledocholithiasis, nearly 95% [24]. How-
ever, the reported sensitivity for the ultrasound diagnosis of
choledocholithiasis ranges from 18 to 63% in the literature,
with the caveat that these numbers may not reflect recent
marked advancements in ultrasound technology as many of
these early reports were published in the 80s and 90s [23,
25–28]. More recent reports suggest 50–80% sensitivity for
choledocholithiasis [24, 29]. Calculi less than 5 mm in diam-
eter typically pass into the duodenum through the ampulla
of Vater. Although in some instances these stones may elicit
only transient pain with stone passage, small gallstones </=
Abdominal Radiology
Fig. 7  32 year-old-female with gallstones and acute pancreatitis.
a Sagittal ultrasound image of the gallbladder showing gallstones
(arrow). b Oblique view of the porta hepatis shows the common
hepatic and common bile duct are normal in caliber but have subtle
ductal wall thickening/edema (arrows). c Ultrasound of intrapancre-
atic distal common bile duct demonstrates distal choledocholithiasis
(small arrows). These images show the importance of interrogating
the entirety of the common bile duct even in the absence of biliary
dilatation
5 mm are also associated with greater risk of recurrent pan-
creaticobiliary complications. Stones greater than 5 mm may
be too large to pass through the ampulla but carry a higher
risk of biliary obstruction, cholangitis, and pancreatitis [30].
There is reported variability in the association between
common bile duct (CBD) diameter and the associated risk
of choledocholithiasis. Serum markers of biliary obstruction
and CBD diameter at imaging have not been shown to be
sufficient for excluding choledocholithiasis (Fig. 7) [6, 31,
32]. One prospective study in patients prior to cholecystec-
tomy showed that no patients with CBD diameter less than
or equal to 3 mm had choledocholithiasis, while 7.7% of
patients with ducts measuring 4 mm or larger had bile duct
stones, with increasing risk with larger duct diameter [33].
Gallstone pancreatitis may not always be associated
with gallstones. Biliary precipitate also known as micro-
lithiasis or biliary sludge is thought to consist of mucin,
cholesterol, and calcium bilirubinate and has been reported
to be a risk factor for pancreatic duct obstruction. (Fig. 8)
[34, 35]. Although, ultrasound has a reported sensitivity of
only 55% for identification of biliary precipitate within the
extrahepatic bile ducts, no other imaging modality has better
performance in identification of biliary sludge. [34].
Scanning technique in imaging
the gallbladder and biliary tree
When evaluating the gallbladder, an intercostal and/or sub-
costal oblique approach is typically used, with the left side
of the transducer higher than the right, and sweeping from
cephalad to caudad beginning with the middle hepatic vein
superiorly, and coursing through the gallbladder fossa/inter-
lobar fissure inferiorly [8]. Decubitus gallbladder images
may elucidate small calculi and/or sludge and determine
whether they are mobile. This can be supplemented with
prone or erect imaging. Images should also include the gall-
bladder neck in order to detect impacted calculi. Focal pain
produced by transducer pressure on the gallbladder fundus
should be noted (Sonographic Murphy Sign).
Multiple techniques can be utilized to visualize differ-
ent portions of the common hepatic and common bile ducts
(CHD; CBD), as outlined in Fig. 9. Visualizing the entire
CBD in the pancreatic head increases the sensitivity for
detecting choledocholithiasis. Placing the patient left poste-
rior oblique (LPO)/left lateral decubitus (LLD) can move the
gallbladder over the pancreatic head, allowing the gallblad-
der to be used as an acoustic window [8]. If bowel gas in the
stomach or duodenum obscures visualization, compression
or changes in positioning to right posterior oblique (RPO)
or right lateral decubitus (RLD) may help shift gas out of
the field of view. Oral ingestion of water can also help to
displace gas in the stomach or duodenum that may otherwise
obscure visualization of the pancreas while providing an
acoustic window for improved visualization. Color Doppler
may be used to differentiate vessels from bile ducts.
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 Abdominal Radiology

Fig. 8  69-year-old male abdominal pain, nausea, and vomiting (lipase ▸

1349, TBili 5, DBili 2.5, Alk Phos 230), transferred from outside hos-
pital with suspected biliary pancreatitis. a contrast-enhanced CT at
level of the pancreas shows a diffusely edematous pancreas with peri-
pancreatic fluid, consistent with acute edematous interstitial pancrea-
titis. b Transverse ultrasound image with color Doppler through the
gallbladder reveals echogenic intraluminal material without posterior
acoustic shadowing or twinkling artifact (curved arrow), suggestive
of conglomerate biliary precipitate (tumefactive sludge). c Ultrasound
through the common bile duct shows normal-caliber of the extrahe-
patic bile ducts, though with faint intraluminal echogenic material
(arrow), suggestive of biliary precipitate. Extensive workup for alter-
native causes of acute pancreatitis was unrevealing and thus the cause
of pancreatitis was presumed to be related to biliary precipitate

Complications

Ultrasound can be used to detect complications of acute

pancreatitis, including peripancreatic fluid collections and
vascular complications. High spatial resolution of ultrasound
allows characterization of peripancreatic collections rang-
ing from those that contain anechoic fluid versus echogenic
debris [12]. Internal echoes in a collection may indicate
hemorrhage, necrotic debris, or infection (Fig. 10) [8]. Vas-
cular complications of acute pancreatitis include thrombosis
and pseudoaneurysm. The splenic vein is the vessel most
frequently involved by thrombosis, although the superior
mesenteric vein can also be affected [8]. With pancreatic
inflammation, pancreatic proteolytic enzymes leak from the
gland and can erode adjacent vessel walls, resulting in pseu-
doaneurysms. Due to its proximity, the splenic artery is most
commonly affected (Fig. 11) [8]. Whenever a pancreatic or
peripancreatic collection is encountered, Doppler interroga-
tion should be performed to differentiate a pseudoaneurysm
or tortuous artery from a cyst or fluid collection [8, 36].
Partially or completely thrombosed pseudoaneurysms may
mimic solid pancreatic masses; however, a thrombosed pseu-
doaneurysm may be suspected when the solid material has
a laminated appearance [8]. Pseudoaneurysm is the most
common cause of hemorrhage associated with pancreati-
tis and carries a mortality rate of up to 90% in untreated
patients [37].

Limitations of ultrasound

In the critically ill patient with acute pancreatitis, transab-

dominal ultrasound imaging of the pancreas has limited util-
ity in the diagnosis and prognosis of acute pancreatitis espe-
cially after 48–72 h of onset of disease [5]. Moreover, in this
setting, complete pancreatic visualization is rarely achieved
due to associated ileus as described above; visualization is necrosis and peripancreatic collections, particularly in days
further challenged in overweight or obese patients [38, 39]. 5–7+. Of note, complications of pancreatitis may not mani-
Thus, contrast-enhanced CT remains the modality of choice fest on any imaging modality in the early acute phase (1st
in these patients for follow-up and assessment for pancreatic

13
Abdominal Radiology
Fig. 9  Strategies for sonographic visualization of the common bile
duct. a Transverse view of the pancreatic head demonstrates the distal
CBD posteriorly (white arrow) and the gastroduodenal artery ante-
riorly (white arrowhead). b Color Doppler confirms blood flood in
the GDA (arrowhead) and the absence of flow in the CBD (arrow).
c Proximal common bile duct/hepatic duct demonstrated in the left
posterior oblique (LPO) or left lateral decubitus (LLD) at end inspira-
tion using a right subcostal approach, the common hepatic/common
week), when management is primarily driven by clinical
assessment [6, 38–40].
Detection of choledocholithiasis by ultrasound is often
limited in the setting of acute pancreatitis because of obscu-
ration of the distal CBD and pancreatic head by bowel gas.
Further, sensitivity for choledocholithiasis may be lower
in obese patients in whom the distal CBD is often poorly
visualized at baseline [7, 23, 28]. Although choledocholithi-
asis could be inferred by upstream ductal dilatation, serum
markers of biliary obstruction and CBD diameter have not
been shown to be sufficient for excluding downstream ductal
stones [6, 31, 32]. For patients with unexplained acute pan-
creatitis with or without biliary dilatation on initial evalu-
ation with ultrasound, further evaluation with magnetic
resonance cholangiopancreatography (MRCP), endoscopic
bile duct (white arrow) is anterior to the main portal vein. The hepatic
artery (white arrowhead) appears as a ‘circle’ between the CHD
(white arrow) and portal vein (black arrowhead). d Elongated view
of the common bile duct imaged with patient in the LPO/LLD posi-
tion obtained by identifying the CBD in the pancreatic head in the
transverse plane and turning the transducer toward the patient’s right
shoulder to elongate the CBD (white arrowheads) and trace it into the
porta hepatis
retrograde cholangiopancreatography (ERCP), or endo-
scopic ultrasound may be warranted [1–3].
Advanced applications
Ultrasound is commonly used to guide interventional
therapies. Ultrasound-guided percutaneous drainage of
acute peripancreatic fluid collections (APFC) and acute
necrotic collections (ANC) is a safe and effective way
to treat infected pancreatic fluid collections [41]. This
approach can help avoid emergent surgical intervention by
bridging patients to elective surgery and, in some patients,
alleviate the need for surgery [41]. Necrotic collections
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Fig. 10  71-year-old female with severe abdominal pain and food
intolerance found to have gallstone pancreatitis. a Ultrasound image
through the gallbladder reveals innumerable small echogenic intralu-
minal foci layering dependently and causing posterior acoustic shad-
owing (white arrows), indicating cholelithiasis. b Ultrasound images
through the pancreas in transverse orientation reveals marked pan-
creatic parenchymal heterogeneity (white arrowheads) and a thick-
walled fluid collection anterior to the pancreatic tail (white arrows). c
In the longitudinal orientation, ultrasound image shows a similar col-
often require larger bore catheters (24–28 French), along
with frequent irrigation with normal saline, to achieve
effective drainage [41]. It goes without saying that unlike
fluoroscopy or CT-guided interventions, an advantage
of ultrasound in this situation is that it uses no ionizing
radiation.
13
Abdominal Radiology
lection between the left lobe of liver and pancreas (white arrows). d
Corresponding images from a contrast-enhanced CT in transverse and
sagittal (reoriented, E) reveals walled-off peripancreatic necrotic col-
lections (*) surrounding the pancreatic tail (d) and within the lesser
sac (e). f Ultrasound image of the right kidney shows extensive per-
inephric edema (white arrowheads). g Sagittal view of the right kid-
ney on CT similarly demonstrates perinephric edema (white arrow-
heads) related to retroperitoneal fluid from pancreatitis
Pseudoaneurysm formation is a less common though
potentially catastrophic complication of pancreatitis. Coag-
ulation of pseudoaneurysms by percutaneous ultrasound-
guided thrombin injection is a viable alternative to endo-
vascular or surgical intervention in select cases [42]. This
Abdominal Radiology

approach is typically reserved for aneurysms that are not

readily accessible or visible via catheter angiography [42].
Microbubble contrast-enhanced ultrasound (CEUS)
visualizes capillary level perfusion comparable to contrast-
enhanced CT or MRI. CEUS has been shown to have a simi-
lar performance to CT in detection of pancreatic necrosis
in acute pancreatitis [43]. This overcomes the inability of
grayscale and Doppler ultrasound to accurately differentiate
vascularized pancreatic tissue from necrosis. As microbub-
ble contrast is safe in patients with impaired renal function
or an allergy to iodinated contrast, CEUS can assess patients
with a contraindication to intravenous iodinated contrast
[43]. In addition, CEUS can be performed at the bedside in
patients who are too ill to undergo CT or MRI in the radiol-
ogy department.

Conclusion

Initial imaging assessment of patients with epigastric pain

and suspected acute pancreatitis typically includes transab-
dominal ultrasound. The primary role of ultrasound in evalu-
ation of acute pancreatitis is the identification of gallstones
and signs of biliary obstruction as potential etiologies of
pancreatitis (i.e., gallstone pancreatitis). Knowledge of
various scanning techniques allows for improved visualiza-
tion and detailed assessment of the pancreatic parenchyma
and peripancreatic tissues. Although ultrasound does not
replace CT or MRI in the evaluation of complications of
pancreatitis, fluid collections, venous thrombosis, and arte-
rial pseudoaneurysm identification is possible with careful
sonographic assessment in the appropriate setting. Finally,
ultrasound-guided percutaneous intervention minimizes use
of ionizing radiation and can alleviate the need for emergent
surgical intervention in select patients.

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