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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5782_Библиотеки_им_академика_М_И_Перельмана.pdf
CHAPTER 8 Pancreas Scanning Protocol 159
5. To evaluate the head and uncinate process of the pancreas, relocate
the long axis of the neck and very slightly move the transducer
inferior and right lateral. Look for the head and uncinate process to
appear directly anterior to the round or oval anechoic, axial section
of the inferior vena cava (IVC). The uncinate process will be just
posterior to the anechoic, axial superior mesenteric vein section.
Very slightly twisting/rotating the transducer can help resolve the
longitudinal margins of the head and uncinate. To evaluate the rest
of the pancreas head and uncinate begin by moving the transducer
very slowly superiorly, scanning through and beyond the pancreas
margin. Now very slowly slide the transducer inferiorly until you
scan through and beyond the level of the head and uncinate. In
the head, look for the small, round, anechoic, axial sections of the
common bile duct at the posterolateral edge and the gastroduodenal artery at the anterolateral edge. In the central portion of the
head, try to identify the pancreatic duct.
LT
RT
NOTE: If gas is obscuring the view of the pancreas head and uncinate
process and the fluid technique cannot be utilized because the patient
is restricted from fluids, then you may have to evaluate the head and
uncinate from an angle. The angled view is obtained by relocating the
pancreas body, moving to a level just inferior to the body, then angling
the transducer toward the patient’s right at varying degrees until the
pancreas head and uncinate are identified. Once located, finish evaluating
the head and uncinate from that angle. (If any images are taken from an
angle it must be noted as part of the image labeling.)
RT
LT
6. To find the long axis of the pancreas you must visibly connect the
head, neck, body and tail. Begin by relocating the long axis of the
pancreas body. Next, very slowly twist the transducer—first one
way then the other—to oblique the scanning plane according to
the exact lie of the pancreas. At the same time, it may be necessary to barely slide the transducer a little superior or inferior to
resolve the long axis.
160 PART III Abdominal Scanning Protocols
Pancreas • Axial Survey
Sagittal Plane • Transabdominal Anterior Approach
1. Start the axial survey with the pancreas head. Begin scanning with
the transducer perpendicular, at the midline of the body, just inferior to the xiphoid process of the sternum. Locate the anechoic,
distal, long portion of the IVC. Slowly slide the transducer inferiorly
along the IVC. Look for a long section of the anechoic portal vein
anteriorly. You should be able to identify the head of the pancreas
at the inferior margin of the portal vein section.
LT
RT
2. When the head of the pancreas is identified, slowly move the transducer toward the patient’s right, scanning through the head until
you are beyond it. Now slowly move the transducer toward the
patient’s left, until the head portion reappears. As you evaluate the
head, an anechoic, long section of the common bile duct should
appear anterior to the portal vein, running inferiorly toward the
posterior margin of the head. In some cases, the anechoic long section of the gastroduodenal artery can be identified anterior to the
common bile duct, running inferiorly toward the anterior margin
of the pancreas head.
LT
RT
CHAPTER 8 Pancreas Scanning Protocol 161
3. Continue by slowly moving the transducer slightly left lateral to
evaluate the uncinate process and neck of the pancreas. Look for the
anechoic, long section of the superior mesenteric vein that runs
between the pancreas neck (anteriorly) and the uncinate process
(posteriorly). Generally the uncinate lies directly anterior to the
IVC, but it can extend as far left to lie anterior to the aorta.
RT
LT
4. Scan left lateral through and beyond the neck and uncinate process
and onto the pancreas body. It can be helpful to resolve the long
axis of the aorta and superior mesenteric artery and look for the
pancreas body anterior to them. Other vascular landmarks helpful
when identifying the pancreas body include anechoic, axial sections of the splenic artery seen at its superior margin and anechoic,
axial sections of the splenic vein seen along its posterior edge.
RT
LT
5. Continue to slowly scan left lateral, through and beyond the pancreas body onto the tail of the pancreas. In most cases this will be
the area left lateral to the aorta. Like the pancreas body, the tail
is bordered superiorly by the splenic artery and posteriorly by the
splenic vein. Look for the tail between the stomach (anteriorly)
and longitudinal sections of the left kidney (posteriorly). Scan left
lateral through and beyond the tail of the pancreas.
RT
LT
RT
LT
162 PART III Abdominal Scanning Protocols
Posterior
Confluence of
NOTE: If gas from the stomach is obscuring the view of the pancreas
tail and the fluid technique cannot be utilized because the patient is
restricted from fluids, then you may have to evaluate the tail from a posterior approach. When using a posterior approach, the patient may sit
erect or lie prone. It is usually helpful to begin by locating the superior
pole of the left kidney (just lateral to the spine) then look for the tail in
the area directly anterior to the superior pole.
Pancreas Required Images
NOTE: The required images are a small representation of what a sonog-
rapher visualizes during a study. Therefore, the images should provide
the interpreting physician with the most telling and technically accurate
information available.
NOTE: Measurements of the normal pancreas are not required.
NOTE: If the pancreas cannot be visualized because of overlying stom-
ach or bowel gas, and the patient is restricted from fluids, and every
effort has been made to image the pancreas, take the required images
in the designated areas to demonstrate nonvisualization and add “area”
to the image label.
Pancreas • Longitudinal Images
Transverse Plane • Transabdominal Anterior Approach
1. Image of the PANCREAS LONG AXIS to include as much head,
uncinate, body, tail, and pancreatic duct as possible.
superior mesenteric
vein and splenic vein
Gastro-
duodenal
artery
Head
Common
bile duct
Duodenum
Inferior
vena
cava
Right
renal
artery
Anterior
Neck
Liver
Body
Stomach
Spine
Splenic
vein
Tail
Aorta
Left kidney
Pancreatic
duct
LeftRight
Labeled: PANCREAS TRV LONG AXIS
CHAPTER 8 Pancreas Scanning Protocol 163
Stomach
Posterior
c
Gastro-
y
Posterior
2. Longitudinal image of the PANCREAS BODY and NECK to
include the splenic vein.
duodenal
artery
Head
Common
bile duct
Right
Inferior
vena
cava
Confluence
of superior
mesenteric
vein and
splenic vein
Labeled: PANCREAS TRV BODY/NECK
3. Longitudinal image of the PANCREAS TAIL.
Uncinate
process
Head
Neck
Liver
Body
Anterior
Liver
Body
Anterior
Spine
Ligamentum
teres
Tail
Aorta
Left kidney
Stomach
Superior
mesenteric
artery
Spleni
vein
Left
Right
Inferior
vena
cava
Labeled: PANCREAS TRV TAIL
Spine
Aorta
Left renal
vein
Tail
Splenic
vein
Left
Left kidne
164 PART III Abdominal Scanning Protocols
Splenic vein
Posterior
Superior
Anterior
4. Longitudinal image of the PANCREAS HEAD to include the
uncinate process and common bile duct (if bile filled).
Right
kidney
Spine
Anterior
Liver
Head
Inferior
vena cava
Neck
Superior
mesenteric
artery
Left renal
vein
Aorta
Left
Left
kidney
Left renal
artery
mesenteric vein
Uncinate process
Gallbladder
Duodenum
Right
Liver
Common
bile duct
Labeled: PANCREAS TRV HEAD
Pancreas • Axial Images
Sagittal Plane • Transabdominal Anterior Approach
5. Axial image of the pancreas head to include the COMMON BILE
DUCT (CBD)
(if bile filled).
Superior
Liver
Inferior
vena
cava
Labeled: PANCREAS SAG HEAD
Liver
Common
bile duct
Posterior
Inferior
Bowel
Head
Portal vein
CHAPTER 8 Pancreas Scanning Protocol 165
Anterior
Posterior
e
Superior
Anterior
Posterior
Inferior
6. Axial image of the PANCREAS NECK and UNCINATE PROCESS
to include the superior mesenteric vein.
Bowel
Superior
Liver
Hepatic
artery
Neck
Spine
Right renal
artery
Labeled: PANCREAS SAG NECK/UNCINATE
7. Axial image of the PANCREAS BODY to include the splenic vein.
Splenic
artery
Superior
Liver
mesenteric vein
Inferior
Uncinat
process
Inferior
vena cava
Splenic vein
Body
Diaphragm
Esophageal
gastric
junction
Labeled: PANCREAS SAG BODY
Spine
Aorta
Superior
mesenteric
artery
166 PART III Abdominal Scanning Protocols
Anterior
Posterior
Inferior
c
Left
y
Superior
Stomach
Spine
Left renal vein
8. Axial image of the PANCREAS TAIL.
Superior
Labeled: PANCREAS SAG TAIL
Required Images When the Pancreas is Part of Another Study
Splenic
vein
Liver
Tail
Left kidney
Pancreas • Longitudinal Images
Transverse Plane • Transabdominal Anterior Approach
1. Long axis image of the PANCREAS to include as much head,
uncinate, body, tail, and pancreatic duct as possible.
Ligamentum
teres
Duodenum
Neck
Right
Head
Uncinate
process
Inferior
vena
cava
Right renal
artery
Labeled: PANCREAS TRV LONG AXIS
Anterior
Body
Liver
Posterior
Aorta
mesenteric
artery
Spleni
vein
Tail
Left kidne
CHAPTER 8 Pancreas Scanning Protocol 167
Posterior
Aorta
Ligamentum teres
Posterior
Inferior
Common
2. Longitudinal image of the PANCREAS HEAD to include the uncinate process and common bile duct (CBD) (if bile filled).
Anterior
Gastroduodenal
Gallbladder
Right
artery
Head
Liver
Common
bile duct
Inferior
vena cava
Liver
Spine
Labeled: PANCREAS TRV HEAD
Pancreas • Axial Image
Sagittal Plane • Transabdominal Anterior Approach
3. Axial image of the PANCREAS HEAD to include the common
bile duct (CBD) (if bile filled).
bile duct
Superior
Anterior
Confluence of
splenic vein
and superior
mesenteric vein
Body
Head
Bowel
Splenic
vein
Tail
Left
Left
kidney
Superior
mesenteric
artery
Liver
Inferior
vena cava
Labeled: PANCREAS SAG HEAD
Portal vein
168 PART III Abdominal Scanning Protocols
Review Questions
Answers on page 629.
1. The sonographic appearance of the pancreas is described as
a) heterogeneous and hyperechoic relative to the liver.
b) heterogeneous and isosonic relative to renal parenchyma.
c) homogeneous and hypoechoic relative to the liver.
d) homogeneous and hyperechoic relative to the liver.
2. The contour of the normal pancreas
a) appears smooth and even.
b) may be difficult to evaluate due to retroperitoneal fat
infiltration.
c) appears uneven.
d) may be difficult to evaluate because there are no fat interfaces
to distinguish it from adjacent structures.
3. A longitudinal view of Wirsung’s duct is
a) seen in a transverse plane.
b) seen in a sagittal oblique plane.
c) too small to distinguish sonographically.
d) seen only in the head of the pancreas.
4. The long axis of the pancreas is
a) seen in a transverse plane.
b) seen in a sagittal oblique plane.
c) not appreciated sonographically due to the different positions
of its various parts.
d) is an axial portion.
5. The head of the pancreas is
a) posterior to the liver and stomach, medial to the duodenum,
anterior to the IVC.
b) posterior to the liver, medial to the duodenum, anterior to the
SMV.
c) posterior to the liver, medial to the duodenum, anterior to the
IVC.
d) right lateral to the pancreas body, posterior to the liver, superior
to the IVC.
6. The neck of the pancreas is
a) anterior to the SMA and uncinate process.
b) posterior to the liver and duodenum.
c) anterior to the SMV, portal splenic confluence, and uncinate
process.
d) posterior to the liver, duodenum, and hepatic artery.
7. The body of the pancreas is
a) anterior to the SMV and SMA; inferior to the splenic artery.
b) anterior to the splenic vein and SMA; inferior to the splenic
artery.
c) posterior to the liver and duodenum; anterior to the SMV.
d) posterior to the liver and duodenum; just anterior to the portal
splenic confluence.