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C. M. Leeper et al.70
Fig. 6.12 Normal common bile duct (0.36 cm)
sonographic indicators of pediatric cholecystitis
have lower sensitivities and predictive values as
compared to those for adults [27], therefore nuclear medicine studies are important adjuncts. In
a HIDA scan that is positive for acute cholecystitis, the radioactive tracer is excreted in the liver,
but does not accumulate in the gallbladder due to
obstruction of the cystic duct by stone or edema.
Choledocholithiasis
Ultrasound can also diagnose dilation of the
CBD secondary to an obstructing stone, or choledocholithiasis. Choledocholithiasis is uncommon in children with an incidence of 2–7 % [16,
28]. The CBD may be followed distally toward
the duodenum to evaluate for impacted stones
as the underlying pathology. Intraductal stones
are hyperechoic and immobile. Shadowing is
evident in some cases but may be absent in others due to the lack of surrounding bile. Of note,
a dilated CBD can be confused with the portal
vein, in which case color Doppler may be helpful
to clarify whether the structure contains vascular
flow [25] (Figs. 6.12 and 6.13). The management
of choledocholithiasis includes antibiotics and
ERCP for biliary tree decompression followed
by cholecystectomy.
Fig. 6.13 Dilated common bile duct (1.36 cm) in a pa-
tient with choledocholithiasis. Color Doppler has been
applied to clarify portal structures
Cholangitis
Cholangitis is a rare entity in children with typical hepatobiliary anatomy; diagnosis may be
challenging as pediatric patients who present
with this disease may not meet all criteria of the
classic Reynold’s pentad (right upper quadrant
pain, jaundice, fever, hypotension, and altered
mental status). In the case of ascending cholangitis caused by distal obstruction, ultrasound
may demonstrate dilation of the common bile
duct and possibly visualize the impacted stone.
Of note, biliary dilatation is not always present
in the early stages of bile duct obstruction and
MRCP may be required to diagnose the cause and
level of biliary tree obstruction [29]. Cholangitis
in pediatric patients is also an uncommon complication of hepaticoenterostomy that has been
performed after choledochal cyst excision, liver
transplant, or treatment for another hepatobiliary
pathology [30]. Cholangitis after portoenterostomy for biliary atresia is a clinical diagnosis and
carries no sonographic correlate.
Summary
Ultrasound is an important diagnostic tool in
the pathology of the gallbladder and biliary system. It is reliable and accurate in the detection of
6 Gallbladder and Biliary Tract 71
Murphy AJ, Axt JR, Crapp SJ, Martin CA, Crane
hepatobiliary malformations such as choledochal
cysts, as well as gallbladder disease including
cholelithiasis, cholecystitis, choledocholithiasis, and cholangitis. It plays an important role in
the evaluation of biliary atresia. Abdominal ultrasound should be used as a first-line imaging
modality in the workup of suspected gallbladder
or biliary disease.
References
1. Soto JA, Castrillon G. Gallbladder and biliary tree
imaging techniques. In: Hamm B, editor. Abdominal
imaging. Heidelberg: Springer; 2013. p. 1229–40.
2. Marvin M, Jones CM, Byam JA, Iannitti DA. Hepatobiliary ultrasound. In: Schrope B, editor. Surgical
and interventional ultrasound. New York: McGrawHill Education; 2014.
3. Hernanz-Schulman M, Ambrosino MM, Freeman
PC, Quinn CB. Common bile duct in children: sonographic dimensions. Radiology
4. Yamataka ACJ, Miyano T. Bilia
comb GWMJ, Ostlie DJ, editors. Ashcraftʼs pediatric
surgery. Philadelphia: Elsevier Inc; 2014. p. 580–92.
5. Azuma T, Nakamura T, Nakahira M, Harumoto K,
Nakaoka T, Moriuchi T. Pre-operative ultrasonographic diagnosis of biliary atresia–with reference to
the presence or absence of the extrahepatic bile duct.
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6. Farrant P, Meire HB, Mieli-V
features of the gall bladder in infants presenting
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7. Park WH, Choi SO, Lee HJ. The ultrasonographic
‘triangular cord’ coupled
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infantile intrahepatic cholestasis. J Pediatr Surg.
1999;34(11):1706–10.
8. Tan Kendrick AP, Phua KB, Ooi BC, T
ary atresia: making the diagnosis by the gallbladder
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9. Tainaka T, Kaneko K, Nakamura
W, Ando H. Histological assessment of bile lake
formation after hepatic portoenterostomy for biliary
atresia. Pediatr Surg Int. 2008;24(3):265–9.
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Inoue Y, Kato Y,
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lakes after surgery for biliary atresia. J Pediatr Surg.
2008;43(12):2165–8.
11. Abramson SJ, Berdon WE, Altman RP, Amodio JB,
Levy J. Biliary atresia and noncardiac polysplenic
syndrome: US and surgical considerations. Radiology. 1987;163(2):377–9.
12. Liem N, Holcomb GW. Choledochal
bladder disease. In: Holcomb GWMJ, Ostlie DJ,
editors. Ashcraftʼs Pediatric Surgery. Philadelphia:
Elsevier Inc.; 2014. p.
Tamura T, Kobayashi H, Ichikawa
al. Prognostic implications of bile
593–606.
. 1995;195(1):193–5.
ry Atresia. In: Hol-
ergani G. Ultrasound
with gallbladder images
an CE. Bili-
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GL, Lovvorn HN 3rd. Concordance of imaging
modalities and cost minimization in the diagnosis
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2012;28(6):615–21.
14.
Huang CT, Lee HC, Chen WT, Jiang
Yeung CY. Usefulness of magnetic resonance cholangiopancreatography in pancreatobiliary abnormalities in pediatric patients. Pediatr Neonatol.
2011;52(6):332–6.
15. Otto AK, Neal MD, Slivka AN, Kane TD. An
appraisal of endoscopic retrograde cholangiopancreatography (ERCP) for pancreaticobiliary disease
in children: our institutional experience in 231 cases.
Surg Endosc. 2011;25(8):2536–40.
16. Rescorla FJ. Cholelithiasis, cholecystitis, and
common bile duct stones. Curr Opin Pediatr.
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Palasciano G, Portincasa P, V
Tardi S, Baldassarre G, et
and gallbladder volume in children and adolescents:
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1989;84(11):1378–82.
18. Wesdorp I, Bosman D, de Graaff A, Aronson D, van
der Blij F, Taminiau J. Clinical presentations and predisposing factors of cholelithiasis and sludge in children. J Pediatr Gastroenterol Nutr. 2000;31(4):411–7.
19. Gubernick JA, Rosenberg HK, Ilaslan H, Kessler A. US approach to jaundice in infants and
children. Radiographics: a review publication of
the Radiological Society of North America. Inc.
2000;20(1):173–95.
20.
Mehta S, Lopez ME, Chumpitazi BP, Mazziotti MV,
Brandt ML, Fishman DS. Clinical characteristics and
risk factors for symptomatic pediatric gallbladder
disease. Pediatrics. 2012;129(1):e82–8.
Balaguer EJ, Price MR, Burd RS. National trends in
21.
the utilization of cholecystectomy in children. J Surg
Res. 2006;134(1):68–73.
22. Herzog D, Bouchard G. High rate of complicated
idiopathic gallstone disease in pediatric patients of a
North American tertiary care center. World J Gastroenterol. 2008;14(10):1544–8.
23.
Tannuri AC, Leal AJ, V
Tannuri U. Management of gallstone disease in children: a new protocol based on the experience of a
single center. J Pediatr Surg. 2012;47(11):2033–8.
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Gruber PJ, Silverman RA, Gottesfeld S, Flaster E.
Presence of fever and leukocytosis in acute cholecystitis. Ann Emerg Med. 1996;28(3):273–7.
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A, Renslo R. Cholelithiasis and its complications in
children and adolescents: update and case discussion.
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UL, Boswell
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Tsai J, Sulkowski JP, Cooper
KJ, Minneci PC. Sensitivity and predictive value
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Lugo-Vicente HL. Trends in management
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Gallix BP, Aufort S, Pierredon MA, Garibaldi F
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Yamataka A, Ohshiro K, Okada Y, Hosoda
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,
Y, Fuji-
The Pancreas
Julia Scholsching and Oliver J. Muensterer
7
Introduction
Obtaining high-quality sonographic images of
the pancreas in children is challenging in many
aspects. Most importantly, the retroperitoneal location of the pancreas makes it difficult to visualize without good respiratory cooperation of the
patient. Furthermore, pathologies of the pancreas
in children are rare and may be misinterpreted
easily. However, with high-resolution modern
ultrasound devices, the resulting images have
improved, and sonographic examination of the
pancreas has become somewhat more routine.
This chapter describes instructions for choosing
the appropriate equipment, preparing the patient,
and systematically scanning the pancreas in order
to obtain clinically relevant pictures.
Scanning Techniques
Position of the Patient
Imaging of the pancreas is achieved with the
curvilinear and linear array transducer. A sector transducer can be useful in neonates. Fasting
of 4–6 h in older children or 3 h in neonates is
O. J. Muensterer () · J. Scholsching
Department of Pediatric Surgery, University Medicine
of the Johannes Gutenberg University Mainz,
Langenbeckstraße 1, 55131 Mainz, Germany
e-mail: oliver.muensterer@unimedizin-mainz.de
J. Scholsching
e-mail: julia.scholsching@unimedizin-mainz.de
© Springer International Publishing Switzerland 2016
S. Scholz, M. D. Jarboe (eds.), Diagnostic and Interventional Ultrasound in Pediatrics
and Pediatric Surgery, DOI 10.1007/978-3-319-21699-7_7
mandatory for best results since air in the colon
or bowel may limit visualization. It is advisable,
however, to have non-carbonated water or other
clear liquids available on-site to fill the stomach
as an acoustic window.
Usually, ultrasound imaging of the pancreas
starts in a supine position but can be changed
throughout the examination for best results.
A slight left lateral decubitus angulation of the
patient facilitates imaging of the body and tail,
whereas a right lateral position enhances the
view on the pancreatic head.
In a compliant child, locating the pancreas
is best achieved during maximum inspiration,
which places the left hepatic lobe over the pancreas to act as an acoustic window. Gentle pressure with the probe can be used to disperse any
overlying intestinal gas.
A useful adjunct for creating an acoustic window is to fill the stomach with non-carbonated
clear liquids. This should be done at the end of a
complete abdominal scan, and it is advisable to
postpone imaging for 15 min to allow air bubbles
ingested when swallowing the liquids to resolve.
Changing the position of the patient thereafter
leads to a shift of liquid from the gastric antrum
to the duodenum and can thereby improve visualization of the pancreatic head.
Anatomical Features/Sonographic Neighborhood/Probe Placement
The pancreas is located in the retroperitoneum
extending from the duodenum to the splenic
73
74 J. Scholsching and O. J. Muensterer
hilum. Closest to the duodenum is the pancreatic head (Latin, caput). Overlying the vertebral
column is the body (corpus), and the tail (cauda)
extends towards the spleen. Vessels dominate the
sonographic “neighborhood” of the pancreas and
serve as important landmarks. The pancreatic
head is surrounded by duodenum laterally, with
the superior mesenteric artery and vein running
along the posterior aspect of the head, anterior
to the uncinate process. The splenic vein accompanies the posterior wall of body tail in a mostly
parallel fashion, joining the superior mesenteric
vein forming the portal vein in a retropancreatic
location between the head and body. The superior margin of the corpus and cauda is marked by
the splenic artery. Left to the spine is the aorta,
which is typically round on transverse sections
and gives off the two renal arteries at this level. In
contrast, the vena cava is usually teardrop shaped
and located to the right of the spine.
These landmarks are used to localize the pancreas: Initially, the probe is placed beneath the
xhiphoid process, starting with a transverse epigastric view. By angulating the probe downward
slightly, the celiac trunk is seen superior to the
pancreas and the splenic vein running along in
parallel to the gland. With the probe in transverse
position, the splenic vein appears like a hockey
stick, whereas the celiac trunk often impresses
with a dove-like shape. The pancreas can be fully
visualized by moving the probe slowly from the
upper transverse epigastric view downward to a
subgastric angulation. In addition, the longitudi-
nal depiction—a “head to tail” survey—should
be performed with the probe in sagittal orientation, completed by an oblique subcostal view
with slow rotation of the probe in a clockwise
manner.
The main pancreatic duct is displayed parallel to the splenic vein, but is often hard to visualize if not dilated. Changes in diameter related
to obstruction due to a tumor, postinflammatory
stenosis, or choledocholithiasis should be noted
on the ultrasound report. Normal age findings of
the diameter of the main pancreatic duct in children have been poorly investigated, but the upper
limit for a non-dilated duct range from 1 mm in
1–6-year-olds up to 2 mm in teenagers [1], see
Table 7.1 Average approximate age-dependent sonographic measurements of the pancreatic duct in millimeters. (Adapted from [1])
Age (years) Normal Acute pancreatitis Chronic
1–3 1.13 1.9 n.a.
4–6 1.35 2.07 n.a.
7–9 1.67 2.13 2.42
10–12 1.78 2.34 2.77
13–15
16–18 2.05 2.63 3.15
1.92 2.56 2.91
pancreatitis
Table 7.1. Everything above 2 mm, particularly
when associated with an elevation of serum amylase and clinical findings of abdominal pain,
should be considered highly suspicious for acute
or chronic pancreatitis.
Examination of the pancreas should always be
considered as an integral part of a comprehensive evaluation of the hepatobiliary system, in
addition to the mandatory examination of the bile
duct, gallbladder, and liver parenchyma.
Age-Dependent Size and Echogenicity
The size of the pancreas is age dependent, with a
high interindividual variability [2, 3]. Measurements of the pancreas, particularly during routine
scans in otherwise healthy children without pancreatic disorders, are optional and usually have no
clinical significance. The corpus of the pancreas
is usually the easiest part to assess. When taking
measurements, the anterior–posterior diameters
of all parts of the pancreas should be obtained
and reported (see age-depending dimensions in
Table 7.2). The most substantial growth of the
Table 7.2 Average approximate age-dependent sonographic measurements of the pancreas in centimeters.
(Adapted from [1])
Age (years) Normal Acute pancreatitis Chronic
1–3 0.98 1.15 n.a.
4–6 1.01 1.22 n.a.
7–9 1.04 1.30 1.05
10–12 1.06 1.35 1.15
13–15 1.11 1.37 1.15
16–18 1.18 1.43 1.20
pancreatitis
757 The Pancreas
pancreas occurs in the first year of life [2, 3].
Pathologic increase in size at a young age mostly
occurs in cases of acute pancreatitis or congenital
hyperinsulinism (formerly known as nesidioblastosis). Patients with chronic pancreatitis often
have normal or decreased pancreatic caliber due
to fibrosis [1]. In cases of insulin-dependent diabetes mellitus (IDDM), studies have shown that
long duration of the disease was associated with
a reduction in the size of the pancreas at all ages.
Furthermore, the decrease in the size was correlated with the severity of insulin deficiency due
to fibrosis [4].
In healthy children, the echo structure of the
pancreas appears “cobblestone-like” on high-
resolution ultrasound imaging. In infants, the
echogenicity initially appears similar to liver,
becoming more hyperechogenic with increasing
age (Fig. 7.1a, b). In newborns, however, the pancreas may also be transiently slightly hyperechoic [5]. Reasons for diffuse hyperechoicity include
fibrosis, fatty degeneration, long-term corticosteroid or cytostatic therapy, Shwachman–Diamond
syndrome, congenital hyperinsulinism, chronic
pancreatitis, edematous pancreatitis, hemosiderosis, parenteral nutrition, Cushing’s disease, and
obesity. Focal alterations of the size and echogenicity are described separately below.
Fig. 7.1 a Normal pancreas (P) imaged through the left
lobe of the liver (L). The pancreatic duct is partially visible (D), while the tail is obscured by the gas-containing
stomach (S). b Transverse ultrasonography (US) image
shows the measurements of the head, body, and tail of the
pancreas in a child. [6]
Sonographic Pathology of the Pancreas
Pancreatic Embryology and Related Anomalies
The embryological fusion of the pancreas from
a ventral and dorsal bud gives rise to a certain
variance in the anatomy of the major and minor
pancreatic duct. Note that in 60 %, the two ducts
insert separately into the duodenum, whereas in
about 30 %, the individual ducts unite before the
main pancreatic duct drains into the duodenum in
a single location. Pancreatic duct anomalies can
predispose to recurrent pancreatitis.
Pancreas divisum is the most common anatomical variant and occurs if no or only incomplete fusion of the ventral and dorsal bud takes
place. The major portion of the pancreatic secretion drains into the duodenum through the minor
papilla via the dorsal duct. It can be a reason for
recurrent pancreatitis due to relative obstruction,
but the need of therapy in asymptomatic cases is
still controversial. Ultrasound is the first diagnostic tool to rule out pancreatitis or pancreatic pseudocysts as a manifestation of pancreas divisum.
In order to clearly evaluate the ductal anomaly,
ultrasound should be complemented by endoscopic retrograde cholecystopancreatography
(ERCP) or magnetic resonance cholecystopancreatography (MRCP). However, new ultrasound
techniques, including secretin-stimulated ultrasonography (US) [7] or endoscopic ultrasonography (EUS) [8], have also been employed and
may be more accurate.
76 J. Scholsching and O. J. Muensterer
Fig. 7.2 Gallstone pancreatitis. The pancreatic head
(PH) is echogenic and swollen. The pancreatic duct (1)
is mildly dilated. The mesenteric artery is visible (A) as
a landmark
Annular pancreas can cause congenital duodenal obstruction, seen on ultrasound as the typical
“double bubble” appearance as an indirect sign
of the diagnosis.
Acute Pancreatitis
Acute pancreatitis in children is rare, but recent
studies found that the prevalence is increasing, possibly due to improved diagnostic tools
or higher awareness [9]. It is associated with a
high mortality and morbidity [10]. While idiopathic in 23 % of cases, the most common causes
are trauma (22 %), structural anomalies (15 %),
multisystem disease (14 %), drugs and toxins
(12 %), as well as viral infections (10 %). Cholelithiasis causing pancreatitis due to obstruction
has previously been considered unusual [11], but
lately the incidence has been increasing, in part
due to a rise in pediatric and adolescent obesity
(Fig. 7.2) [12].
Acute pancreatitis is defined by an acute onset
of symptoms (abdominal pain, vomiting, paralytic ileus, rebound tenderness, jaundice), elevated
levels of serum/urine amylase, and a pathological ultrasound with compromise of pancreatic
structure and function. Factors secondary to the
pancreatitis itself may obscure the sonographic
diagnosis, particularly in children. For example,
increased intestinal gas due to paralytic ileus or
lack of compliance due to pain can negatively
impact the examination.
Fig. 7.3 Doppler study of acute pancreatitis. The head
(H) and body of the pancreas are visible, with the splenic artery (SA) serving as a landmark. The spine is in the
background (S). There is peripancreatic fluid (F) visible
as a sign of inflammation
Ultrasound may show an increase in anterior–posterior diameter of the pancreas, usually
because of edematous swelling with diffuse or
focal-elevated echogenicity. Organ enlargement,
however, can be absent in up to 50 % of cases.
Peripancreatic fluid is another typical finding
(Fig. 7.3). As mentioned beforehand, dilation
of the pancreatic duct greater than 1.5 mm in
children between 1 and 6 years, 1.9 mm at ages
7–12 years, 2.2 mm at ages 13–18 years is significantly associated with the presence of acute
pancreatitis [1].
In summary, diagnostic accuracy of acute pancreatitis by native ultrasound depends on severity, the presence of complications such as paralytic ileus, typical associated findings, including
a pancreatic pseudocysts, as well as operator
experience. Increased diagnostic accuracy can
be achieved with contrast-enhanced ultrasound,
which is particularly useful to detect ischemic
areas seen with pancreatic necrosis [13]. Using
ultrasound elastography to gain information
about organ stiffness not accessible to exterior
palpation could also increase the rate of correct
diagnosis in the future, but is currently mostly
experimental [14].
When in doubt, the diagnostic tools can be
extended to MRCP with full imaging of the
pancreatic duct system, discovering structural
anomalies. In most young children, sedation or
full anesthesia is needed for this study, and visu-
777 The Pancreas
Fig. 7.4 Transverse ultrasonography (US) image in a
5-year-old boy with chronic hereditary pancreatitis shows
the typical features of chronic pancreatitis: calcifications
(small arrows) and dilatation of the pancreatic duct (large
arrow). C confluence of the superior mesenteric and
splenic veins [19]
alization of ducts with a diameter less than 1 mm
is still difficult [15].
Chronic Pancreatitis
In chronic pancreatitis—which is rather rare in
children—the etiology includes cystic fibrosis,
fibrosing pancreatitis, hereditary chronic pancreatitis, inborn errors of metabolism, or structural
anomalies (Fig. 7.4). Chronic pancreatitis is defined as a combination of clinical symptoms such
as abdominal pain, exocrine (malabsorprion, steatorrhea, etc.) and endocrine dysfunction (diabetes mellitus), along with imaging findings characteristic of the irreversible morphologic damage
of the pancreatic parenchyma [10, 16–18].
The sonographic examination of chronic pancreatitis may show inhomogeneous echogenicity
and prominent margins caused by progressive fibrosis and fatty injections of the gland. The size
of the pancreas can be normal or reduced. The
duct appears dilated and sometimes irregular in
its course, with intermittent dilation and stenosis.
Ultrasound-guided fine needle aspiration biopsy
to confirm the diagnosis has been found to have
a lower complication rate (1 %) than ERCP [15].
Potential complications of chronic pancreatitis
are pseudocystformation, focal calcifications,
and recurrent intraductal stones (Fig. 7.5).
Fig. 7.5 Transverse ultrasound of the pancreas in an
older with chronic pancreatitis. The liver is used as a sonographic window. Note the two large stones obstructing
the dilated pancreatic duct (arrows). (Case courtesy of Dr
Maulik S. Patel, radiopaedia.org)
Cystic Fibrosis
Pancreatic involvement in patients with cystic
fibrosis occurs more often than liver disease (85–
90 %) with progressive fatty tissue replacement
and atrophy resulting in exocrine insufficiency
[17]. In most cases, the pancreas appears as a
homogeneous hyperechoic band representing
the lipomatosis and overall decreased size due to
progressive atrophy. The pancreatic duct can be
dilated or inhomogeneous in size because of cell
debris, scarring, and obstruction. Multiple small
pancreatic cysts, calcifications, and focal hypoechoic areas representing fibrosis can be present. Detection of very small cysts with diameters
of less than 1–3 mm can be difficult. Contrastenhanced US or EUS may increase detection of
very small lesions. Despite the mentioned risk
factors, pancreatitis is actually rarely (1.2 %)
seen sonographically in patients with cystic fibrosis [15].
Pseudocysts
In children, pancreatic cysts are usually secondary to pancreatitis caused by blunt abdominal
trauma but can also occur in pancreatitis of other
origin or genetic diseases such as cystic fibrosis.
Solitary, congenital cysts are rare and may be re-
78 J. Scholsching and O. J. Muensterer
lated to ductal anomalies with a higher incidence
in patients with von Hippel–Lindau syndrome or
polycystic kidney disease [20].
Sonographically they appear as anechoic,
round, thin-walled structures which are well distinguishable from the surrounding tissue.
Pancreatic Neoplasms
The most common pancreatic tumors in children
are adenomas, insulinoma, and so-called solid
pseudopapillary (or Frantz) tumors (Fig. 7.6).
On ultrasound, the two former entities usually
present as round areas of uniform echogenicity.
The latter are usually well marginated with solid
and cystic areas surrounded by a well-demarcated, fibrous capsule [21]. Solid pseudopapillary tumors are more common in girls and usually behave like a very low-grade malignancy
[23]. Therefore, complete removal is the treatment of choice. Ultrasound is an ideal modality for postoperative follow-up to rule out local
recurrence.
Other, but much less common tumors of the
pancreas in children are pancreatoblastoma and
adenocarcinoma. The sonographic imaging features are those of a large heterogeneous tumor
that invades into adjacent tissues and is not well
demarcated. A sonographer who discovers a pancreatic tumor in a child should think of the pos-
sible association with Type 1 multiple endocrine
neoplasia (MEN).
Intraoperative ultrasound may be useful to
detect pancreatic tumors during surgery and to
determine resection margins more accurately
[24].
Blunt Pancreatic Trauma
The pancreas itself is not assessed during the
focused assessment with sonography in trauma
(FAST) scan. A comprehensive ultrasound exam,
however, in a stable pediatric trauma victim
can aid in the diagnosis, although the sensitivity for traumatic injuries of the pancreas may
be lower than that of computed tomography
[25].
Pancreatic lacerations may present as a lowechogenic gap in the continuity of the organ. Free
fluid may be visible in the retroperitoneum as a
sign of ductal disruption (Fig. 7.7a, b). Moore
et al. have proposed a grading system of blunt
pancreatic trauma [26], which is adaptable to sonographic findings (Table 7.3).
Traumatic injuries of the pancreas that involve the duct may lead to pseudocyst formation
(Fig. 7.8a, b, c, d; [27]). Ultrasound is an ideal
modality for the follow-up of these sequellae
since size, wall thickness, and surrounding tissue
reaction can be assessed. Once formed, pediatric pseudocysts are drainable under endoscopic
ultrasound guidance with a high success rate
[28, 29].
Fig. 7.6 Heterogenous mass at the junction of the pancre-
atic head and the caudate lobe of the liver [22]
Future Tools and New Horizons in Pancreatic Sonography
Endoscopic Ultrasound
In recent years, endoscopic ultrasound has been
employed and established for a variety of pediatric indications, including pancreatitis, pancreatic masses, cystic lesions, suspected annular
pancreas, suspected common bile duct stones,
abdominal pain, and ampullary adenoma [31].
797 The Pancreas
Fig. 7.7 a Young boy with history of blunt abdominal
trauma showing bulky and heterogenous pancreas with
linear anechoic laceration in the region of body of pancreas (arrow) with minimal free fluid around pancreas [22].
Furthermore, therapeutic interventions guided by
endoscopic ultrasound, and sometimes combined
with ERCP, have been performed successfully in
children [32]. The technique entails placement
of the ultrasound probe endoscopically into the
stomach or duodenum to obtain high-resolution
Table 7.3 Grading of blunt pancreatic injuries. (Adapted from [25])
Grade Description
1
Minor contusion or superficial laceration without duct injury
2 Deep contusion or laceration without duct injury
or tissue loss
3 Distal transection or parenchymal injury with
duct injury
4 Proximal (right of the superior mesenteric vein)
transection
5 Complete disruption of the pancreatic head
b Typical location for pancreatic trauma due to the underlying spine. (Courtesy of S. Ledbetter and R. Smithuis,
Acute Abdomen—Role of computed tomography (CT) in
Trauma. www.radiologyassistant.nl)
real-time ultrasound pictures of the pancreas.
The main disadvantage is that the intervention
is more invasive than transabdominal ultrasound
and mostly requires sedation or even general anesthesia in children.
Ultrasound Elastography
As mentioned above, ultrasound elastography is
currently being investigated to add tissue elasticity to the conventional morphologic and flow
information acquired during the sonographic
exam. In children, elastographic techniques have
been used to assess for pancreatic fibrosis in patients with cystic fibrosis [33] and the degree of
inflammation in patients with acute pancreatitis
[19], some of which were children as young as
6 years old.