X-ray of the pancreas

The pancreas is located in the retroperitoneum. Its head is to the right of the midline in the loop of the duodenum, and the tail extends towards the collar of the spleen. The total length of the gland is 12-15 cm, width - 3-6 cm, thickness 2-4 cm. The secretion of the gland is released through the pancreatic duct (virsung duct), whose diameter usually does not exceed 2-3 mm. It opens into the duodenum together with the common bile duct through the large nipple of the duodenum. An additional duct of the pancreas (santorionium in the duct) opens through the small nipple of the duodenum.

On the survey radiographs of the abdominal cavity the pancreas is indistinguishable. Exceptions are only rare cases of calcifications - parenchyma, pseudocyst walls and stones in ducts with chronic pancreatitis. On the survey images, as well as in the contrast X-ray examination of the stomach and intestine, indirect signs of lesion of the gland may be revealed. Thus, with volumetric lesions of her there is a separation of the loops of the small intestine, an increase in the distance between the stomach and the transverse colon. Especially visually the volumetric processes in the gland's head appear from the side of the duodenal loop: it expands, the walls of the intestine deform, the descending part of it acquires the form of an "inverted triplet" (Frostberg's symptom). In acute pancreatitis, chest radiographs can reveal infiltrates in the basal parts of the lung and pleural effusion.

Sonography is the primary method of studying the pancreas. On the sonograms of the iron is revealed as an elongated, not quite uniform band between the left lobe of the liver and the stomach in front and inferior vena cava, the abdominal aorta, the spine and the spleen vein from behind. Near the gland, you can identify other anatomical structures: the superior mesenteric artery and vein, splenic artery, hepatic artery, portal vein. Echogenicity of the gland is usually somewhat higher than that of the liver. It should be taken into account that the pancreas is visible on sonograms far from all individuals. In about 20% of patients, the ultrasound location of the gland is hampered by swollen intestinal loops. The duct of the gland is detected on sonograms in only 1/3 of patients. Some useful information is provided by color Doppler mapping. It allows to evaluate the intraorganic blood flow, which is used in the differential diagnosis of bulk lesions. The spatial resolution of sonography in the diagnosis of volumetric processes in the pancreas is about 1 cm.

Computer tomography allows you to obtain extremely important information about the condition of the pancreas. Its spatial resolution is much better than that of sonography, and is about 3-4 mm. CT provides an opportunity to accurately assess the condition of the gland itself, as well as other organs: bile ducts, kidneys, spleen, mesentery, intestine. An important advantage of CT before sonography is the ability to visualize the gland in those cases when ultrasound is powerless - in conditions of pronounced meteorism. For differential diagnostics of volumetric formations, a CT with gain is used, i.e. The introduction of contrasting substances. MRI and scintigraphy are at present still of limited importance in the examination of patients with pancreatic lesions.

Endoscopic retrograde cholangiopancreatography (ERCP) is an important diagnostic study of the pancreatic ducts and to some extent its parenchyma. This method makes it possible to assess the patency of the ducts in cancer and pancreatitis, which is extremely important in the design of the surgical treatment plan, and also to reveal the pathological communication of the ducts with cystic formations.

Angiography of the pancreas is currently used rarely, mainly for differential diagnosis of endocrine gland tumors and in some cases to clarify the nature of the surgery. Contrast the celiac trunk and the superior mesenteric artery.

Interventional methods in the study of the pancreas include fine needle biopsy, drainage and embolization. Fine-needle biopsy is performed under the control of sonography or CT. With its help, it is possible to examine the contents of the cyst, an abscess, and perform a biopsy of the tumor tissue. Through percutaneous drainage, abscesses and cysts are treated. In some cases, pseudocysts of the pancreas in the stomach or intestine are being internally drained. This makes it possible to avoid surgical intervention in those patients in whom it is contraindicated for some reason. Embolization of pancreatic arteries is performed in the presence of aneurysms, which can arise as complications of chronic inducing pancreatitis.

X-ray diagnosis of pancreatic lesions

Acute pancreatitis is diagnosed on the basis of the results of not only clinical examination and laboratory tests (in particular, an increase in the concentration of trypsin in the blood), but also mainly CT and MRI. When CT is determined by the increase in the gland, increasing its density due to edema. After a preliminary survey tomographic study, an enhanced CT scan is performed. This allows us to distinguish acute edematous pancreatitis, in which there is an increase in the density of the gland shadow after the administration of contrast medium, and a hemorrhagic necrotic form of pancreatitis, in which such an increase in the density of the gland tissue in response to the introduction of a contrast agent does not occur. In addition, CT can identify complications of pancreatitis - the formation of cysts and abscesses. Sonography with this disease is of less importance, since ultrasound imaging of the gland is generally difficult due to the presence of a large number of swollen bowel loops.

With chronic pancreatitis, the results of sonography are more convincing. The gland can be enlarged or reduced (with fibrous pancreatitis). Even small deposits of lime and concrements are well diagnosed, as well as pseudocysts. On computer tomograms, the outlines of the pancreas are uneven and not always clear, the tissue density is not uniform. Abscesses and pseudocysts cause areas of reduced density (5-22 HU). Additional data can be obtained by ERCP. On pancreatograms, deformation of the ducts, their expansion, narrowing, unfilling, penetration of contrast medium into pseudocysts are detected.

A survey of patients with suspicion of a pancreatic tumor begins with sonography. A tumor causes an increase in any part of the gland, most often its head. The outlines of this department become uneven. The tumor node itself is seen as a uniform formation with uneven contours. If a cancerous tumor squeezes or sprouts the common biliary and pancreatic ducts, then they expand in places. Simultaneously, a stagnant increase in the gallbladder, as well as compression of the splenic or portal vein, is detected. Metastases in the lymph nodes of the abdominal cavity and liver can be detected.

On computer tomograms, many similar signs are determined: an increase in the affected part or the entire pancreas, the unevenness of its contours, the expansion of the bile ducts, the non-homogeneity of the structure of the gland in the tumor region. It is possible to establish tumor germination in vessels and adjacent tissues, metastases in lymph nodes, liver, kidneys, etc. In doubtful cases resort to the introduction of contrast medium. On amplified computer tomograms tumor nodes are displayed more clearly, as the increase in the density of their shadows lags considerably behind the strengthening of the shadow of normal pancreatic tissue. Density of cystic lesions on the strengthened computer tomograms does not change at all.

A number of important symptoms are found in ERCP. These include narrowing or amputation of the ducts (sometimes with the expansion of the prostenotic section), destruction of the lateral branches of the duct, displacement of the duct, deformation of the terminal part of the common bile and pancreatic ducts.

The pancreas function is studied using not only laboratory diagnostics, but also radioimmunoassay. As is known, the pancreas performs two basic physiological functions. First, as exocrine (exocrine) iron, it releases into the duodenum the juice containing enzymes that hydrolyse the main groups of food polymers. Secondly, as an endocrine (intrasecretory) gland, it secretes into the blood polypeptide hormones that regulate food assimilation and certain metabolic processes in the body. Both the exocrine and intrasecretory functions of the gland are studied using radioimmune tests. The release of lipase by the gland is judged on the basis of radiometry of the whole human body after ingestion of radioactive trioleate-glycerol. The content of trypsin is determined by the radioimmune method.

Insulin is involved in the breakdown of sugar and is the main regulator of blood glucose levels. It is produced by β-cells of the pancreas in the form of proinsulin. The latter consists of two parts: the biologically active form - the actual insulin and the inactive form - the C-peptide. The release of these molecules occurs in the blood. Insulin reaches the liver and is involved in the metabolism. At the same time about 60% of it is inactivated, and the rest returns to the bloodstream. The C-peptide passes the liver unchanged, and its concentration in the blood is preserved. Thus, although insulin and C-peptide are excreted in the pancreas in equal amounts, the latter in the blood is greater than insulin.

The study of hormone-enzymatic activity of the pancreas is performed by loading samples with glucose. Using a standard test kit, analyze the concentration of hormones before, and also after 1 and 2 hours after taking 50 g of glucose. Normally, the concentration of insulin after taking glucose begins to increase, and then decreases to normal levels. In patients with concealedly manifested diabetes and normal sugar content in the blood, the level of insulin in the blood rises slowly, the maximum recovery occurs in 90-120 minutes. With apparent diabetes, the rise of insulin in response to the sugar load is even more suppressed, the maximum is recorded after 2-3 hours. The value of the determination of the C-peptide is great in those cases when patients have been treated with insulin for a long time, since it is not possible to determine insulin in the radioimmunological way.