Der Radiologe

, Volume 46, Issue 4, pp 321–338 | Cite as

Pankreas — Teil I

Angeborene Veränderungen, akute und chronische Pankreatitis
  • W. Schima
  • A. Ba-Ssalamah
  • C. Plank
  • C. Kulinna-Cosentini
  • A. Püspök
Weiterbildung · Zertifizierte Fortbildung

Zusammenfassung

Das Pankreas entsteht durch Verschmelzung der ventralen und dorsalen Pankreasanlage in der Embryonalperiode. Die wichtigsten angeborenen Störungen sind Pancreas divisum (Häufigkeit 5–10%), mit fehlender Verschmelzung der beiden Anlagen und separat mündendem Ductus santorini und Ductus wirsungianus, und Pancreas anulare (Häufigkeit etwa 1:2000) mit zirkulär das Duodenum umgebendem Gewebe (Duodenalstenose!). Die akute Pankreatitis wird meist durch Cholangiolithiasis oder Alkoholabusus verursacht. Sie wird in der Atlanta-Klassifikation in eine ödematöse und eine nekrotisierende Form eingeteilt. Methode der Wahl zu ihrer Beurteilung und relevanter Komplikationen (Thrombosen, Abszesse, Pseudozysten) ist die kontrastverstärkte Multi-Detektor-CT. Die MRT wird meist nur zum Nachweis einer Choledocholithiasis bei Verdacht auf biliäre Pankreatitis eingesetzt. Chronische Pankreatitis führt zu irreversiblem Funktionsverlust der Bauchspeicheldrüse. Mit der MRCP kann das Pankreasgangsystem nichtinvasiv exzellent dargestellt werden. Die sekretinverstärkte MRCP zeigt besser ein Pancreas divisum und Strikturen, zudem kann die exokrine Funktion des Pankreas beurteilt werden. Der entzündliche Pseudotumor und die Groove-Pankreatitis sind schwierig von einem Karzinom zu differenzieren, hier sichert multimodale Bildgebung (MDCT, MRT, Endosonographie, Biopsie) den Befund.

Schlüsselwörter

Pankreas Pankreatitis Pancreas divisum Pancreas anulare Kontrastverstärkte CT/MRT 

Pancreas — part I

Congenital changes, acute and chronic pancreatitis

Abstract

The pancreas develops from ventral and the dorsal buds, which undergo fusion. Failure to fuse results in pancreas divisum, which is defined by separate pancreatic ductal systems draining into the duodenum. Risk of developing pancreatitis is increased in pancreas divisum because of insufficient drainage. MR cholangiopancreatography (MRCP) is the technique of choice for detecting pancreas divisum non-invasively. Annular pancreas is the result of incomplete rotation of the pancreatic bud around the duodenum with the persistence of parenchyma or a fibrous band encircling (and sometimes stenosing) the duodenum. Acute pancreatitis is usually caused by bile duct stones or alcohol abuse. The Atlanta classification differentiates between mild acute and severe acute pancreatitis associated with organ failure and/or local complications such as necrosis, abscess or pseudocyst. Contrast-enhanced multi-detector row CT is the method of choice to assess the extent of disease. Balthazar et al.’s CT severity index assesses the risk of mortality and morbidity. In acute pancreatitis, the role of MRCP is mainly limited to finding bile duct stones in patients with suspected biliary pancreatitis. Chronic pancreatitis results in relentless and irreversible loss of exocrine (and sometimes endocrine) function of the pancreas. MDCT even shows subtle calcifications. MRCP is the method of choice for non-invasive assessment of the duct. Inflammatory pseudotumor in chronic pancreatitis and groove pancreatitis are difficult to differentiate from pancreatic cancer. In these cases, multiple imaging methods such as MDCT, MRI and endosonography including biopsy may be used to make a diagnosis.

Keywords

Pancreas Pancreatitis Pancreas divisum Annular pancreas Contrast-enhanced CT/MRI 
This is a preview of subscription content, log in to check access.

Notes

Interessenkonflikt:

Es besteht kein Interessenkonflikt. Der korrespondierende Autor versichert, dass keine Verbindungen mit einer Firma, deren Produkt in dem Artikel genannt ist, oder einer Firma, die ein Konkurrenzprodukt vertreibt, bestehen. Die Präsentation des Themas ist unabhängig und die Darstellung der Inhalte produktneutral.

Literatur

  1. 1.
    Axon ATR (1989) Endoscopic retrograde cholangiopancreatography. Cambridge classification. Radiol Clin N Am 27: 39–50PubMedGoogle Scholar
  2. 2.
    Baert AL, Delorme G, van Hoe Le (1999) Radiology of the Pancreas, 2nd edn. Springer, Berlin Heidelberg New YorkGoogle Scholar
  3. 3.
    Balthazar EJ (2002) Staging of acute pancreatitis. Radiol Clin N Am 40: 1199–1209PubMedGoogle Scholar
  4. 4.
    Balthazar EJ (2002) Complications of acute pancreatitis. Clinical and CT evaluation. Radiol Clin N Am 40: 1211–1227PubMedGoogle Scholar
  5. 5.
    Balthazar EJ, Ranson JHC, Naidich DP, Megibow AJ, Caccavale R, Cooper MM (1985) Acute pancreatitis: prognostic value of CT. Radiology 156: 767–772PubMedGoogle Scholar
  6. 6.
    Balthazar EJ, Robinson DL, Megibow AJ, Ranson JHC (1990) Acute pancreatitis: value of CT in establishing prognosis. Radiology 174: 331–336PubMedGoogle Scholar
  7. 7.
    Balthazar EJ, Freeny PC, van Sonnenberg E (1994) Imaging and intervention in acute pancreatitis. Radiology 193: 297–306PubMedGoogle Scholar
  8. 8.
    Brambs HJ (1996) Developmental anomalies and congenital diseases of the pancreas. Radiologe 36: 381–388CrossRefPubMedGoogle Scholar
  9. 9.
    Cappeliez O, Delhaye M, Deviere J et al. (2000) Chronic pancreatitis: evaluation of pancreatic exocrine function with MR pancreatography after secretin stimulation. Radiology 215: 358–364PubMedGoogle Scholar
  10. 10.
    Cavestro GM, Comparato G, Nouvenne A, Sianesi M, Di Mario F (2003) The race from chronic pancreatitis to pancreatic cancer. J Pancreas 4: 165–168Google Scholar
  11. 11.
    Chari ST, Singer MV (1994) The problem of classification and staging of chronic pancreatitis. Proposals based on current knowlege of its natural history. Scand J Gastroenterol 29: 949–960PubMedGoogle Scholar
  12. 12.
    Chong M, Freeny PC, Schmiedl UP (1998) Pancreatic arterial anatomy: depiction with dual-phase helical CT. Radiology 208: 537–542PubMedGoogle Scholar
  13. 13.
    Enriquez G, Vazquez E, Aso C, Castellote A, Garcia-Pena P, Lucaya J (1998) Pediatric pancreas: an overview. Eur Radiol 8: 1236–1244CrossRefPubMedGoogle Scholar
  14. 14.
    Fletcher JG, Wiersma MJ, Farrell MA et al. (2003) Pancreatic malignancy: value of arterial, pancreatic, and hepatic phase imaging with multi-detector row CT. Radiology 229: 81–90PubMedGoogle Scholar
  15. 15.
    Graf O, Boland GW, Warshaw AL, Fernandez-del Castillo C, Hahn PF, Mueller PR (1997) Arterial versus portal venous helical CT for revealing pancreatic adenocarcinoma: conspicuity of tumor and critical vascular anatomy. AJR Am J Roentgenol 169: 119–123PubMedGoogle Scholar
  16. 16.
    Helmberger T, Gauger J, Holzknecht N, Fölsing C, Reiser M (1996) MRT des Pankreas: Stellenwert, Technik und Applikation. Radiologe 36: 413–418CrossRefPubMedGoogle Scholar
  17. 17.
    Ichikawa T, Sou H, Araki T et al. (2001) Duct-penetrating sign at MRCP: usefulness for differentiating inflammatory pancreatic mass from pancreatic carcinomas. Radiology 221: 107–116PubMedGoogle Scholar
  18. 18.
    Irie H, Honda H, Kuroiwa T et al. (1998) MRI of groove pancreatitis. J Comput Assist Tomogr 22: 651–655CrossRefPubMedGoogle Scholar
  19. 19.
    Isenmann R, Buchler M, Uhl W, Malfertheiner P, Martini M, Beger HG (1993) Pancreatic necrosis: an early finding in severe acute pancreatitis. Pancreas 8: 358–361PubMedGoogle Scholar
  20. 20.
    Itoh S, Takada A, Satake H, Ota T, Ishigaki T (2005) Diagnostic value of multislice computed tomography for pancreas divisum. Assessment with coronal oblique reconstruction images. J Comput Assist Tomogr 29: 452–460CrossRefPubMedGoogle Scholar
  21. 21.
    Johnson CD, Stephens DH, Sarr MG (1991) CT of acute pancreatitis: correlation between lack of contrast enhancement and pancreatic necrosis. AJR Am J Roentgenol 156: 93–95PubMedGoogle Scholar
  22. 22.
    Karlson B-M, Ekbom A, Josefsson S, McLaughlin JK, Fraumeni JFJr, Nyren O (1997) The risk of pancreatic cancer following pancreatitis: an association due to confounding? Gastroenterology 113: 587–592CrossRefPubMedGoogle Scholar
  23. 23.
    Lowenfels AB, Maisonneuve PM, Cavallini G et al. (1993) Pancreatitis and the risk of pancreatic cancer. N Engl J Med 328: 1435–1437CrossRefGoogle Scholar
  24. 24.
    Lu DSK, Vedantham S, Krasny RM, Kadell B, Berger WL, Reber HA (1996) Two-phase helical CT for pancreatic tumors: pancreatic versus hepatic phase enhancement of tumor, pancreas, and vascular structures. Radiology 199: 697–701PubMedGoogle Scholar
  25. 25.
    Manfredi R, Costamagna G, Brizi MG et al. (2000) Pancreas divisum and „Santorinicele“: diagnosis with dynamic MR cholangiopancreatography with secretin stimulation. Radiology 217: 403–408PubMedGoogle Scholar
  26. 26.
    Morana G, Tapparelli M, Faccioli N, D’Onofrio M, Pozzi Mucelli R (2005) Autoimmune pancreatitis: instrumental diagnosis. J Pancreas [Suppl] 6: 102–107Google Scholar
  27. 27.
    Morgan DE, Logan K, Baron TH, Koehler RE, Smith JK (1999) Pancreas divisum: implications for diagnostic and therapeutic pancreatography. AJR Am J Roentgenol 173: 193–198PubMedGoogle Scholar
  28. 28.
    Nino-Murcia M, Jeffrey RB, Beaulieu CF, Li KCP, Rubin GD (2001) Multidetector CT of the pancreas and bile duct system: value of curved planar reformations. AJR Am J Roentgenol 176: 689–693PubMedGoogle Scholar
  29. 29.
    Schima W (2003) Pankreas. In: Lechner G, Breitenseher M (Hrsg) Lehrbuch der radiologisch-klinischen Diagnostik. Maudrich, Wien, S 209–218Google Scholar
  30. 30.
    Schima W, Függer R, Schober E et al. (2002) Diagnosis and staging of pancreatic cancer: comparison of mangafodipir-enhanced MRI and contrast-enhanced helical hydro-CT. AJR Am J Roentgenol 179: 717–724PubMedGoogle Scholar
  31. 31.
    Schueller G, Prokesch R, Weidekamm-Schueller C et al. (2006) MDCT imaging of the pancreas: effects of contrast material flow rates and individualized scan delay. Radiology (in press)Google Scholar
  32. 32.
    Tublin ME, Tessler FN, Cheng SL, Peters TL, McGovern PC (1999) Effect of injection rate of contrast medium on pancreatic and hepatic helical CT. Radiology 210: 97–101PubMedGoogle Scholar
  33. 33.
    Yogi Y, Shibue T, Hashimoto S (1987) Annular pancreas detected in adult, diagnosed by endoscopic retrograde cholangiopancreatography. Gastroenterol Jpn 22: 92–94PubMedGoogle Scholar

Copyright information

© Springer Medizin Verlag 2006

Authors and Affiliations

  • W. Schima
    • 1
    • 3
  • A. Ba-Ssalamah
    • 1
  • C. Plank
    • 1
  • C. Kulinna-Cosentini
    • 1
  • A. Püspök
    • 2
  1. 1.Universitätsklinik für RadiodiagnostikMedizinische Universität Wien
  2. 2.Abteilung für Gastroenterologie und HepatologieUniversitätsklinik für Innere Medizin 4, Medizinische Universität Wien
  3. 3.Universitätsklinik für RadiodiagnostikMedizinische Universität WienWienÖsterreich

Personalised recommendations