hi learners i'm from sano nerds and this video is on the pancreas where we will learn about the anatomy physiology and normal ultrasound appearance now the pancreas is an incredibly important organ it sits very central in the body and it's surrounded by many key landmarks it also has a dual function as an exocrine and endocrine organ due to its location though it's a really hard organ to see by ultrasound but we'll make sure to cover some tips to recognize the pancreas and how to image it section 5.1 global anatomy the vascular landmarks around the pancreas are huge for recognizing the pancreatic tissue by ultrasound you should be very familiar with the parts of the pancreas and how they are related to other midline structures the pancreas starts to form at about week four and starts functioning at week 10. now remember we all start as tubes and so the pancreas is going to arise from two buds off that duodenal portion of the embryonic tube the dorsal bud is going to give rise to the neck body and tail of the pancreas where the ventral bud gives rise to the head and incident process eventually those buds should fuse together creating the pancreas and the main pancreatic duct the pancreas sits across the back of the abdomen behind the stomach and the head of the pancreas is on the right side of the abdomen and it's connected to the duodenum which is the first section of the small intestines through a small tube called the pancreatic duct the more narrow end of the pancreas called the tail extends to the left side of the body near the spleen it is essential for the sonographer to understand how the structures in the abdomen surround the pancreas first i'm going to just give you kind of a summary of the relational anatomy then we'll go into a little bit more detail for each section of the pancreas and then we'll look at it again when we take a look at how the pancreas appears under ultrasound in general though the pancreas occupies the anterior peri-renal space and lies a weekly between the c-loop of the duodenum and the splenic hylum posterior to the pancreas are the connective pre-vertebral tissues the portal splenic confluence superior mesenteric vessels the aorta inferior vena cava and the lower border of the diaphragm the stomach duodenum and transverse colon are going to form the superior and lateral borders of the pancreas so in our image here we can see that we have the pancreas this yellow kind of lumpy bumpy comma shaped structure the head sits within the cradle of the sea loop of the duodenum the duodenum is the first part of the intestines right from the stomach so we see that wrap around the pancreas head the tail then extends more superiorly towards the hilum of the spleen the tricky part about the pancreas though is that it does sit right behind or posterior to the stomach and so we actually are kind of seeing the stomach being transparent in this image so we can see more of the pancreas but you can kind of see the outline here everything that's this darker yellow is covered by the stomach which makes it hard to see by ultrasound section 5.2 pancreas anatomy the pancreas is divided into five main parts the onsonic process the head neck body and tail so again we have our c loop of our duodenum the unsettling process is this little curly q-tip of the pancreas wrapping around to the head that sits on the cradle of the c-loop the neck is another little tiny part next to the head and then we have the body and tail let's take a look at each of these sections and talk about some of their landmarks starting with the uncertain process the incident process again is a very small curved tip at the end of the head of the pancreas the size of the incident process is going to vary from person to person the major landmarks for the ultimate process are going to include the ivc posterior to it and the superior mesenteric vein anterior to it so in other words the enzyme process is kind of sandwiched between the ivc and the smv in our image here we can see the ivc we have the onsen process just anterior to it and then just anterior to the onsen process or the top of the sandwich is the smv here as it connects back to the portal confluence next up we have the pancreas head now due to the angle of the pancreas in the body the head ends up being the most inferior portion of the gland because it sits at an oblique angle the head is going to be surrounded by the sea loop of the duodenum and although the head is usually a little bit easier to see by ultrasound depending on how that duodenum is acting up it can also make it kind of hard to see a couple important things about the head of the pancreas it is home to the common bile duct groove and the gastroduodenal artery and it's also the most common place for pancreatic cancer to form the head ends up being a very important area for the sonographer to evaluate for pathology and to use for finding other structures when we're looking for the head on ultrasound we are going to look for the ivc being posterior to it we're going to see that the head is towards the patient's right of the portal confluence the main portal vein and caudate lobe are going to be just superior to the head and then we'll see the duodenum even further right into the body so here's the head of the pancreas we have the unseen process coming off of it you can see it's going to sit right in that c-loop of the duodenum you should be able to identify the gastroduodenal artery in the more anterior portion of it and then we see the common bile duct groove in the more posterior portion of the pancreas head moving to the neck the neck is located between the pancreatic head and body and oftentimes pancreatic neck is just going to be included as part of the body but we do recognize that it has its own landmarks so the neck is just this very small sliver of pancreas right here the superior mesenteric vein is going to run a posterior and inferior to it so it comes up inferiorly and then kind of turns deep into the body running posteriorly to the portal confluence we can also see then that the portal confluence is posterior to the neck as well so here's that portal confluence where the superior mesenteric vein and the splenic vein join together again that's just posterior to the pancreas neck moving down the pancreas then we have the pancreatic body now the body is going to make up the largest portion of the pancreas and the body is often the most difficult to see in its entirety due to its position posterior to the stomach so this is all body here most of the pancreas is made up by the body and most of that body sits right behind the stomach so it is not uncommon to have to say pancreas area because the stomach or other bowel in the area is blocking our visualization of it the landmarks that will use them to identify the body of the pancreas are going to include the aorta celiac access left renal vein adrenal gland and kidney all sitting posterior to the body so in this image we have the aorta we have the superior mesenteric artery coming off here so that's kind of the start of the body and then as we follow the body over we'll find the left renal vein running underneath it the adrenal gland and then the kidney is kind of right over here as well sitting a little bit more medial into the body so the body of the pancreas sits mostly from the aorta over to about the kidney maybe just a little bit more medial to that some other structures that we'll see are the splenic artery running along the superior border of the body so again you can see the splenic artery coming off as the left branch of the celiac axis it's a very tortuous vessel that runs on the superior side of the pancreas coursing along the body ventures the tail and into the spleen not so much a sonographic landmark but definitely a landmark is the antrim of the stomach and that's going to be anterior to it as well so again we have the stomach here we have the fundus of the stomach body of the stomach and the antrum is the part right before the pylorus muscle the pylorus muscle then connects into the duodenum so the antrum is just that last little bit of stomach right before going into the small intestines so that again is going to be the start of the body of the pancreas our last section then is the pancreatic tail so the tail is just this last little bit back here the pancreas tail is going to extend more superior into the body towards the hilum of the spleen and ends up being kind of sandwiched in between the spleen and the left kidney and there's actually some transverse colon that comes along here too so this can also be a very difficult spot to see if you haven't noticed the pattern yet the fingers is a very hard organ to see by ultrasound looking at some of the landmarks for the tail then we're going to see the kidney posterior to it so we'll see the kidney kind of down here the aorta is going to be seen more towards the right of the patient the splenic vein is probably our most prominent landmark and we're going to see that coursing along the posterior border so you can see in this picture here it's on the back side because it's on the posterior but it comes out of the spleen kind of wraps around the tail and up towards that portal confluence and then as i mentioned earlier the spelling artery does continue along the tail and into the spleen when we are imaging the tail on ultrasound you want to make sure that you increase your depth a little bit even though it does angle a little bit more superior into the body it does dive a little bit deeper into the body as well so especially when we are transverse on the pancreas we want to include enough depth so we can see all of the tail and then here's this image again just with all of those landmarks that we talked about if you read through the chart start on the left side you say the unsung process is anterior to the ivc the unsung process is posterior to the smv and pancreas so the first time i presented everything i told you how the landmarks are in relationship to the pancreas in this chart i'm telling you how the pancreas is in relationship to the landmark so it's a little bit backwards between the two you should know how to flip flop them both ways ivc is posterior to the head of the pancreas the head is anterior to the ivc you should know it both ways section 5.3 pancreatic ducts there are two ducts on the pancreas that we need to know about the first one is the duct of worst sung and the second one is the duck of santorini now the dr boar song is also known as our main pancreatic duct and that makes sense because it runs all the way from the tail down through the body into the head joins up with the common bile duct and then we'll enter through the ample of water into the duodenum so the duct of warsong is the big one it's the main pancreatic duct the accessory duct then is also known as the ductus santorini and the ductal santorini does branch off of the main duct and it is going to have its own entrance into the duodenum about two centimeters superior to where the aquila water enters so dect of warsang is the main pancreatic duct duct santorini is the smaller accessory duct for the pancreas we call them to the ethylene peel of water we have the sphincter of odi remember that is going to be the muscle that controls how the bile and pancreatic enzymes enter into the duodenum section 5.4 pancreatic vasculature now the pancreas is a highly vascularized structure however we cannot see most of these blood vessels and so they hold very little importance to ultrasound in the sense of being able to visualize them and to make any diagnosis off of that the big two that you need to know are that the gastroduodenal artery is going to supply the head of the pancreas and the splenic and superior mesenteric artery are going to be responsible for supplying the body and the tail with blood so remember we have our aorta leaving the heart one of the big first branches is the celiac axis the left branch is a splenic artery the right branch is the common hepatic artery a common hepatic artery is going to give rise to the gastroduodenal artery after the gastroduodenal artery branches off the common hepatic artery turns into the proper hepatic artery as it heads to the liver but we are going to focus a little bit more on that gastroduodenal artery in relationship to the pancreas head as the gastroduodenal artery courses inferior across the pancreas head it's going to give rise to two more branches that are more responsible for supplying the head and the duodenum and that's going to be the anterior pancreaticoduodenal artery and the inferior pancreaticoduodenal artery both anterior and inferior arteries are going to not only supply the head but they are going to continue branching over into the duodenum to supply blood flow to the small intestine looking at the other side then the splenic artery is going to mostly head to the spleen but it also has lots of little branches that are going to come down and profuse into the pancreas as far as venous drainage goes for the pancreas it is performed mostly by the splenic vein we do get a little bit of drainage from the superior and inferior mesenteric veins and all the blood from both of those are going to pull back into the portal vein to be processed by the liver section 5.5 variants just like with all of our other organs sometimes the pancreas doesn't get put together quite right so we do see some anatomical variants so the first one we'll talk about is called an annular pancreas now the annular pancreas is a condition in which a ring of pancreatic tissue surrounds the second portion of the sea loop of the duodenum so remember in our normal pancreas our pinkers sat at an angle and the head was just kind of cradled within that c loop well with the annular pancreas instead of being cradled within that c loop it comes out and around and kind of gives the duodenum a big hug so if we were to look from it from the top we'd have the tail and this would be the head here normally the head would end at the duodenum in the case of the annular pancreas it wraps around the duodenum that can cause some issues that can cause some structure within the duodenum causing issues of how the stomach empties and how well the intestines work next we have the ectopic pancreas ectopic pancreas that's also known as a heterotopic or an aberrant pancreas and basically with this variant what we'll see is little bits of pancreatic tissue scattered throughout the gi tract it doesn't have any ductal or vascular connection to the pancreas it's just kind of its own little blob of pancreas out there so because these little bits can be very small it is actually very difficult for ultrasound to diagnose them but we do have an example of one on the ct here in the red circle just a little bit of pancreas tissue that does not connect back to the main part of the pancreas next up then we have a genesis as we've learned with other organs a means abnormal genesis means creationism so this is the abnormal creation of the pancreas that's really uncommon for all of the pancreas to be missing so typically a genesis is going to present more as a good portion of the pancreas missing and as this image is showing us we're actually missing a lot of the dorsal portion of the pancreas it should kind of be hanging out over here because this is the aorta right here so we should expect the body and the tail of the pancreas to kind of be hanging out in this area this is a spleen coming in here so in this patient in particular they have their ventral bud their dorsal bud never formed and again it's more common for them to be missing a big part of their pancreas versus missing the whole thing and lastly we have the pancreas divisium now pancreastivism is the most common anomaly that we'll see of the pancreas normally when we are developing remember we have that ventral bud and we have the dorsal bud and usually they're going to fuse together to create the entire pancreas and the main pancreatic duct in the case of pancreas division the dorsal portion and the ventral portion never fuse causing the dorsal portion to have its own ductile system and then the head or the ventral portion having its own ductile system and being the part that connects with the common bile duct so in our normal pancreas usually this blue duct is going to make up most of the main duct it's going to fuse in with the ventral and that's going to complete the main duct and then we have that little accessory duct that keeps going into the duodenum in this case the whole dorsal duct just does that second opening into the duodenum where the ventral duct is the one that will connect with the common bile duct and enter in through the opulent water they have no connection with one another section 5.6 microanatomy now the pancreas is responsible for both exocrine and endocrine functions therefore the pancreas is made up of different cell groups that perform these functions the exocrine function of the pancreas is performed by what we call the acini cells now ceni means berries in a cluster are the cells that are connected to the ducts within the pancreas and these cells are going to produce the digestive enzymes that travel through the ducts to the duodenum most of the cells in the pancreas are the ascini cells so looking at our image here we've got a close-up of the pancreas so we have a duct coming through here and we can see that it terminates in kind of this cluster of cells so all of the cells that are connected to the ductal system are called the acini cells they make up a really big portion of the pancreatic cells so all of these orangish cells with the purple dots in them represent the ascini cells now the endocrine function of the pancreas is going to be formed by the cells that are found in the eyelids of linger hands and the eyelids and layer hands are going to make up the rest of the cells in the pancreas really only counting for about five percent of the total volume so you can see in the middle of these ascini cells is this kind of green area and this is the eyelet of langerhans within the eyelid of linger hands are five more types of cells we have alpha cells which i've got represented by the blue the beta cells being represented by the green delta cells which are the pink ones the gamma cells which are these yellow ones and lastly the epsilon cells which are the light blue ones now the green ones the beta cells are the most abundant making up about 65 to 80 percent of the eyelid langerhans cells followed then by the alpha cells these two types of cells do a lot of the endocrine work that the pancreas is responsible for the rest of the cells have important work to do as well but are less abundant within the eyelid to laying your hands the other thing we'll see in the eyelid laying our hands are a multitude of capillaries that's all these little red spots here lots of capillaries to grab those hormones and bring them out to the body for circulation so i've got this picture again with just a little bit more information here remember our senior cells are the ones that are connected to the ducts they're going to be responsible for digestive enzymes and are part of the exocrine system so the ducts and the senior cells are the exocrine part all the other cells are found in the islets of laying hands and are all responsible for endocrine function and we're going to go over this a little bit more in detail in the physiology portion section 5.7 physiology knowing that the pancreas is an endocrine and exocrine organ will talk about each of its physiological roles separately the physiology of the pancreas is also more related to systemic disease versus disease that would arise directly from the pancreas and very few diseases of the pancreas are able to be diagnosed solely by ultrasound therefore we're going to do a very limited discussion of the physiological function of the pancreas so we're going to start with the exocrine function the functional unit of the exocrine portion of the pancreas is the assini cells and the ductal system remember back to our image it was the orange cells the ascenia cells that were connected to the ducts that we're talking about now those zuccini cells are responsible for making enzymes for digestion storing those enzymes and then secreting them when the time comes the ducts also have an important role in the exocrine function and that when they receive the right hormones they're going to secrete water or like an oculus substance that's going to help flush these seeny enzymes through the ductal system the mexican portion of the pancreas is controlled by what we call the parasympathetic system that's known as the rest digest system it's the part of our nervous system that's kind of taking care of some of those background jobs and this is opposed to the sympathetic nervous system which is more of our fight and flight system going back to the ischemia cells remember i said that they're responsible for creating enzymes well those are the digestive enzymes that the body needs to help break down those macronutrients that we eat the yacini cells are responsible for making amylase lipase and proteases those proteases are going to include trypsin chylotripsyn and a carboxy peptidase and lastly they're also responsible for creating bicarbonate now each of those digestive enzymes are going to be responsible for breaking down certain complex macronutrients that we ingest amylase is going to break down carbohydrates lipase is going to break down the fats and the proteases are going to break down different proteins so they see cells in the pancreas are responsible for making these digestive enzymes but they're also responsible for storing them and what's kind of interesting is that technically the body is made of these macronutrients that these enzymes are responsible for breaking down so what the ascini cells do is stores these enzymes as zymogens and these zymogens are kind of inactive enzymes until they become activated in the small intestine so they hang out safely in the pancreas and then once we eat and they get released into the duodenum then they're activated they kind of lose their shell and they can break down the food that we eat so we have a self-protective system so we don't digest ourselves to get those digestive enzymes into the duodenum though the assini cells have produced these enzymes and then they're kind of hanging out as zymogens waiting to be secreted once they are secreted into the main pancreatic duct that aqueous substance is going to be flushed through grabbing those zymogens where they're going to go through the water and into the duodenum where they can do the job that they need to do on the chyme or the stomach mash that has passed through into the first part of the small intestine the bicarbonate that the acini cells are responsible for creating is something that is going to neutralize the stomach acid to protect the small intestine so the stomach has a mucosal lining and its whole job is to hold this hydrochloric acid to help start breaking down our food well the duodenum doesn't have that protective mucosal layer so as that acidic kind comes into the duodenum it recognizes the acidity secretin is released from the duodenum which tells the pancreas to release bicarbonate and that bicarbonate is going to come in with the digestive enzymes to help neutralize the chyme and make a more basic environment so those digestive enzymes can operate better so to recap how digestion works between the pancreas and the gallbladder first things first just the site of food is going to make our enzyme production start when we put that food into our mouth and start mashing it up our salivary glands are going to produce saliva and in that saliva is amylase we're then going to use our muscular tentacle or tongue to swallow that food it's going to go down the esophagus and into the stomach now down in the stomach there are specialized cells that create mucus and pepsin and hydrochloric acid and this is all going to help start to break the food down even further after rolling around in the stomach for a little bit the food is going to pass through the antrum of the stomach and into the duodenum it is now called chyme and when that acidic chyme enters the duodenum it's going to activate cells within the duodenum that are going to produce hormones the two hormones are going to tell the pancreas in the gallbladder to activate the first one cholecystokinin is going to activate the gallbladder to release bile and it'll activate the acidic cells to release their enzymes a second hormone secretin is also going to tell the pancreas to release water and that bicarbonate so when the cholecystokinin interacts with the gallbladder that bile is released through the cystic duct into the common bile duct where it's going to join with the ductive worst sun from the pancreas then through the duct of worksang are going to come the amylase lipase protease and bicarbonate and those are going to join together and enter into the duodenum through the envelope water once in the duodenum the bile is going to help to emulsify the fat and once those fats are a little bit smaller the lipase is going to break them down into even smaller pieces that can be absorbed through the intestinal wall the amylase and proteases are going to do the same thing breaking down carbohydrates into glucose and proteins into amino acids at this point the exocrine portion of the digestive check is done and endocrine function is going to pick up now that the food is broken down into their small molecules so switching over to the endocrine function of the pancreas remember that the hormones are produced by the cells that are found in the eyelids of langerhans there are six key polypeptide hormones that are secreted by the endocrine pancreas one of the big hormones that we probably have all heard of is insulin and that is produced by the beta cells and that is going to help decrease the blood glucose levels or decrease the sugar in the blood another job of the beta cells is to produce amylin amlin is going to help the stomach slow down its emptying so it doesn't put too much food into the duodenum which should prevent spikes in the blood glucose levels glucagon is produced by the alpha cells and that's going to increase blood glucose levels if we haven't eaten for a little bit and the body needs more energy remember that the liver is storing glycogen and when that glucagon is released into the blood that glycogen is released from the liver so it can increase the blood glucose levels the delta cells are responsible for releasing somatostatin and that's going to help kind of control some of the other things that happen in the eyelids of laying your hands the gamma cells are responsible for pancreatic polypeptides which also kind of control some of the gi function and then the epsilon cells release ghrelin which really doesn't have a strong purpose as far as scientists can tell the best thing they can tell is that it helps to increase our appetite so when the body recognizes that there is low fuel amounts the epsilon cells release the ghrelin and kind of make us a little bit hungry so we'll give the body some more food at the end of the digestion recap i had stated that the endocrine system is going to take over after the food is digested into the small molecules so we're going to take a look at what happens at the cellular level with digestion and hormones we'll pick up the final steps of digestion then in the gi tract unit when we eat carbohydrates we are basically eating sugar so carbohydrates are basically all those oats molecules lactose glucose all of that and when the body absorbs the broken down carbs the most simple form of carbohydrates or sugar is glucose and when we increase the blood sugar levels that is called hyperglycemia increased glucose or hyperglycemia is going to stimulate the beta cells to release insulin and the alpha cells to stop making glucagon now that insulin being in the blood is going to tell cells around the body to do different things the fat cells are going to be told to take in sugar and make more fat which is called lipogenesis the muscle cells are going to be told to take in sugar and make glycogen and that's called glycogenesis it's also going to be they're also going to be told to make proteins because now they have the energy to do it and then lastly the liver cells are going to be told to stop making sugar for the body start making glycogen and make more fat so the little gift on below you can see that the insulin comes in sits in a little door kind of key receptor on the cell which opens up the door for the sugars to come in the sugars come in from the blood into the cell so the cell can use them for energy to do their jobs so insulin's main job is to tell the cells to bring that sugar inside the cell because there's work to do and by doing so all of these functions are going to lower the blood sugar now when we don't eat because we're in a time of fasting so we have no energy coming in or maybe we're exercising expending a lot of energy the cells are still going to need sugar to do their job if we haven't eaten or if we've used all the sugar that's in the blood the blood now has low sugar and low sugar in the blood is called hypoglycemia and when the body is in state of hypoglycemia it is going to activate the alpha cells of the pancreas to release their glucagon and glucagon is also going to tell the beta cells that there's going to be some work to do soon because the body's gonna get ready to send some more sugar out and the only way that sugar can get into the cells is with that insulin from the beta cells so the glucagon goes out into the body and talks to a bunch of cells again again the liver cells are going to be told to convert glycogen to glucose so that's glycogenolysis and they're going to be told to make sugar out of ketones which is gluconeogenesis those fat cells are going to be told to break down and send ketones to the liver so the liver can make that sugar and then the muscles are also going to convert glycogen to glucose the presence of glucagon in the body tells the cells that are responsible for making sugar out of their storages to release that sugar and therefore glucagon tells the cells to do things that will all raise blood sugar now there were a bunch of other hormones that we talked about right at the beginning too i kind of briefly described which each of them did this is all in your workbook if you want to read through it a little bit closer basically amlin is also secreted by the beta cells and it helps to tell the stomach to like don't put too much food into the system we're not quite ready to handle all of that sugar it's supposed to help kind of act as a sadie agent as well telling the person that they're full somatostatin then is released by the delta cells and these are going to kind of affect how the rest of the endocrine organs produce their hormones so the gastrointestinal tract the pancreas and the adrenal glands are all kind of affected by the somatostatin it's basically saying we've eaten we've got some stuff to do start making your hormones the pancreatic polypeptides are produced by the gamma cells in the pancreas and they become active when we're kind of getting to the end of eating and there isn't as much work to do in the intestines so the pancreatic polypeptides tell the gallbladder to stop releasing bile stop the pancreas from releasing pancreatic juices and then tells the intestines that you know we're kind of done with our job we can slow down absorption and lastly that ghrelin is produced by the epsilon cells not a whole lot of understanding about what ghrelin does but the best thing that we figured out is that ghrelin is there to increase appetite when our stomach is empty section 5.8 pancreas chemistry so just like with our other organs we do want to evaluate the lab test that can help us to identify any sort of pancreas malfunction and the two big ones that we're going to look at are amylase and lipase if you recall amylase and lipase were both digestive enzymes that were produced by the assini cells and when there's a lot of amylase in the blood it's usually because there's some sort of blockage in the pancreas causing that amylase to spill out into the bloodstream and this is usually due to pancreatitis so pancreatitis is inflammation of the pancreas usually when somebody presents with pancreatitis we can treat it and they'll get better within a few days but multiple bouts of acute pancreatitis can turn into chronic pancreatitis and then we have a whole different set of issues so pancreatitis will be discussed much more in detail when we start to talk about pathology now increased light paste same idea there's probably pancreatitis and that's again because lipase is produced by the essini cells something is causing the pancreas to malfunction and release those enzymes into the blood instead of releasing them into the ducts lipase and amylase are both functions of the exocrine side of the pancreas to test the endocrine function of the pancreas blood glucose levels are going to be the most useful so we are testing sugar in the blood and that'll tell us how well the pancreas is releasing insulin to counteract that sugar as far as hormones for the other cells in the islets of linger hands we do see that if any of those hormones are high or in excess it usually means that there is a tumor made of those cells releasing extra hormone however insulin is probably one of the bigger ones that we are concerned about because higher than normal glucose levels are going to mean a higher risk for developing diabetes now we can't diagnose diabetes just on an ultrasound but diabetes has a really big effect on the rest of the body and sometimes that can cause pathology in other organs for example we might see plaque in the arteries you might start to see other cancers around the body liver disease is very common with diabetes as well as kidney disease as usual we're going to wrap up our anatomy physiology and ultrasound lecture with the normal appearance of the organ by ultrasound so let's go ahead with section 5.9 normal appearance of the pancreas when you see the pancreas by ultrasound it should be more echogenic than the liver remember kids love soda pop pop is the pancreas it should be the most echogenic organ and we also want it to be homogeneous and smooth and echo textured we can see in this image here we have the uncertainty process the pancreas head neck body and tail comparing the pancreas tissue to the liver we can see that the pancreas is more echogenic like it should be it's also very smooth in echo texture and homogeneous meaning that it's all kind of the same grain the same level of gray now the tail and the head of the pancreas don't always sit in the same plane so you might need more than one image that's going to focus on the head and neck and one that focuses on the body and tail remember that the head and neck sits a little bit more inferior into the body and is covered by peritoneum so the head of the pancreas is considered peritoneal but on the whole the pancreas is considered a retroperitoneal organ that tail is going to be more superior into the body and then as we can see in this picture here it dives a little bit more posterior because of the positioning of the stomach and the duodenum it's not uncommon that the pancreas especially the tail and body are obscured by gas whenever you can use that liver as a window you kind of angle through the liver tissue down to the pancreas tissue you're going to have a much better chance of seeing pancreatic tissue recall back to our liver lecture we talked about how some people don't really have a leftover liver those tend to be harder people to see the pancreas on if you're struggling to see the pancreas though you always want to take a look for your vascular landmarks we can usually see the midline vascular structures very well remember the uncertain process is sandwiched in between the ivc and the smv which is not pictured here the head is going to have the gda in it and the common bile duct in it it's also going to be anterior to the ivc the neck of the pancreas is just anterior to the portal confluence the body of the pancreas is going to be left lateral to the superior mesenteric artery and the aorta and then we'll see the tail being wrapped by the splenic vein on the posterior side so again this is all pancreatic tissue and we can see all those major landmarks surrounding to help us identify where the pancreas is and we can also look for those landmarks in the longitudinal plane so if we have the ivc in long we know that we should be able to see the pancreas head just anterior to it if we can see the portal confluence we know we should be able to see the pancreas neck so this is all pancreas in the longitudinal plane anterior to the ivc same idea if we have the aorta we know that we should be getting into pancreas body over here again we can see the portal confluence we can see the splenic artery we know that this is all pancreas sandwiched in between the liver and the aorta this example is a great example of showing us how it can be kind of difficult to see the pancreas this is a fatty pancreas so it's a little bit more echogenic than what we would expect but this shows nicely the stomach kind of overlying the tail and body of the pancreas the transverse colon also comes across here so that can obscure the tail quite a bit and then the duodenum sits right around the head and that can obscure the head quite a bit so this is why we want our patients to be npo or nothing by mouth we want to give us the best chance of not having that pancreas obscured if possible but we can use our portal confluence as a landmark we have the aorta as a landmark to help us identify where that pancreatic tissue is as far as measuring the pancreas we don't typically measure the pancreas but if it looks kind of big to your edematous and you want to measure it you should find that the measurements of the pancreas are less than three centimeters in the ap dimension at any point so notice in the chart down here nothing is bigger than three centimeters the head and the body are the thickest parts everything else should be less than that three again we don't typically measure the total length of the pancreas if you wanted to you could typically in the 12 to 18 centimeter range oftentimes just imaging the pancreas enough you'll start to kind of get a feel for what a normal pancreas size looks like and it'll be easier the more that you do to recognize a pancreas that is on the larger side sometimes you will be able to see the duct of work sun going through the middle of the pancreas you do want to make sure that you use color on it because the splenic artery can also kind of mimic the ductile bursting so put color on if it doesn't fill in then it's most likely the duct and then you'll want to measure it many ducts that measure more than two millimeters in the pancreas are considered abnormal make sure too that you don't get confused with the gastroduodenal artery and the common bile duct remember those are going to be more in transverse in the pancreas head the gastroduodenal artery is the more anterior spot and should fill with color for the common bile duct is the more posterior spot at the head and should not fill with color again these are more into the head where the duct of warsong is going to be visualized and long through the body of the pancreas let's wrap up this lecture then we're talking a little bit more about the pancreas protocol in section 5.10 so the pancreas is typically included in the right upper quadrant ultrasound and the abdomen complete ultrasound depending on your facility it may or may not be part of the liver ultrasound protocol however there are multiple indications for ordinary exam that includes the pancreas those are going to include getting measurements of the pancreas if another imogene modality showed that it was large looking for masses that involve the pancreas itself or the biliary tree looking for any sort of obstruction along the biliary or pancreatic ductal path using ultrasound to diagnose and to follow up acute or chronic pancreatitis again diagnosing or following up pancreatic pseudocysts which are pockets of digestive enzymes outside of the pancreas we can also perform endoscopic pancreatic ultrasounds in the event that we saw something with a transabdominal ultrasound they go to ct and the ct results don't tell us a whole lot we can go in with an endoscope and perform an ultrasound from inside the esophagus so speaking of the esophageal ultrasound first we usually start with that trans abdominal and that's going to just be using one of our curve linear probes or possibly a vector probe using a lower frequency because that is a transducer that we are using for most of our abdominal work now that transesophageal ultrasound means inserting an ultrasound camera into the esophagus and lowering it to the level of the pancreas so here we have that example this is the ultrasound head this is inside the esophagus and this is the pancreas tissue right next to it here is the splenic vein and the portal confluence so we can see that pancreas parenchyma in so much more detail because we are right next to it patients are typically sedated for these these usually are not performed within the general ultrasound department and are performed by a specially trained doctor with the endoscope transducers patient prep for the pancreas is going to follow right along with what we've been doing for abdomen already which typically means npo or nothing by mouth for six to eight hours to position the patient the pancreas is typically visualized best with the patient on their back however you can get possibly a little bit more visualization if you try sitting the patient up a little bit remember with that left low of the liver being directly superior to the pancreas by sitting them up a little bit it can kind of cause that liver to flop down and now we can use the liver as a little bit more of a window to visualize the pancreas remember that breathing can also change the positioning of the organs and so you should always try multiple techniques to visualize the pancreas when possible some other scanning tips that i've got for you here are also in your workbook so make sure to take a read through them i think the biggest ones that i go through quite often with new scanners is that you really want to use that liver as a window position your transducer above the left lobe of the liver and then you're going to angle through the liver and down towards the patient's feet to image the pancreas if you think about getting your trans left lobe image the pancreas is typically right below it and in that picture so try that window when trying to visualize the pancreas remember to use enough pressure in this area as well there's a lot of bowel in the area so you want to make sure that you're kind of pushing that bowel out of the way so you can get closer to the pancreatic anatomy because it does sit a little bit deeper into the body as far as protocol goes there's not a whole lot to it again not all facilities are going to have the same protocol but in general you need a picture of the pancreas while in the transverse plane on the body so quite often we label it transverse pancreas even though we have the pancreas completely elongated out if the head and neck and body and tail do not sit well enough in the same plane to get a good diagnostic picture it's okay to take a focused picture of the body and tail and a focused picture at the head of the neck what i found that works out best is to have the notch of the transducer at the nine o'clock position to image the head and neck so it true transverse and then when you want the body and tail you're going to slightly oblique turning the notch down to the seven o'clock position to elongate that tail because you'll remember that the pancreas sits obliquely in the body so we want to elongate that tail by also obliquing our transducer if you do need to find longitudinal pictures of the pancreas as well remember your landmarks being over the ivc shows you the head of the pancreas where being over the aorta is going to show you more of the body and tail and as you move lateral towards the patient's left you should come into even more tail of the pancreas and that brings us to the end of our pancreas lecture so we've covered normal anatomy physiology and ultrasound appearance make sure to go through the activities in your workbook and the open-ended nerd check questions to help you evaluate how well you can recall the information presented there are tons of pictures on the internet not only diagrams of the pancreas but ultrasound images of the pancreas look through the variety of images that are out there the more you can present to yourself for studying the better off you will be when for whatever you get on your test or on your boards and just keep practicing visualizing that pancreas the more you look for it the more comfortable you're going to be able identifying it