Ultrasound Upper Abdominal Pain “Acute Pancreatitis”

Acute Pancreatitis is serious condition, for the firs act of using ultrasound, Clinical manifestations Acute Pancreatitis : Pain of variable intensity, most severe in the epigastrium and usually radiating to the back in a girdling pattern. The pain is exacerbated by lying down. Nausea, vomiting, meteorism, hypotension, tachycardia, fever.

Diagnosis of acute pancreatitis:

x History (women often have a prior history of gallstones, men usually have a history of alcoholism); pain characteristics.
x Clinical examination: Tenderness that is maximal in the epigastrium. Basal lung findings are common (rales, atelectasis, pleural effusion) and usually involve the left side.

x Laboratory findings: Leukocytosis, elevated amylase and lipase (serum levels do not correlate with disease severity), LDH o, hyperglycemia, hypocalcemia, hyperbilirubinemia (usually without jaundice), hypertriglyceridemia, hypoxemia, albumin deficiency.
x Abdominal sonography, pleural sonography
x Radiography: Plain abdominal radiograph, standing or in left lateral decubitus (to detect or exclude ileus and/or perforation).
x Endoscopic retrograde cholangiopancreaticography (ERCP): For diagnosing ductal obstruction and relieving the obstruction by stone extraction (not indicated in alcohol-related pancreatitis).
x Contrast-enhanced sonography or pre- and postcontrast CT may also help to differentiate viable from nonviable tissue.

Sonographic findings Acute Pancreatitis :

x The pancreas is frequently obscured by overlying gas, which may be due in part to gastric dilatation.
x The pancreas shows no sonographic changes during the first few hours. Later it becomes acutely hypoechoic and shows marked swelling or enlargement

ultrasound images a, b Acute pancreatitis. The pancreas (P) is thickened and hypoechoic, and the pancreatic duct (DP) is dilated. a Upper abdominal transverse scan. The stomach (S) lies between the liver (L) and pancreas. Arrows: peripancreatic fat necrosis. b Upper abdominal longitudinal scan shows dilatation of the pancreatic duct (DP) in the head of the pancreas (P) and of the bile duct (BD).
SV = splenic vein, AO = aorta, VC = vena cava, B = Bowel

Acute necrotizing pancreatitis. Between the posterior wall of the stomach and the nonhomogeneous pancreas (P) are a hypoechoic mass (M) and an echoic mass (arrows) signifying free fluid and necrosis. SV = splenic vein

Necrosis extending to the cul-de-sac in pancreatitis: hypoechoic to anechoic mass (M) located behind the bladder

The pancreatic duct cannot be visualized in edematous pancreatitis, or it may be accentuated or dilated by an obstructing stone.
x Areas of necrosis often appear hypoechoic or anechoic with ill-defined margins.
x Free fluid in the abdomen often appears as an anechoic rim surrounding the pancreas, liver, and particularly the splenic hilum.
x Pseudocysts
x Pleural effusion
x Etiologic signs:
– Gallstones in biliary pancreatitis
– Fatty liver in alcoholic pancreatitis

Accuracy of sonographic diagnosis: Presumably low in the early stage of the disease. Reportedly, CT scanning has an accuracy rate of 60–85 %. Sonography is a particularly important modality for follow-up.

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