1. Dr/ ABD ALLAH NAZEER. MD.
Ultrasound study of the spleen and pancreas.

2. ULTRASOUND OF THE SPLEEN - Normal
Intercostal scan plane. Normal Spleen.

3. The size of the spleen can be extremely
variable ranging from 7cm- 14cm.
Accessory spleens or
splenunculi are common.

4. Ultrasound appearance.
The spleen has a homogeneous, "inverted comma"
appearance.
When it becomes enlarged it loses this shape and, as
it expands, it becomes very rounded and sometimes
appears as an egg shape extending beyond the Left
kidney.
Measurement:
Normal Spleen Size
<14 cm superior to inferior axis
6-7cm in the medial to lateral axis
5 to 6cm in the anterior to posterior plane. Average
volume is approximately 350mls

5. Normal Variants
And congenital
anomalies.
1-Small spleen.
2- Asplenia.
3- Polysplenia.
4- Splenunculus.
5- Splenic artery.
6- Calcification.
7- Wandering spleen.
Common Pathology
Splenomegally >13-14 cm (or
Volume >500cc)and becomes
rounded.
Infection- multiple echogenic foci
(granulomata).
Haemangioma.
Cysts.
Metastases.
Lymphoma.
Varices - portal hypertension.
Haematomas-intraparenchymal,
subcapsular and pericapsular.
Abscess.
Splenic infarction.

6. Normal spleen.
. Homogenous, moderately echogenic.
. Less visible vessels than the liver(No
second set of veins equivalent to portal vein.

7. An accessory spleen (supernumerary spleen, splenule, or
splenunculus) is a small nodule of splenic tissue found apart
from the main body of the spleen. Accessory spleens are found
in approximately 10 percent of the population and are typically
around 1 centimeter in diameter. They form either by the result
of developmental anomalies or trauma. More common with
splenomegally. Usually solitary and may be multiple.

8. Splenosis is one type of ectopic splenic tissue and spontaneous
transplantation of the splenic tissue at unusual site after splenic
trauma/rupture. It is an acquired condition and is defined as
autoimplantation one or more focal deposits of splenic tissue in various
compartments of the body. Nodules of ectopic splenic tissue develop on
peritoneal, mesenteric surfaces similar to endometriosis deposits.

9. Wandering spleen (Pelvic spleen, ectopic, ptotic, aberrant)
is a rare medical disease caused by the loss or weakening of
the ligaments that help to hold the spleen stationary. They
susceptible to torsion around the vascular pedicle.

10. Splenomegaly is a term which refers to enlargement of
the spleen. The normal adult splenic length upper limit is
usually around 12-15 cm. The thickness must be less than
6 cm and the spleen is much longer than the left kidney.

11. Splenic pathology

12. Splenic cyst is either congenital (true cyst), inflammatory
(abscesses, hydatid cyst), vascular (infarction, peliosis),
posttraumatic (hematoma, false cyst), and neoplastic
(hemangioma, lymphangioma, lymphoma, metastasis).

13. Post traumatic splenic pseudocyst.

14. Echinococcal cyst.
. Hydatid disease is endemic area, usually sheep raising areas.

15. Splenic Hydatid Disease.

16. Intraparenchymal splenic hematoma.

17. Subcapsular splenic hematoma.

18. Peri-splenic hematoma.

19. Splenic abscess.
.Usually result of bacterial endocarditis or septicemia.
. IV drug abuse, Immunocompromised patients.

20. Splenic abscess with poorly defined hypoechoic and isoechoic area
at US images. CT show multiple hypodense area at enlarged spleen.

21. Splenic fungal abscess with poorly defined hypoechoic
and hypodense area at US and CT images.

22. Splenic artery aneurysm.
Splenic artery aneurysms are rare, but
still the third most common abdominal
aneurysm, after aneurysms of the
abdominal aorta and iliac arteries. They
may occur in pregnant women in the
third trimester and rupture carries a
maternal mortality of greater than 50%
and a fetal mortality of 70% - 90%. Risk
factors include smoking and
hypertension.
A splenic artery pseudoaneurysm
is rare situation of a
pseudoaneurysm forming in
relation to the splenic artery .
It occur after trauma or post-
pancreatitis.

23. Spleen infarction - hypoechogenic bearing marked with a white arrow. Duplex
color sonography was used as well, there is no color signal from the ischemic area.

24. Splenic infarct with a wedge shaped non vascularized splenic lesion.

25. Splenic granuloma.
US shows hyperechoic
foci with posterior tiny
shadow.
Splenic granuloma as
a result from previous
exposure to
histoplasmosis, TB and
sarcoidosis.

26. Splenic granuloma.

27. Splenic hemangiomas (also known as splenic venous
malformations) while being rare lesions, are considered
the second commonest focal lesion involving the spleen
after simple splenic cysts.
Splenic hemangioma with a small hyperechoic lesion.

28. Large, complex hyperechoic
solid hemangioma with
scattered hypoechoic foci.
Cystic hemangioma.

29. Asymptomatic Splenic Hamartoma with Rapidly Expansive Growth.
Hamartomas is a benign primary neoplasm of spleen, they are
normally an incidental finding at imaging, surgery or autopsy. They
can occur in any age group. Symptoms occur from mass effect if they
grow large. Most splenic hamartomas are hyperechoic solid masses,
with or without cystic changes at ultrasound examination.

30. Lymphangioma.

31. Lymphoma with Splenomegally and hypoechoic splenic masses.
Splenic lymphoma is often a manifestation of the diffuse dissemination
characteristic of Hodgkin's and non-Hodgkins lymphoma. Splenic lymphoma
may be single or multiple and appears hypoechoic or hyperechoic masses
and they are usually associated with hilar lymphadenopathy.

32. Splenic lymphoma with hypoechoic splenic masses.

33. Splenic angiosarcoma is exceedingly rare, but it is the most common
primary non-hematolymphoid malignant neoplasm of the spleen. It is a
highly aggressive malignancy with a poor prognosis. The majority of
patients present with abdominal pain or a palpable abdominal mass.
Angiosarcoma of the Spleen

34. Cystic splenic metastasis.
. Primary tumour is cystic.
. Secondary changes are,
-Degeneration.
- Hemorrhage.
- Necrosis.
- Infection.

35. Splenic
metastasis.

36. ULTRASOUND OF THE PANCREAS – Normal.
Pancreas Scan Plane. Normal Pancreas and surrounding anatomy.

37. Sagittal Scan Plane Pancreatic Head. Head of pancreas.

38. Scanning Technique
Technique
Begin transversely, high in the epigastrum.
You may need to apply enough pressure to help displace bowel gas.
Adjust image depth so the aorta is at the bottom of the screen.
Head of pancreas - Use both transverse & sagittal planes as the head can be quite
long and continue left caudally for several centimeters.
Body of Pancreas - Transverse probe. Use the splenic vein to help identify the
pancreas superficial to this.
Tail of pancreas - Start with the probe transverse then angle the heel of the probe
cephalad and left as the tail can be sitting up under the spleen. Thus the spleen can be
used as a window and a left intercostal coronal approach can also be utilized.
Ultrasound Appearances
Normal appearance is usually homogeneous and almost isoechoic with the liver.
It is frequently hyperechoic compared to the liver because of fatty infiltration.
Size
Varies with age and history.
Approximate normal measurements are:
Head 35mm (anterior to posterior)
Neck 10-15mm
Tail 20mm

39. Ultrasound of the pancreas.
What to look for in pancreatic US.
. Size
. Contour
. Texture
. Echogenicity
. Main pancreatic duct.
. Common bile duct
. Major peripancreatic vessels(Portal vein,
superior mesenteric artery and vein, Splenic
artery and vein, Aorta and inferior vena cava.

40. Pancreas and its proportions + neighboring anatomical
structures in classic transverse epigastrial plain.

44. Pancreatic lipomatosis refers to fatty replacement of pancreatic parenchyma.
This finding is most often associated with obesity and aging.
It tends to be commonest pathological condition involving the pancreas. The condition
may occasionally simulate a mass like lesion particularly when fatty replacement is
uneven.
Pathology
Subtypes
even pancreatic lipomatosis
uneven pancreatic lipomatosis
type 1a: preferential fatty replacement of head
type 1b: preferential fatty replacement of head, neck and body
type 2a: preferential fatty replacement of head and uncinate process
type 2b: fatty replacement of most of pancreas except peri biliary region
Causes
Systemic
cystic fibrosis (most common cause in childhood)
metabolic/endocrine: hyperlipidemia, diabetes mellitus
storage disease: haemochromatosis
drugs: steroids
infectious: viral infection, sepsis
Local
chronic pancreatitis

45. Lipomatous pancreas - Pancreatic tissue brightness is much higher than the liver one.

46. Pancreas - Cystic Lesions
Pseudocyst - Think pseudocyst when there is a history of pancreatitis,
alcohol abuse, stone disease or abdominal trauma and the lesion is
unilocular or contains non-enhancing dependent debris.
Cystic neoplasm- Think of the possibility of a cystic neoplasm, when there
is no history of pancreatitis or trauma, or when the cyst has internal septa,
a solid component, central scar or wall calcification.
Mucinous cystic neoplasm - This is usually a unilocular cyst filled with
mucin sometimes with wall calcification, exclusively seen in women.
Serous cystic neoplasm - This is a microcystic lesion, that contains serous
fluid with sometimes a characteristic scar which may calcify. It can look
like a branch-duct IPMN, but SCN has no communication with the
pancreatic duct. The typical appearance makes a specific diagnosis
possible, which is important, because SCN is the only tumor that is not
premalignant.
Branch-duct IPMN - This tumor can look like a SCN, but has no scar or
calcifications. MRCP or heavily weighted T2WI may show the connection
to the pancreatic duct, which is highly specific.

48. Benign cyst in the pancreatic tail.

50. Mucinous cystadenoma manifesting as a multiseptated cyst. High-resolution
endoscopic US image demonstrates the septated internal architecture of the cyst.

51. Mucinous cystic tumor. Endoscopic US image shows
a complex pancreatic cyst with internal septa.

52. Mucinous cystadenoma (MCA).

55. Serous cystic adenoma, Macroscopic type.

57. Acute pancreatitis refers to acute inflammation
of the pancreas. The sonographic findings in acute
pancreatitis include increased anteroposterior
measurement of the pancreatic body at the level of
the superior mesenteric artery. Decreased pancreatic
echogenicity compared with the liver, heterogeneous
echo pattern, Focal intrapancreatic regions of
abnormal echogenicity, Focal masses,Hypoechoic
peripancreatic areas of inflammation and acute
peripancreatic fluid collections. Diffuse decreased
echogenicity, focal contour, and focal echogenicity
changes within the pancreas are associated with
extra-pancreatic disease is also noted.

58. Causes of Acute Pancreatitis
Gallstones (45%)
Alcohol (35%)
Other (10%)
Medications
Hypercalcemia
Hypertriglyceridemia
Obstruction
After endoscopic retrograde cholangiopancreatography
Heredity
Trauma
Viral infection
Vascular ischemia
Idiopathic (10%)

59. Pancreatic Diseases.

60. Acute pancreatitis - Pancreatic gland (P) is edematous and there is a fluid visible in
front of the pancreas. (Black anechogenic strip marked by arrows). From other
anatomical structures we see splenic vein (SV), aorta (A) and inferior vena cava (IVC).

61. Acute pancreatitis:

62. Pancreatitis with inhomogeneous swollen pancreas and extra-pancreatic
soft tissue edema caused by an obstructing bile duct stone

63. Acute pancreatitis with area of inflammation localized to the at the pancreatic neck.

64. Pancreatitis with inhomogeneous pancreas and peripancreatic effusion.

65. Chronic pancreatitis - Granular structure of the gland with calcifications

67. Chronic pancreatitis. Transverse sonogram shows an echogenic, enlarged
pancreas with multiple small hyperechoic non-shadowing foci in the pancreas.

68. Chronic pancreatitis. Longitudinal sonogram through the head of the
pancreas (in the same patient as in the previous image) shows an
echogenic pancreas with multiple, small, hyperechoic, nonshadowing foci.

69. Chronic pancreatitis, longitudinal US scan of pancreas: head and part of body
of pancreas is normal in size with regular borders a few small hyperechoic
areas in pancreas parenchyma - calcification – non dilated pancreatic duct

71. Pseudo-cyst - Big round object in a narrow contact with pancreatic head.
A tumour could be similar, but it would not be probably so anechogenic.

72. Pseudo-cyst within the pancreatic head.

73. Pseudocyst at (a) conventional and (b) echo-enhanced ultrasound.
(a) Lesion with an echo-free pattern and a sharply delineated wall.

74. Chronic pancreatitis presented with moderate left upper
quadrant pain. Transverse sonogram through the pancreas
shows a 4.37-cm pseudocyst in the tail of the pancreas (arrow).

75. Endoscopic US of small pancreatic head tumor obstructing the common bile duct.
Pancreatic carcinoma.

76. Ultrasound image of the head of the pancreas of a mouse with a 4mm diameter tumor.

77. Endoscopic Ultrasound (EUS) of pancreatic head mass and liver metastasis.

78. Pancreatic tumour - Pancreatic head is enlarged by a hypoechogenic mass.
The tumour probably also blocks the pancreatic duct which seems to be dilated.

79. Cystic mass in the pancreatic head with a normal pancreatic corpus and tail
and normal bile ducts. Histology proved this to be a pancreatic adenocarcinoma.

80. Pancreatic adenocarcinoma with solid, focal irregular hypoechoic mass.

81. Ultrasonographic examination of pancreatic
carcinoma localized in the head of the pancreas.

83. Pancreatic endocrine islet cell tumors (PETs) are
predominantly well-differentiated pancreatic or peripancreatic
tumors that demonstrate endocrine differentiation. They
include Insulinoma, Gastrinoma, Glucagonoma,
Somatostatinoma and VIP-Oma (vasoactive intestinal
polypeptide). Endoscopic US is sensitive for diagnosis.

84. Islet cell tumor manifesting as a cyst with a solid component. endoscopic US image
obtained in a patient with a malignant primary neuroendocrine tumor of the pancreas
show a cystic lesion in the pancreatic body with peripheral mural nodules (arrows).

86. EUS image of gastrinoma (TU) in the tail of the pancreas, next to the pancreatic
duct (P GANG) and splenic vein (V.LIENALIS), measuring 1 cm in diameter.

87. Insulinoma of the pancreatic body, US and CT images.

88. Burkitt lymphoma longitudinal US scan of pancreas: globally enlarged
pancreas with decreased non-homogenous echogenicity not dilated duct

89. Burkitt lymphoma longitudinal US scan of
pancreas: no increased blood flow in Doppler.

90. Thank You.