145

Published on 04/05/2015 by admin

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Last modified 22/04/2025

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CASE 145

History: A 49-year-old man with chronic alcoholic pancreatitis presents with increasing right upper quadrant pain. Liver function tests show increased bilirubin.

1. What should be included in the differential diagnosis of the imaging finding shown in Figure A? (Choose all that apply.)

A. Acute pancreatitis

B. Pancreas divisum

C. Chronic pancreatitis

D. Senile pancreatic atrophy

E. Patulous sphincter of Oddi

2. What is the tumor most commonly diagnosed in association with dilation of the pancreatic duct?

A. Glucagonoma of the pancreaticoduodenal groove

B. Ductal adenocarcinoma of the pancreatic head

C. Ampullary duodenal adenocarcinoma

D. Intraductal papillary mucinous tumor

3. What is the significance of signal poor filling defects within a dilated pancreatic duct on magnetic resonance cholangiopancreatography (MRCP)?

4. Which statement regarding imaging of chronic pancreatitis is true?

A. Pancreatic calcification visible on plain film radiographs occurs most commonly with idiopathic pancreatitis.

B. Although MRCP has many advantages over CT and endoscopic retrograde cholangiopancreatography (ERCP), its main disadvantage is the lower spatial resolution.

C. The feature on endoscopic ultrasound most predictive of chronic pancreatitis is the degree of pancreatic atrophy.

D. ERCP is the traditional gold standard for the diagnosis of chronic pancreatitis because a normal study excludes the disease.

References

Matos C, Winant C, Deviere J. Magnetic resonance pancreatography. Abdom Imaging. 2001;26(3):243–253.

Vitellas KM, Keogan MT, Spritzer CE, et al: MR cholangiopancreatography of bile and pancreatic duct abnormalities with emphasis on the single-shot fast spin-echo technique. Radiographics. 2000;20(4):939–957.

Cross-Reference

Gastrointestinal Imaging: THE REQUISITES, 3rd ed, p 158.

The considerable controversy regarding the role of MRCP in the work-up of biliary and pancreatic lesions can be summed up with this straightforward question: Will MRCP replace ERCP? The question begs an answer, in that any noninvasive diagnostic procedure that has the potential to replace an invasive procedure and achieve the same results is a straightforward patient care issue. ERCP is currently considered the gold standard for diagnosis of biliary obstruction and some pancreatic processes. However, ERCP carries with it the same risks of bowel perforation as routine endoscopy.

MRCP is often used after failed ERCP or in patients who might not tolerate ERCP. However, this situation may change. No patient preparation is required for MRCP, usually no sedation is necessary, and contraindications of MRCP are fewer than ERCP. Because of all this, studies to compare the sensitivity and specificity of the two techniques are ongoing. The initial results suggest that MRCP is a comparable examination for diagnostic purposes to ERCP without many of the associated risks (see figures). However, ERCP can also be an interventional procedure (e.g., used to place a stent or remove a stone) and will remain an important part of biliary-pancreatic medicine.