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71 Cards in this Set

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  • Back
In ___% of people, the ventral duct connects to the distal common bile duct at the ampulla and drains through the head of the pancreas through the ___ papilla. The dorsal duct then drains the remainder of the pancreas through the ___ papilla. This is referred to as ___ ___.

major papilla

minor papilla

pancreas divisum
In most people, the dorsal and ventral duct join to form one duct that then joins the CBD to drain through the ___ papilla.
major papilla
What is the location of the uncinate process?
inferior and medial to the head

between the SMV and IVC

Middleton 192 Fig 7-1
What is the location of the head?
immediately anterior to the IVC

caudal to the portal vein
What is the location of the body and tail?
anterior to the splenic vein and the portal splenic confluence
What is the relationship between the celiac trunk and the pancreas?
The pancreas is located inferior to the celiac axis
What is the relationship between the splenic artery and the pancreas?
The splenic artery runs near the superior aspect of the pancreas
What is the relationship between the gastroduodenal artery and the pancreas?
The gastroduodenal artery arises from the common hepatic artery and travels inferiorly directly over the anterior and lateral aspects of the pancreatic head.

It lies in the anterior aspect of the head.
What causes the prominent ring around the SMA, separating it from the pancreas?
retroperitoneal fat
What is the relationship between the SMV and the pancreas?
The SMV is immediately adjacent to the posterior aspect of the pancreatic neck and body and to the medial aspect of the pancreatic head and anterior to the uncinate process
Is the pancreatic duct more commonly visualized in the head or the body?
What is the upper limit of normal for diameter of the pancreatic duct?

The duct does enlarge with age
How can you avoid the pitfall of mistaking the posterior wall of the stomach for the pancreatic duct?
Scan in a sagittal orientation

Middleton 193 Fig 7-2
Why does the pancreas become more echogenic with age?
The amount of fat increases
Sometimes, as a person ages, the anterior/posterior part of the pancreas has more fatty infiltration, and is therefore more echogenic than the other part.

Middleton 193 Fig 7-3
Upper limit of normal size for pancreatic head ___ body ___ tail ___
head 3.0cm
body 2.5 cm
tail 2.0 cm
The normal sagittal shape of the pancreas is ___
Should the pancreas be visualized fasting or after a meal?
fasting, to reduce the amount of overlying bowel gas. However, drinking water may help visualization
Having the patient make a "___ ___" by pushing out their stomach can aid in visualization of the pancreas in the anterior subxiphoid view.
beer belly
Using a left or right lateral view, angling medially and slightly anterior may help to visualize the tail and head of the pancreas.
What is the relationship between the tail of the pancreas and the spleen?
The tail is in the splenic hilum, just anterior to the left kidney and inferior to the splenic vein. you can visualize by starting in a coronal plane and start with a transplenic view of the upper pole of the kidney, then angle slightly anteriorly
What are the 2 most common causes of acute pancreatitis?

What are some less common causes of acute pancreatitis, besides ETOH and gallstones?
biliary crystals / sludge
peptic ulcers
familial pancreatitis
What are some common causes of bile duct obstruction in someone with pancreatitis?
gallstone or stricture obstruction of the duct

compression of the duct by pseudocyst or inflammation of the pancreatic head
What are the sonographic findings of acute pancreatitis?
pancreatic enlargement
DECREASED pancreatic echogenicity
HETEROGENIOUS echogenecity
peripancreatic fluid collection
perivascular fluid collection (along the splenic vein)
periduodenal fluid collection
pararenal fluid collection
Middleton 195 Fig 7-4
What part of the pancreas is usually involved in focal acute or chronic pancreatitis?

Middleton 196 Fig 7-5
How can you distinguish focal pancreatitis from pancreatic cancer?
They are difficult to distinguish sonographically, but clinical features, vascular invasion, or other evidence of metastatic disease can help.
What is a pseudocyst?
walled-off fluid collections that have a capsule composed of fibrous tissue rather than true epithelial cells
What is the sonographic appearance of a pancreatic pseudocyst?
well-defined smooth margins
anechoic or low-level internal echoes
hemorrhage or infection can produce complex internal echoes

Middleton 197 Fig 7-6
What are some complications of pancreatitis?
bile duct obstruction
pancreatic abscess or phlegmon
pancreatic necrosis
venous thrombosis (splenic vein usually, but also SMV and PV)

Middleton 199 Fig 7-9
What is the differential diagnosis of cystic pancreatic lesions?
cystic neoplasm
von Hippel-Lindau disease
cystic fibrosis
vascular lesions (Doppler should always be performed on a pancreatic cyst!)

Middleton 198 Fig 7-7
How does a pseudo aneurysm develop from pancreatitis? What artery is most commonly involved?
Erosion of the adjacent arteries produced by the proteolytic pancreatic enzymes.

splenic artery
What is the sonographic appearance of chronic pancreatitis?
multifocal calcifications

Dilitation and irregularity of the pancreatic duct

Parenchymal atrophy

Middleton 200 Fig 7-10
Do the calcifications of chronic pancreatitis shadow?
They may or may not shadow depending on size and amount of calcification

Middleton 200 Fig 7-10
The calcifications of chronic pancreatitis are located ___
Intraductally, although this is not readily distinguished on US
Pancreatic calcifications with chronic pancreatitis occur in ___% of ETOH pancreatitis and ___% of gallstone pancreatitis

The intraductal calcifications of chronic pancreatitis can lead to obstruction of the duct and worsened pancreatitis.

What is the "chain of lakes" sign?
strictures and tortuosity of the pancreatic duct

seen with chronic pancreatitis or pancreatic cancer

Middleton 200 Fig 7-10F
From what does pancreatic adenocarcinoma arise?
90% are from ductal epithelium
What location of pancreas tumor causes painless jaundice, which should raise suspicion for pancreatic cancer?

this is where most pancreatic tumors arise
What is the usual sonographic appearance of pancreatic cancer?
hypoechoic mass

dilation of the pancreatic duct or CBD from obstruction is common

Middleton 201 Fig 7-11
What is the Ddx of a solid, hypoechoic pancreatic mass?
pancreatic ca*
focal pancreatitis*
islet cell tumor
thrombosed aneurysm
When visualizing a focal hypoechoic pancreatic mass, what things would make you lean towards cancer and what things towards focal pancreatitis?
Cancar = metastasis or vascular encasement

Chronic pancreatitis = calcific foci in the mass

Middleton 202 Fig 7-12
Endocrine tumors of the pancreas arise from the ___ __ ___
Islets of Langerhans
___ account for 75% of islet cell tumors
What are the symptoms of insulinomas?
What is the sonographic appearance of an islet cell tumor?
hypoechoic solid mass

Middleton 203 Fig 7-14 and 204 Fig 7-15
What islet cell tumor accounts for 20% of islet cell tumors?
What are the symptoms of a gastrinoma?
peptic ulcer disease and diarrhea (Zollinger Ellison syndrome)
Match these
insulinoma gastrinoma
benign malignant
insulinoma = benign
gastrinoma = malignant
Match these:

microcystic adenoma macrocystic adenoma


microcystic = serous = benign

macrocystic = mucinous = malignant

Middleton 205 Fig 7-17/18
What is the Ddx of pancreatic cystic lesions?
macrocystic tumor
microcystic tumor
von Hipple Lindau
cystic fibrosis

Pancreatic cancer and islet cell tumors are both typically hypoechoic

Intraoperative US is the most sensitive means of localizing islet cell tumors
Where is the pancreatic head located?
In the duodenal C-loop
What is the normal length of the pancreas?
Does the pancreas have a capsule?
The head of the pancreas lies inferior and to the right of the more posterior and superior tail.

The portal confluence lies anterior/posterior to the neck of the pancreas?
The body is located ___ to the splenic vein and SMA
The __ __ __ is another name for the main pancreatic duct
Duct of Wirsung
The __ __ __ is another name for an accessory pancreatic duct
Duct of Santorini
The ___ artery supplies blood to the head of the pancreas.
gastroduodenal artery
The ___ and ___ arteries supply blood to the body and tail of the pancreas
SMA and splenic artery
Name 4 exocrine (acinar cells) enzymes produced by the pancreas and their functions
amylase = carbohydrates
lipase = lipids
peptidases = proteins
bicarbonate = neutralize gastric acid
Name 5 endocrine (islet cells) enzymes produced by the pancreas
insulin, glucagon, gastrin, pancreatic polypeptide, and vasoactive intestinal polypeptide are produced by the Islets of Langerhans
Does chronic pancreatitis increase risk of pancreatic cancer?
What is the sonographic appearance of cystic fibrosis changes of the pancreas?
increased echogenecity 2/2 fibrosis and fatty infiltration
Why is it important to evaluate vasculature for a pancreatic adenocarcinoma?
vascular involvement renders the rumor inoperable
What is the composition of a true pancreatic cyst?
Walled by mucinous epithelium
Do most pseudocysts resolve spontaneously or require decompression?
most resolve spontaneously