MEDICAL RADI"OLOGY Diagnostic Imaging and Radiation Oncology Editorial Board Founding Editors: L.W. Brady, M.W. Donner(t), H.-P. Heilmann, F.H.W. Heuck Current Editors: A.L. Baert, Leuven· L.W. Brady, Philadelphia H.-P. Heilmann, Hamburg· F.H.W. Heuck, Stuttgart· J .E. Youker, Milwaukee Radiology of the Pancreas With Contributions by A.L. Baert . P.H. Bernard· M. Boisserie-Lacroix . P. Cauquil . J.F. Chateil e. Douws . J. Drouillard· P.M. Dubois· J. Grellet . N. Grenier G. Kloppel . F. Laurent· E. Ponette . A. Roche· E. Therasse . V. Vilgrain With the Collaboration of Y. Ajavon . J.e. Brichaux . J.-M. Bruel . A.M. Brunet· P. Brys H. Caillet . M. Cauquil . F. Diard . J.-F. Flejou . P. Grelet . B. Maillet G. Marchal· D. Mathieu· A. Rahmouni . H. Rigauts . B. Suarez P. Taourel . J.P. Tessier· W. Van Steenbergen· J.P. Verdier Edited by A.L. Baert Co-edited by G. Delorme Foreword by M.W. Donner and F.H.W. Heuck With 301 Figures and 21 Tables Springer-Verlag Berlin Heidelberg New York London Paris Tokyo Hong Kong Barcelona Budapest ALBERT L. BAERT, MD Professor, Department of Radiology University Hospital K.U.L. Herestraat 49 B-3000 Leuven Belgium GUY DELORME, MD Professor Centre H6spitalier Regional de Bordeaux H6pital Pellegrin F-33076 Bordeaux Cedex France MEDICAL RADIOLOGY· Diagnostic Imaging and Radiation Oncology Continuation of Handbuch der medizinischen Radiologie Encyclopedia of Medical Radiology ISBN-13: 978-3-642-97489-2 e-ISBN-13: 978-3-642-97487-8 DOl: 10.1007/978-3-642-97487-8 Library of Congress Cataloging-in-Publication Data. Radiology of the Pancreas/with contributions by A.L. Baert ... let al.); with collaboration of Y. Ajavon ... let al.); edited by A.L. Baert, co-edited by G. Delorme; foreword by M.W. Donner and F.H. W. Heuck. p. cm. - (Medical radiology) Includes bibliographical references and index. ISBN-13: 978-3-642-97489-2 (alk. paper) 1. Pancreas-Radiography. I. Baert, A. L. (Albert L.), 1931- . II. Delorme, G. (Guy) III. Series. [DNLM: 1. Pancreatic Diseases-diagnosis. 2. Pancreas-pathology. 3. Diagnostic Imaging-methods. WI 800 R129 1994) RC857.5.R33 1994 616.3'70754-dc20 DNLMIDLC 94-6222 This work is subject to copyright. All rights are reserved whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag. Violations are liable for prosecution under the German Copyright Law. © Springer-Verlag Berlin Heidelberg 1994 Softcover reprint of the hardcover 1st edition 1994 The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even -in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and there fore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application con tained in this book. In every individual case the user must check such information by consulting the relevant literature. Typesetting: Best-set Typesetter Ltd., Hong Kong 21/3130-5 4 3 2 1 0 - Printed on acid-free paper All our knowledge stems from our observation Leonardo da Vinci Foreword For a long time the morphologic diagnosis of diseases of the pancreas - which is the most hidden organ of the abdomen - by means of radiologic methods was inade quate. Diagnostic radiology of pancreatic diseases has been revolutionized by new cross-sectional methods such as computed tomography with volume CT scanning, further progress in ultrasonography in the form of color duplex Doppler, and magnetic resonance imaging. Therefore we had the idea of publishing an up-to-date treatise on radiology of the pancreas in order to convey the contributions made by various new imaging modalities for the diagnosis of pancreatic disorders. The editors of this volume are outstanding specialists in diagnostic radiology of the abdomen. Albert L. Baert is the author of one of the very first books on computed tomography of the body, published by Springer-Verlag in 1980. Since then he has published extensively on this method, especially as it is applied to the abdomen. He is a well-known teacher on computed tomography of the body, and especially the pancreas, and on diagnostic angiography. As a publisher he is active on the editorial boards of several radiologic journals. Guy Delorme has published extensively on the radio diagnosis of the digestive system. Moreover he has been very active as editor of French textbooks and was the chief editor of the volume dealing with the liver, biliary ducts, spleen, and pancreas in the prestigious series Traite du radiodiagnostic covering the whole field of diagnostic radiology. Under his chairman ship at the Department of Radiology of the University of Bordeaux, talented young scientists have been able to develop their careers and have contributed to this book. The editors of this volume have engaged experts to describe the state of the art of radiology of the pancreas. The basis for better understanding of the radiologic features is provided by chapters on embryology, anatomy, pathology, histology, physiology, and pathophysiology of the pancreas. Both common and more rare pancreatic lesions are described. The different contributions cover very well the opportunities for noninvasive evaluation as well as the selection of the most appro priate techniques to alleviate the patient's problem. New radiologic modalities have made the diagnostic process more humane. The radiologic approach and inter pretation are combined with the presentation of clinical observations and important pathophysiologic knowledge. The new noninvasive imaging modalities for application in diagnosis and patient management have made possible the treatment of many disorders of the pancreas, especially by means of interventional techniques that replace surgical procedures. The text and illustrations in this book will serve as sources of information for the continuing education of radiologists and other medical specialists, as well as physicians in training and students. Those working within various specialties will find the volume of value in their everyday clinical work. The excellent quality of the illustrative material is attribut able to the efforts of Springer-Verlag. As editors of the Medical Radiology series we hope that this volume will - like earlier volumes - be well received by our colleagues VIII Foreword in many fields of medicine. We would appreciate every constructive criticism that might be offered. MARTIN W. DONNER(t) Baltimore FRIEDRICH H.W. HEUCK Stuttgart Preface This volume is designed to provide a comprehensive review of current radiologic knowledge on diseases of the pancreas. The explosive development of new radiologic techniques and modalities during the last decade has opened this "hidden" organ to detailed diagnostic analysis. In the past radiodiagnostic signs of pancreatic disease were indirect, primarily being based on changes and modifications of the visceral organs surrounding the pancreas; this led to much frustration as radiologists rapidly became disappointed by the limitations and errors of the "new" signs described in the literature of that period. As could be expected, pancreatic disease had to be very pronounced or at an advanced stage before the indirect signs became visible, and this limited the therapeutic possibilities. The last monograph on radiology of the pancreas published in the series Medical Radiology - Diagnostic Imaging and Radiation Oncology (previously: Encyclopedia of Medical Radiology) by J. Rosch dates from more than 25 years ago. Now that noninvasive methods allow direct detailed morphologic depiction of the anatomy and gross pathology of the pancreas, rendering precision radiologic diagnosis a reality, it seemed logical to devote a new volume in the series to this organ. In fact such an update has long been overdue. The revolutionary radiologic potential for visualizing pancreatic changes due to disease has permitted a new therapeutic approach to many of these conditions, such as acute and chronic pancreatitis or cystic and endocrine tumors of the pancreas. One can only regret that the earlier diagnosis of pancreatic ductal adenocarcinoma has not yet led to any substantial improvement in the survival rate of patients affected by this tumor. This book attempts to convey the latest knowledge on the possibilities and the limitations of the new cross-sectional modalities such as ultrasonography, computed tomography, and magnetic resonance imaging. It has been written by a group of European radiologists who are recognized experts in their field. A wide variety of personal case material is provided, combined with a review of current literature. However, this book is not intended to be just a compilation of modern imaging techniques of the pancreas. It also aims to provide a better understanding of the clinical relevance of the radiologic findings. Especially the chapters on the embryo logy, histopathology, and physiology of the pancreas should provide readers, be they radiologists, surgeons, or gastroenterologists, with a basis for a better perspective on the radiologic features. The other chapters deal with the normal radiologic anatomy and all the common and more rare conditions of the exocrine and endo crine pancreas. The availability of so many highly performing radiologic methods that provide diagnostic information on the pancreas necessitates a critical attitude to select the most efficient approach for each clinical situation. This book attempts to outline these guidelines as related to pancreatic diseases. This book resulted from cooperation between several European academic depart ments of radiology. Professor Dr. G. Delorme has been extremely successful in x Preface organizing and coordinating the work from the academic centers in Bordeaux and Paris. I am very much indebted to him for his invaluable help. ALBERT L. BAERT Acknowledgments: Special thanks go to the photographers and secretaries of the different academic departments of radiology in Bordeaux, Leuven, and Paris for their excellent support. The editors also acknowledge the help of Dr. S. Gryspeerdt and Dr. L. Van Hoe for the preparation of the index and of Mrs. D. Pardon for the final editing. Contents 1 The Exocrine and Endocrine Pancreas: Embryology and Histology P.M. DUBOIS ..................................................... 1 2 Physiology of the Exocrine Pancreas P.H. BERNARD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 3 The Normal Radiologic Anatomy of the Pancreas P. CAUQUIL, M. CAUQUlL, J.P. VERDIER, H. CAILLET, B. SUAREZ, Y. AJAVON, A.M. BRUNET, and J.P. TESSIER. . . . . . . . . . . . . . . . . . . . . . . . . . 21 4 Pathology of the Pancreas G. KU)PPEL and B. MAILLET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 5 Pancreatic Diseases in Childhood J.F. CHATEIL and F. DIARD ......................................... 69 6 Acute Pancreatitis J. DROUILLARD and F. LAURENT 83 7 Chronic Pancreatitis F. LAURENT, J. DROUILLARD, E. PONETIE, P. BRYS, and W. VAN STEENBERGEN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 101 8 Ductal Adenocarcinoma A.L. BAERT, H. RIGAUTS, and G. MARCHAL. . . . . . . . . . . . . . . . . . . . . . . . . .. 129 9 Cystic Tumors of the Pancreas V. VILGRAIN, D. MATHIEU, J.M. BRUEL, J.-F. FLEJOU, A. RAHMOUNI, and P. TAOUREL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 173 10 Endocrine Tumors of the Pancreas A. ROCHE, A.L. BAERT, E. THERASSE, H. RIGAUTS, and G. MARCHAL. . . .. 197 11 Rare and Secondary Tumors of the Pancreas J. GRELLET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 235 12 Pancreatic Trauma e. Douws, N. GRENIER, and J.C. BRICHAUX .......................... 247 13 Pancreatic Transplantation N. GRENIER, C. Douws, and J.e. BRICHAUX .......................... 255 XII Contents 14 The Postoperative Pancreas M. BOISSERIE-LACROIX and P. GRELET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 267 Subject Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 275 List of Contributors ................................................... 279