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PRACTICE: J Ashley Guthrie and Maria B Sheridan Investigation of abdominal pain to detect pancreatic cancer BMJ 2008; 336: 1067-1069 [Full text]

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Methods of enhancing visualisation of the pancreas with ultrasound

Anton E Joseph   (16 May 2008)

Methods of enhancing visualisation of the pancreas with ultrasound 16 May 2008
Anton E Joseph, Consultant Radiologist Mayday University Hospital, Croydon CR7 7YE Send response to journal: Re: Methods of enhancing visualisation of the pancreas with ultrasound	A well presented article from a department with good reputation in imaging of the pancreas. This article however has its shortcoming as many other articles on the subject do, namely of identifying the difficulties with ultrasound imaging of the pancreas which everyone in the field is familiar and burdened with but not suggesting solutions for the benefit of the less experienced. A problem I have been aware since the mid seventies and which I believe I have managed to overcome to a significant degree. May I therefore address the difficulties stated namely, ‘overlying bowel gas or fat may obscure much of the gland’. Gas in particular must be obvious to many is a moveable feast. Little emphasis is placed on how this may be got out of the way. In the past there was a lot of emphasis on the use of degassed water or carboxymethyl cellulose to produce a window for the visualisation of the pancreas. Few of us waste much time with these at the present time. May I also emphasise that sonologists should not be disappointed at not being able to demonstrate the entire pancreas at the same time or in the same view. Different parts of the pancreas may be demonstrated in separate views resulting in the coverage of the greater part if not the entire pancreas. I suggest the following starting off with the simple and the straight forward. 1. Scans performed in inspiration and expiration. 2. Scans performed with gentle breathing or even in a static state. 3. Instructing the patient to blow out their tummies and if required breathe in at the same time. Often patients are confused but many finally achieve, often when I tell them to make their tummies look like mine! They all seem to understand that. This seems to work because in spite of the pancreas being a retroperitoneal structure, contrary to popular belief it is capable of significant up and down movements 4. Rolling the patient to the right and then to the left. Turning the patient makes any fluid in the stomach either flow into the antrum and less so into the duodenum or into the fundus of the stomach. Turning the patient to the right makes the head of the pancreas more visible and the head of the pancreas viewed is best viewed with the splenic vein out of view and the SMV and SMA viewed lying side by side (as in bed mates). Turning the patient to the left helps with better views of the tail. Again all this is helped by the significant mobility of the pancreas in respect of the midline. All these may be performed in inspiration expiration or with blown out tummies. 5. Finally no pancreatic scan should be considered complete if the above manoeuvres fail unless the patient if fit enough has been scanned in the erect position. This is rarely mentioned in textbooks and could be very helpful also in abdominal scanning. Competing interests: None declared