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Diffuse Pancreatic Disease

General Considerations Diffuse involvement of the pancreas can occur with various inflammatory, infective, infiltrative, or neoplastic disorders. Any pathologic process that involves the pancreas focally also can cause diffuse involvement ( Box 51-1 ). More common causes of diffuse pancreatic involvement (e.g., pancreatitis) have been discussed previously. This chapter discusses infrequent causes and differential features. Box 51-1 Diffuse Pancreatic Diseases Inflammation Acute pancreatitis Chronic pancreatitis Chronic…

Miscellaneous Pancreatitis

Autoimmune Pancreatitis Etiology Autoimmune pancreatitis (AIP) is a peculiar form of chronic pancreatitis characterized by a fibroinflammatory process involving multiple organs with characteristic histopathologic and serologic features, association with other autoimmune disorders, and a propensity to respond to corticosteroid therapy (CST). Two subtypes of disease have recently been described: type I, also known as lymphoplasmacytic sclerosing pancreatitis, is considered a spectrum of immunoglobulin G4 (IgG4)-related systemic…

Imaging of Chronic Pancreatitis

Etiology Chronic pancreatitis is defined as an ongoing prolonged in­flammatory disease characterized by progressive irreversible structural changes resulting in permanent loss of endocrine and exocrine function. The Cambridge classification of 1983 acknowledged that chronic pancreatitis is typically associated with abdominal pain but occasionally can be painless and may recur. According to the revised pancreatic classification of pancreatitis from the Marseille symposium of 1984, acute and chronic…

Imaging of Acute Pancreatitis

Etiology Acute pancreatitis is an acute inflammatory disorder of the pancreas that has numerous causes ( Box 48-1 ). The most common risk factors are chronic alcohol consumption and choledocholithiasis. In 20% of cases no cause can be found. Box 48-1 Causes of Acute Pancreatitis Gallstones (45%) Alcohol (35%) Others (10%) Medications Hypercalcemia Hypertriglyceridemia Duct obstruction (e.g., tumor) Post–endoscopic retrograde cholangiopancreatography Hereditary Trauma Viral Post cardiac…

Cystic Lesions of the Pancreas

Etiology Cystic lesions of the pancreas encompass a wide spectrum of different pathologic entities, ranging from developmental, to inflammatory, to neoplastic cysts. Neoplastic cystic lesions, which are the most important, owing to their profound impact on patient prognosis and the frequent necessity of surgical treatment, are described in detail in this chapter. Although every pancreatic tumor may undergo central necrosis and manifests predominantly cystic, the term…

Solid Pancreatic Masses

Etiology The term solid pancreatic masses, in its wide meaning, encompasses neoplastic lesions and non-neoplastic masses, ranging from anatomic variants, such as pancreatic head lobulations, to focal inflammatory processes and neoplasms. This chapter will mainly discuss solid pancreatic neoplasms and provide differential diagnoses with other solid lesions, such as variants and focal inflammatory lesions, which are described in detail in other chapters. The cause of pancreatic…

Imaging of the Pancreas

Multidetector Computed Tomography Multidetector computed tomography (MDCT) has become a fundamental technique of pancreatic imaging. Today, higher image quality can be obtained in abdominal imaging, and this is even more significant in pancreatic imaging, in which the reduction of acquisition time, the possibility of multiple phases of enhancement imaging, and higher resolution images in all three spatial planes, with the possibility of excellent multiplanar image reconstructions,…

Hepatic Variants

Technical Aspects Diagnostic imaging of the hepatobiliary system, with multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI), plays a major role in hepatobiliary surgery, helping to choose the best therapeutic approach, reduce complications, and identify the anatomy requiring special attention at surgery. Anatomic variants of the biliary and hepatic vascular anatomy are common; they dictate the surgical technique and also may predict the risk for…

Cholestatic Hepatic Disorders

Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) are the two most common and well-characterized primary cholestatic disorders. In contrast to pathologic processes derived primarily from hepatocellular dysfunction, such as viral hepatitis and autoimmune hepatitis, the primary insult in cholestatic diseases centers on the bile duct epithelium. As with other diffuse liver diseases, PBC and PSC may progress to liver fibrosis, portal hypertension, cirrhosis, and/or…

Hepatic Veno-occlusive Diseases

The hepatic veno-occlusive diseases are a heterogeneous group of circulatory disorders characterized by obstruction of hepatic venous outflow at the sinusoidal or postsinusoidal levels. These disorders uniquely manifest portal hypertension before overt hepatic parenchymal disease and dysfunction, in contrast to other causes of hepatic disease in which hepatic dysfunction precedes portal hypertension. The focus in this chapter is on the most common types of sinusoidal (sinusoidal…

Cirrhosis and Hepatitis

Cirrhosis Etiology Virtually any chronic insult to the liver, if sufficiently severe and long-standing, may result in cirrhosis. In the United States, the most common causes are hepatitis C virus (HCV) infection and alcohol ingestion, whereas in Asia and sub-Saharan Africa, chronic hepatitis B virus (HBV) infection is the most frequent culprit. Nonalcoholic fatty liver disease (NAFLD) is increasing in prevalence and is now the third…

Hepatic Storage Disorders

The hepatic storage disorders are genetic conditions characterized by the accumulation of toxic substances within either hepatocytes or the hepatic extracellular matrix. This deposition causes secondary tissue damage, which may eventually progress to cirrhosis, portal hypertension, and hepatocellular carcinoma (HCC). As genetic conditions, their manifestations are wide-ranging and systemic, with hepatic involvement only one component of the larger illness. The most common of these disorders, hereditary…

Hepatic Iron Overload

Etiology Hepatic iron overload is a generic term that refers to the nonphysiologic accumulation of iron within the hepatic parenchyma. The most clinically significant cause of hepatic iron overload is hereditary hemochromatosis. Hereditary hemochromatosis is associated with several mutations in genes regulating iron metabolism, the most common of which are in the HFE gene. The HFE mutations result in dysregulated iron absorption, which may lead to…

Fatty Liver Disease

Etiology Fatty liver is a generic term that refers to the accumulation of lipids within hepatocytes. This chapter focuses on nonalcoholic fatty liver disease (NAFLD), the most common form of fatty liver. Histologically, it resembles alcoholic liver injury but occurs in patients who deny significant alcohol consumption. NAFLD encompasses a spectrum of conditions, ranging from benign hepatocellular steatosis to inflammatory nonalcoholic steatohepatitis (NASH), fibrosis, and cirrhosis.…

Malignant Focal Lesions

Etiology Malignant liver tumors can be classified either by cell of origin as hepatocellular, cholangiocellular, or mesenchymal or by site of origin as primary or secondary. This chapter will describe the most frequently encountered malignant hepatic tumors arising in the noncirrhotic liver, including hepatocellular carcinoma (HCC), fibrolamellar HCC, epithelioid hemangioendothelioma (EHE), angiosarcoma, and metastatic disease. Also discussed are other rare primary liver tumors, such as lymphoma…

Benign Focal Lesions

Etiology Although benign hepatic tumors have been classified into several histiotypes according to their cell of origin (i.e., hepatocytes, biliary epithelium, or mesenchymal cells), our focus in this discussion is on those lesions most frequently encountered in clinical practice, including simple (nonparasitic) cyst, hemangioma, hepatocellular adenoma, focal nodular hyperplasia (FNH), large benign regenerative nodules, and hepatic abscess ( Table 36-1 ). TABLE 36-1 Clinical and Radiologic…

Imaging of the Liver

Ultrasound Technical Aspects Ultrasound is a widely accessible, noninvasive imaging method that has many advantages over other imaging methods. It is portable and relatively inexpensive with high spatial and temporal resolution. It does not involve ionizing radiation and can be repeated frequently. Despite increased use of other imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI), ultrasound remains, in many settings, the first-line…

Imaging of the Postoperative Bowel

Surgical procedures performed on the bowel are innumerable, and their detailed discussion is beyond the scope of this chapter. To understand the related imaging, it is important to be familiar with the postoperative anatomy. Our purpose in this chapter is to present tools to approach the postoperative bowel by discussing some commonly performed surgical procedures, their appearance on imaging, and common complications. Procedures Esophageal Resection All…

Colon Cancer and Screening Strategies

Etiology The causes of the development of colorectal carcinoma and its precursor lesion, the colonic adenoma, are multifactorial and include both genetic predisposition and environmental insults. Risk factors for colorectal carcinoma include familial polyposis syndrome, ulcerative colitis, family history of colorectal cancer, age, male gender, smoking, alcohol intake, and obesity. Prevalence and Epidemiology Colon cancer is the third most commonly diagnosed cancer and third most common…

Colonic Vascular Lesions

Etiology Vascular lesions of the colon are an important medical problem and have now been recognized as a significant cause of gastrointestinal bleeding. They can be solitary or multifocal, benign or malignant, or associated with a syndrome or systemic dis­order. There are three main groups: vascular malformations, neoplastic lesions, and non-neoplastic lesions ( Figure 32-1 ). Vascular malformations can be broadly classified into arterial, venous, and…