EURORAD ESR

Case 15441

Hypertriglyceridaemia-related recurrent acute pancreatitis with splenic vein thrombosis

Author(s)
Tonolini Massimo, MD.

"Luigi Sacco" University Hospital, Radiology Department; Via G.B. Grassi 74 20157 Milan, Italy; Email:mtonolini@sirm.org
 
Patient
male, 41 year(s)
 
 
  • Figure 1
    Bedside abdominal ultrasound at emergency admission
     

    Sonography revealed hepatomegaly with markedly hyperechoic echotexture consistent with severe steatosis; normal gallbladder without lithiasis and inflammation; absent biliary dilatation.

     
    Area of Interest: Pancreas; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    The visible pancreatic portions (+) did not appear enlarged. Peripancreatic effusion and fluid collections were not seen.

     
    Area of Interest: Pancreas; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Inflammation;
     
     
  • Figure 2
    Unenhanced and post-contrast multidetector CT (24 hours after Fig.1)
     

    Precontrast images (a,b) showed effusion (*) surrounding the spleen and pancreatic tail, extending to the left retroperitoneal fasciae. Note hypoattenuating parenchyma consistent with marked liver steatosis.

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    Precontrast images (a,b) showed effusion (*) surrounding the spleen and pancreatic tail, extending to the left retroperitoneal fasciae. The pancreas (+) did not appear enlarged. Note hypoattenuating parenchyma...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    After iv contrast, the normal-sized pancreas showed focal hypoenhancement at the tail (arrowheads) consistent with necrosis (<30%). Note peripancreatic and fascial fluid (*), marked liver steatosis, normal gallbladder.

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    After iv contrast, the normal-sized pancreas showed focal hypoenhancement at the tail (arrowheads) consistent with necrosis (<30%). Note peripancreatic and fascial fluid (*), marked liver steatosis.

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    Additionally, filling defect (thin arrows) indicating partial thrombosis of the splenic vein was noted. Note peripancreatic and fascial fluid (*), patent portal and mesenteric veins, marked liver steatosis.

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    After iv contrast, the normal-sized pancreas showed focal hypoenhancement at the tail (arrowheads) consistent with necrosis (<30%). Note peripancreatic and fascial fluid (*), marked liver steatosis.

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    Additionally, filling defect (thin arrows) indicating partial thrombosis of the splenic vein was noted. Note peripancreatic and fascial fluid (*), patent portal and mesenteric veins, marked liver steatosis.

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Inflammation;
     
     
  • Figure 3
    Colour Doppler ultrasound (CDUS) 6 weeks later
     

    CDUS follow-up showed patent splenic vein with normal flow spectrum (a) and direction (b) consistent with resolution of thrombosis.

     
    Area of Interest: Pancreas; Imaging Technique: Ultrasound-Colour Doppler; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    CDUS follow-up showed patent splenic vein with normal flow spectrum (a) and direction (b) consistent with resolution of thrombosis.

     
    Area of Interest: Pancreas; Imaging Technique: Ultrasound-Colour Doppler; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    Normal flow direction and spectrum in the portal vein.

     
    Area of Interest: Pancreas; Imaging Technique: Ultrasound-Colour Doppler; Procedure: Diagnostic procedure; Special Focus: Inflammation;
     
     
  • Figure 4
    MRI (9 months later) - T2- and diffusion-weighted images
     

    At clinical relapse, the pancreas maintained normal size. A demarcated post-necrotic collection (arrowheads) had developed at the tail, corresponding to site of initial necrosis (Fig.2), with low T2-weighted signal...

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    At clinical relapse, the pancreas maintained normal size. A demarcated post-necrotic collection (arrowheads) had developed at the tail, corresponding to site of initial necrosis (Fig.2), with low T2-weighted signal...

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    At clinical relapse, the pancreas maintained normal size. A demarcated post-necrotic collection (arrowheads) had developed at the tail, corresponding to site of initial necrosis (Fig.2), with low T2-weighted signal...

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    At clinical relapse, the pancreas maintained normal size, without peripancreatic fluid on fat-suppressed T2-weighted acquisition. Note non-dilated main bile duct, normal-appearing gallbladder.

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    MR-cholangiopancreatography confirmed normal-appearing gallbladder, intrahepatic and common bile ducts. The Wirsung duct did not show appreciable abnormalities.

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    High (800) b-value diffusion-weighted images (f,g) showed increased signal in the pancreatic (+) head and neck compared to body-tail, with corresponding low apparent diffusion coefficient (h,i) indicating segmental...

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    High (800) b-value diffusion-weighted images (f,g) showed increased signal in the pancreatic (+) head and neck compared to body-tail, with corresponding low apparent diffusion coefficient (h,i) indicating segmental...

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    High (800) b-value diffusion-weighted images (f,g) showed increased signal in the pancreatic (+) head and neck compared to body-tail, with corresponding low apparent diffusion coefficient (h,i) indicating segmental...

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    The post-necrotic collection (arrowheads) did not show restricted diffusion (ADC map i, b800 image j).

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    The post-necrotic collection (arrowheads) did not show restricted diffusion (ADC map i, b800 image j).

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;
     
     
  • Figure 5
    MRI (9 months later) - T1-weighted images w/o gadolinium
     

    On precontrast fat-suppressed T1-weighted images, the post-necrotic collection (arrowhead) at the pancreatic tail showed inhomogeneous, intermediate signal intensity consistent with partly fibrotic component.

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    Dynamic gadolinium-enhanced acquisition (b...e) showed normally enhancing pancreatic gland (detail of head an neck in b, body, in c, tail in d), absent enhancement of the distal post-necrotic collection (arrowheads in...

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    Dynamic gadolinium-enhanced acquisition (b...e) showed normally enhancing pancreatic gland (detail of head an neck in b, body, in c, tail in d), absent enhancement of the distal post-necrotic collection (arrowheads in...

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    Dynamic gadolinium-enhanced acquisition (b...e) showed normally enhancing pancreatic gland (detail of head an neck in b, body, in c, tail in d), absent enhancement of the distal post-necrotic collection (arrowheads in...

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    Dynamic gadolinium-enhanced acquisition (b...e) showed normally enhancing pancreatic gland (detail of head an neck in b, body, in c, tail in d), absent enhancement of the distal post-necrotic collection (arrowheads in...

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;
     
     
Sonography revealed hepatomegaly with markedly hyperechoic echotexture consistent with severe steatosis; normal gallbladder without lithiasis and inflammation; absent biliary dilatation.
 
The visible pancreatic portions (+) did not appear enlarged. Peripancreatic effusion and fluid collections were not seen.
 
Precontrast images (a,b) showed effusion (*) surrounding the spleen and pancreatic tail, extending to the left retroperitoneal fasciae. Note hypoattenuating parenchyma consistent with marked liver steatosis.
 
Precontrast images (a,b) showed effusion (*) surrounding the spleen and pancreatic tail, extending to the left retroperitoneal fasciae. The pancreas (+) did not appear enlarged. Note hypoattenuating parenchyma consistent with marked liver steatosis.
 
After iv contrast, the normal-sized pancreas showed focal hypoenhancement at the tail (arrowheads) consistent with necrosis (<30%). Note peripancreatic and fascial fluid (*), marked liver steatosis, normal gallbladder.
 
After iv contrast, the normal-sized pancreas showed focal hypoenhancement at the tail (arrowheads) consistent with necrosis (<30%). Note peripancreatic and fascial fluid (*), marked liver steatosis.
 
Additionally, filling defect (thin arrows) indicating partial thrombosis of the splenic vein was noted. Note peripancreatic and fascial fluid (*), patent portal and mesenteric veins, marked liver steatosis.
 
After iv contrast, the normal-sized pancreas showed focal hypoenhancement at the tail (arrowheads) consistent with necrosis (<30%). Note peripancreatic and fascial fluid (*), marked liver steatosis.
 
Additionally, filling defect (thin arrows) indicating partial thrombosis of the splenic vein was noted. Note peripancreatic and fascial fluid (*), patent portal and mesenteric veins, marked liver steatosis.
 
CDUS follow-up showed patent splenic vein with normal flow spectrum (a) and direction (b) consistent with resolution of thrombosis.
 
CDUS follow-up showed patent splenic vein with normal flow spectrum (a) and direction (b) consistent with resolution of thrombosis.
 
Normal flow direction and spectrum in the portal vein.
 
At clinical relapse, the pancreas maintained normal size. A demarcated post-necrotic collection (arrowheads) had developed at the tail, corresponding to site of initial necrosis (Fig.2), with low T2-weighted signal reflecting fibrosis.
 
At clinical relapse, the pancreas maintained normal size. A demarcated post-necrotic collection (arrowheads) had developed at the tail, corresponding to site of initial necrosis (Fig.2), with low T2-weighted signal reflecting fibrosis.
 
At clinical relapse, the pancreas maintained normal size. A demarcated post-necrotic collection (arrowheads) had developed at the tail, corresponding to site of initial necrosis (Fig.2), with low T2-weighted signal reflecting fibrosis.
 
At clinical relapse, the pancreas maintained normal size, without peripancreatic fluid on fat-suppressed T2-weighted acquisition. Note non-dilated main bile duct, normal-appearing gallbladder.
 
MR-cholangiopancreatography confirmed normal-appearing gallbladder, intrahepatic and common bile ducts. The Wirsung duct did not show appreciable abnormalities.
 
High (800) b-value diffusion-weighted images (f,g) showed increased signal in the pancreatic (+) head and neck compared to body-tail, with corresponding low apparent diffusion coefficient (h,i) indicating segmental acute inflammation.
 
High (800) b-value diffusion-weighted images (f,g) showed increased signal in the pancreatic (+) head and neck compared to body-tail, with corresponding low apparent diffusion coefficient (h,i) indicating segmental acute inflammation.
 
High (800) b-value diffusion-weighted images (f,g) showed increased signal in the pancreatic (+) head and neck compared to body-tail, with corresponding low apparent diffusion coefficient (h,i) indicating segmental acute inflammation.
 
The post-necrotic collection (arrowheads) did not show restricted diffusion (ADC map i, b800 image j).
 
The post-necrotic collection (arrowheads) did not show restricted diffusion (ADC map i, b800 image j).
 
On precontrast fat-suppressed T1-weighted images, the post-necrotic collection (arrowhead) at the pancreatic tail showed inhomogeneous, intermediate signal intensity consistent with partly fibrotic component.
 
Dynamic gadolinium-enhanced acquisition (b...e) showed normally enhancing pancreatic gland (detail of head an neck in b, body, in c, tail in d), absent enhancement of the distal post-necrotic collection (arrowheads in d-e).
 
Dynamic gadolinium-enhanced acquisition (b...e) showed normally enhancing pancreatic gland (detail of head an neck in b, body, in c, tail in d), absent enhancement of the distal post-necrotic collection (arrowheads in d-e).
 
Dynamic gadolinium-enhanced acquisition (b...e) showed normally enhancing pancreatic gland (detail of head an neck in b, body, in c, tail in d), absent enhancement of the distal post-necrotic collection (arrowheads in d-e).
 
Dynamic gadolinium-enhanced acquisition (b...e) showed normally enhancing pancreatic gland (detail of head an neck in b, body, in c, tail in d), absent enhancement of the distal post-necrotic collection (arrowheads in d-e).
 
 
 
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