Pancreatic and Biliary Ultrasound

Learning Objectives

- Recognize common pancreatic and biliary pathologies that can be visualized with POCUS
- Learn how to perform pancreatic and biliary POCUS

Key Points

Acute Pancreatitis: Inflammation- edema (hypoechoic), peripancreatic fluid
Chronic Pancreatitis: Calcifications and atrophy with possible superimposed inflammation similar to acute pancreatitis.
Biliary = CBD dilation >1cm ******************************

Pancreatic Ultrasound

Position: Patient supine or in left lateral decubitus position
Transducer: Curvilinear or Phased Array.
Location: Focus on sub-xyphoid/epigastric region
- [Transverse] Point probe towards 9 o'clock. Pancreas(hyperechoic) is sandwiched between liver(anterior/superior hypogenic organ) and splenic vein (posterior/inferior anechoic vessel).
- [Longitudinal] Focus on sub-xyphoid/epigastric region, point probe towards 12 o'clock. Pancreas (hyperechoic) is sandwiched between liver(anterior/superior hypogenic organ) and splenic vein (posterior/inferior anechoic vessel).
- [Pancreatic tail] Focus on sub-xyphoid/epigastric region, point probe towards 8 o'clock (patient's right hip). Fan towards 5 o'clock. It is important to visualize the entire pancreas to rule out pathology.

Tip: Deep inspiration by the patient can help to aid image acquisition

Hepatopanceatobiliary anatomy

Image Acquisition

[Transverse] Point probe towards 9 o'clock. Pancreas(hyperechoic) is sandwiched between liver(anterior/superior hypogenic organ) and splenic vein (posterior/inferior anechoic vessel).

Transverse view

[Longitudinal] Focus on sub-xyphoid/epigastric region, point probe towards 12 o'clock. Pancreas (hyperechoic) is sandwiched between liver(anterior/superior hypogenic organ) and splenic vein (posterior/inferior anechoic vessel).

Longitudinal view

[Pancreatic tail] Focus on sub-xyphoid/epigastric region, point probe towards 8 o'clock (patient's right hip). Fan towards 5 o'clock. It is important to visualize the entire pancreas to rule out pathology.

Abnormal Findings: Acute /ChronicPancreatitis

Acute Pancreatitis: Inflammation- edema (hypoechoic), peripancreatic fluid
Chronic Pancreatitis: Calcifications and atrophy with possible superimposed inflammation similar to acute pancreatitis.

Acute pancreatitis is characterized on ultrasound by pancreatic edema and peripancreatic fluid.

Chronic pancreatitis is characterized by pancreatic calcifications, pancreatic atrophy, and may be accompanied by pancreatic duct dilation.

Gallbladder Ultrasound

Highly sensitiive (87% for cholelithaisis, 73% for cholecystitis)
Chronic Pancreatitis: Calcifications and atrophy with possible superimposed inflammation similar to acute pancreatitis.

The biliary system and its 'itis's'

Biliary Colic: RUQ/shoulder pain, may/not be ‘colicky’ in nature
Cholecystitis: above + fever/leukocytosis
Cholangitis: above + jaundice, +/-sepsis

Image Acquisition

Position: Patient supine
Transducer: Curvilinear or Phased Array.
Location: Inferior border of right costal margin

[Longitudinal] Point probe towards 10/11 o'clock. Gallbladder is a (hopefully) fluid filled (anechoic) sandwiched between the liver (hypoechoic, anterior) and IVC (anechoic, posterior).
- Fan probe towards patient's right hip/left shoulder to image comprehensively.

[Transverse] From longitudinal view, rotate probe 90 degrees counterclockwise (probe towards 7/8 o'clock). The gallbladder lumen should be circular.
- Fan probe towards patient's left hip/right shoulder to image comprehensively.

[Transverse] From longitudinal view, rotate probe 90 degrees counterclockwise (probe towards 7/8 o'clock). The gallbladder lumen should be circular.
- Fan probe towards patient's left hip/right shoulder to image comprehensively.

Abnormal Findings:

Gallstones: Hyperechoic, moblie, posterior shadowing.
Sludge: Hyperechoic, mobile, no shadowing.
Cholecystitis: Gallbaldder wall thickening (>3cm), pericholecystic fluid, sonographic murphy sound (pain with compression of gallbladder with ultrasound probe).

Gallstones: Hyperechoic, posterior shadowing (like ribs!).

Gallbladder Sludge: Hyperechoic, mobile, no shadowing

Cholecystitis: Note wall thickening with double wall sign.

Cholecystitis: Pericholecystic fluid, wall thickening

Images / information from: https://www.pocus101.com/efast-ultrasound-exam-made-easy-step-by-step-guide/#eFAST_Ultrasound_Exam_Indications https://radiopaedia.org/articles/pancreatic-ultrasound?lang=us https://www.youtube.com/watch?v=TzbdLT-3AxY&ab_channel=Dr.Sam%27sImagingLibrary https://www.youtube.com/watch?v=6HtKv6dbQBQ&ab_channel=Dr.Sam%27sImagingLibrary https://en.wikipedia.org/wiki/Splenic_vein#/media/File:Bilebladder.png https://www.youtube.com/watch?v=HkegFQhONO8&ab_channel=Simon%27strainingvideos https://radiologykey.com/the-biliary-tree/

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