CHAPTER  11 
Pancreas
Thomas G. Nyland • John S. Mattoon
INDICATIONS FOR PANCREATIC
ULTRASONOGRAPHY
The pancreas is a difficult organ to evaluate by most abdomi-
nal imaging methods. In veterinary medicine, survey radio-
graphs of the abdomen have traditionally been the initial
imaging procedure of choice. Radiographic signs suggestive of
pancreatic abnormalities include a soft tissue dense mass or
loss of peritoneal detail in the right cranial abdomen and small
amounts of duodenal gas accumulation indicative of func-
tional ileus. An upper gastrointestinal tract series is helpful to
confirm pancreatic masses that cause duodenal fixation or
displacement, increased width of the cranial duodenal flexure,
or thickening and deformity of the adjacent duodenum or
stomach. However, the radiographic findings may be equivocal
or normal in many cases of pancreatic disease.
Ultrasonography was one of the first modalities that
enabled direct visualization of the pancreas in humans, and its
use was quickly applied to animals. More recently, computed
tomography, magnetic resonance imaging, and scintigraphy
have played major roles in assessing pancreatic disease in
humans. The preliminary use of these modalities to image the
pancreas has also been described in animals.1-10 Fiberoptic
technology has enabled the use of endoscopic retrograde chol-
angiopancreatography and endoscopic ultrasonography for
pancreatic evaluation in humans. The potential applications
and preliminary experience with endoscopic retrograde chol-
angiopancreatography and endoscopic ultrasonography of the
pancreas have also been described in animals.11-17 The expense
and availability of specialized equipment, as well as the need
for anesthesia, have currently limited the routine use of these
techniques in small animals. Ultrasonography is still the
primary means for imaging the pancreas in the dog and cat
because of its wider availability.
Ultrasonography complements but does not replace
abdominal radiography for the work-up of the acute abdomen.
Radiography is important for evaluating peritoneal detail,
bowel patterns, and the displacement of viscera by large
abdominal masses. Radiography is also useful for detecting
gastrointestinal foreign bodies, free abdominal air, and bone
abnormalities. Ultrasonography is better for evaluating pan-
creatic or other small abdominal masses, identifying focal fluid
collections, and recognizing metastasis to adjacent organs or
lymph nodes. In addition, ultrasonography is superior to radi-
ography when there is a large amount of abdominal fluid. The
discovery of a mass in the pancreatic region, with concurrent
lymphadenopathy, metastasis, or other abnormalities, helps
narrow the differential diagnosis and establish a prognosis for
the acute abdomen. If necessary, material for cytologic analysis
438
can be obtained from the pancreas, lymph nodes, or potential
metastatic lesions by guided aspiration. Serial follow-up ultra-
sound examinations allow an accurate determination of treat-
ment response.
Although there are many advantages to pancreatic ultraso-
nography, the technique also has significant limitations. These
include poor visualization of the normal pancreas and interfer-
ence from gas or barium in the gastrointestinal tract. Proper
preparation of animals, judicious use of transducer pressure to
displace overlying gas-filled bowel, and positional studies can
usually overcome the limitations of bowel gas. Ultrasound
examinations should always be performed before procedures
causing aerophagia and before a barium series because of the
high reflectivity of air and barium. The examination should
be repeated if a diagnostic study cannot be obtained. The lack
of abnormalities on an ultrasound examination of the pancre-
atic region does not exclude pancreatic disease, but it helps
rule out significant anatomic abnormalities. In spite of these
limitations, ultrasound has gained an important place in the
diagnostic work-up of almost all cases of suspected pancreatic
disease.
The normal canine or feline pancreas can be difficult to see
as a distinct structure on ultrasound studies, but the surround-
ing anatomy, as described later, helps localize its position.18-23
Fat within and surrounding the pancreas is probably respon-
sible for the high echogenicity of this region. In some cases,
the pancreas is not visualized, but newer ultrasound equip-
ment has allowed more frequent identification of the pancreas
in dogs and cats. The acoustic output and gain settings of the
scanner should be kept as low as possible to decrease overall
reflectivity of the region and permit the greatest chance for
visualizing the pancreas.
EXAMINATION TECHNIQUE
Pancreatic ultrasound examinations may be performed in
dorsal recumbency, ventral recumbency, lateral recumbency,
or the standing position. The sonographer may begin the study
from the ventral abdomen with the dog or cat positioned in
dorsal recumbency (Figure 11-1, A and B). However, some
sonographers prefer left lateral recumbency, especially with
deep-chested dogs (Figure 11-1, C). Hair removal and imaging
through the right 9th to 12th intercostal space facilitates
transverse views when excessive bowel gas is present.24,25 The
ventral or lateral recumbent position is also used as needed to
avoid bowel gas. An 8- to 15-MHz linear or curvilinear trans-
ducer is preferred for pancreatic examinations in small dogs
and cats, but large dogs may require a 5- to 8-MHz transducer