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Pancreas: Complete Radiology Reference

PART 1 - NORMAL PANCREAS ANATOMY

Gross Anatomy

The pancreas is a retroperitoneal organ lying obliquely across the posterior abdominal wall at the level of L1-L2. It is soft, tan-colored, and measures approximately 15-20 cm in length.

Parts and key relationships:

Part	Level	Key Relations
Head	L1-L3	Nestled in the C-loop of the duodenum; CBD runs in a groove posteriorly; SMA/SMV pass behind/in front of uncinate
Uncinate process	Projects left/posterior from head	Hooks behind the SMA, anterior to IVC and aorta
Neck	Overlies portal vein confluence	SMV + splenic vein join behind neck to form portal vein
Body	L1-L2	Anterior to aorta, SMA origin; posterior to lesser sac/stomach; splenic artery along superior border
Tail	Obliquely to left	Enters splenorenal ligament; lies in contact with splenic hilum; only intraperitoneal part

Surrounding structures:

Anterior: stomach, transverse colon, lesser sac
Posterior: aorta, IVC, left adrenal, left kidney, splenic vein, portal vein confluence
Superior border: splenic artery (tortuous), celiac axis
Inferior border: root of transverse mesocolon, SMA
The celiac plexus wraps around the celiac axis just above the superior border of the body

(Yamada's Textbook of Gastroenterology, anatomy chapter)

Duct Anatomy

Main duct (Wirsung): Runs the full length; drains via major papilla (ampulla of Vater) at the medial wall of the 2nd duodenum (D2), level L2-L4 in 92% of people
Accessory duct (Santorini): Drains superior head/uncinate via minor papilla, 2 cm proximal to major papilla
Normal main duct diameter: up to 3 mm in head, 2 mm in body, 1.5 mm in tail (widens slightly with age)
On MRCP: the "chain of lakes" pattern = chronic pancreatitis

Blood Supply

Vessel	Territory
Gastroduodenal artery (GDA) - branch of CHA	Pancreatic head (anterior & posterior superior pancreaticoduodenal arteries)
SMA branches	Inferior pancreaticoduodenal arteries - head
Splenic artery	Body and tail (dorsal pancreatic + great pancreatic artery of Haller)

Venous drainage mirrors arterial supply - into splenic vein and portal vein.

PART 2 - ANATOMICAL VARIANTS

1. Pancreas Divisum

Most common congenital variant (7% of autopsy series)
Failure of fusion of dorsal and ventral ducts during 6th-7th week of gestation
The entire dorsal pancreas (body, tail, superior head) drains via the minor papilla (Santorini), the smaller orifice
15-20% are "incomplete divisum" - tiny ductal communication persists
Christmas tree pattern on ventral ductography (side branches diminishing in size)
Increased risk of recurrent acute/chronic pancreatitis in 25-30% of symptomatic patients (often in combination with CFTR/SPINK mutations)
ERCP/MRCP finding: Ventral duct fills via major papilla as a short stub; dorsal duct fills only via minor papilla cannulation
MRCP key sign: Dorsal duct crosses the CBD without joining it

2. Annular Pancreas

Ventral pancreatic bud fails to rotate properly and wraps around the 2nd part of duodenum
Can cause duodenal obstruction (in neonates: "double bubble" on X-ray)
Associated with Down syndrome, intestinal malrotation, duodenal atresia
CT/MRCP: Ring of pancreatic tissue encircling D2; duct encircles duodenum
Adults may present with postprandial pain, gastric outlet obstruction, pancreatitis

3. Ectopic Pancreatic Tissue (Heterotopic Pancreas)

Most common in stomach antrum, duodenum, proximal jejunum, Meckel's diverticulum
Radiological appearance: Submucosal nodule often with central umbilication (representing the duct opening) - classic on upper GI or CT

4. Agenesis / Hypoplasia

Dorsal agenesis: absence of body and tail; associated with polysplenia syndrome
Lipomatous pseudohypertrophy: diffuse fat replacement (seen in cystic fibrosis, Shwachman-Diamond syndrome)

5. Groove Pancreatitis (Paraduodenal Pancreatitis)

A form involving the anatomical groove between the pancreatic head, duodenum and CBD
Can mimic pancreatic adenocarcinoma on imaging; look for cystic changes in the groove/duodenal wall on MRI

PART 3 - PANCREATIC NEOPLASMS

Classification Overview

PANCREATIC TUMORS
├── SOLID NEOPLASMS
│   ├── Malignant: Ductal adenocarcinoma (PDAC), Acinar cell carcinoma, Pancreatoblastoma
│   ├── Low malignant potential: Solid pseudopapillary neoplasm (SPN/Frantz tumor)
│   └── Variable behavior: Pancreatic neuroendocrine tumor (PanNET)
│
└── CYSTIC NEOPLASMS
    ├── Mucinous (premalignant→malignant)
    │   ├── IPMN (Main duct / Branch duct / Mixed)
    │   └── Mucinous cystic neoplasm (MCN)
    ├── Serous (benign)
    │   └── Serous cystadenoma (SCN/SCA)
    ├── Mixed solid-cystic
    │   └── Solid pseudopapillary neoplasm (SPN)
    └── Non-neoplastic mimics
        ├── Pseudocyst
        ├── Lymphoepithelial cyst
        └── Retention cyst

SOLID NEOPLASMS

1. Pancreatic Ductal Adenocarcinoma (PDAC)

Most common pancreatic malignancy (~85%)
4th most common cause of cancer death in Western countries
5-year survival ~5-12%; only 10-20% resectable at diagnosis
Location: 60-70% pancreatic head, 15% body, 5% tail

Radiological features - CT (workhorse):

Hypodense/hypoattenuating mass (desmoplastic stroma = poor vascularity) - best seen in the pancreatic parenchymal phase (35-50s)
Double duct sign - simultaneous dilatation of CBD and main pancreatic duct (MRCP/CT - pathognomonic for periampullary/head carcinoma)
Upstream pancreatic duct dilatation with abrupt cut-off
Pancreatic atrophy distal to mass
Interrupted duct sign (abrupt duct cut-off at mass)
Loss of normal pancreatic lobulation
Perineural/perivascular infiltration (soft tissue stranding around vessels)
Vascular involvement (critical for staging):
- Abutment: ≤180° contact with vessel
- Encasement: >180° contact
- Teardrop sign of SMV = vessel deformity/narrowing
Liver metastases: hypovascular; portal venous phase best
Peritoneal spread, lymphadenopathy

MRI features:

T1: Hypointense (normal pancreas is T1 bright due to secretory protein)
T2: Mildly hyperintense or iso/hypointense
DWI: Restricted diffusion (high signal DWI, low ADC) - excellent for small/isoattenuating tumors
Post-gadolinium: Hypovascular enhancement (less than parenchyma in all phases)
MRI solves the "isoattenuating PDAC" problem invisible on CT
Duct-penetrating sign on MRCP: The duct traverses the mass without obstruction = favors inflammatory mass, NOT cancer

Indirect CT signs of isoattenuating PDAC:

Contour bulge/deformity
Loss of fat interspersed between lobules
Duct cut-off without visible mass
Focal atrophy

TNM Staging (8th edition AJCC):

Stage	Definition
T1	≤2 cm
T2	>2 cm, ≤4 cm
T3	>4 cm
T4	Involves celiac axis, SMA, or common hepatic artery (unresectable)
N1	Peripancreatic regional nodes
M1	Distant metastasis

Resectability classification (NCCN):

Resectable: No vascular involvement
Borderline resectable: Abutment of major vessels (≤180°) or short segment venous occlusion
Locally advanced/unresectable: Encasement of SMA/celiac (>180°) or IVC involvement

2. Pancreatic Neuroendocrine Tumors (PanNETs)

~1-2% of pancreatic neoplasms
Arise from islets of Langerhans or precursor cells
Functional (hormone-secreting) vs. Non-functional

Common functional tumors:

Tumor	Hormone	Syndrome	Key Feature
Insulinoma	Insulin	Whipple's triad	Most common functioning PanNET; usually benign (<10% malignant); usually <2 cm
Gastrinoma	Gastrin	Zollinger-Ellison	Often in "gastrinoma triangle"; 60% malignant
Glucagonoma	Glucagon	Necrolytic migratory erythema, DM	Usually large, tail; high malignant potential
VIPoma	VIP	WDHA/Verner-Morrison (watery diarrhea, hypokalemia, achlorhydria)	Large, often tail
Somatostatinoma	Somatostatin	"Somatostatinoma syndrome"	Head; associated with NF1

Radiological features:

Hypervascular - most PanNETs enhance avidly in arterial phase (opposite of PDAC)
Round, well-circumscribed
T2: Hyperintense (important differentiator from PDAC)
Larger tumors may be cystic, calcified, or rim-enhancing
Small insulinomas: may be difficult to find; EUS >90% sensitivity
Non-functional PanNETs tend to be larger at presentation and have poorer prognosis
Liver metastases are hypervascular (bright arterial phase)

Gastrinoma triangle: Bounded by junction of cystic duct and CBD (superiorly), junction of 2nd and 3rd parts of duodenum (inferiorly), and neck/body of pancreas (medially)

3. Acinar Cell Carcinoma

Rare (<1%); older men; often large at presentation
CT: Large, well-defined, heterogeneous; hypervascular (distinguishes from PDAC)
May cause Schmid triad: lipase hypersecretion syndrome (subcutaneous fat necrosis, polyarthralgia, eosinophilia)

4. Pancreatoblastoma

Most common pancreatic tumor in children
CT: Large heterogeneous mass, may be partly cystic, head predominance

CYSTIC NEOPLASMS

(Reference table - Clinical Gastrointestinal Endoscopy, 3e)

Feature	IPMN (MD)	IPMN (BD)	MCN	SCN	SPN
Sex	M>F	M=F	Nearly all F	F > M	Predominantly F (90%)
Age	65+	65+	~40	60+	30-38
Location	Head	Head/uncinate	Body & tail	Head > Body/tail	Body/tail (60%)
Duct communication	Yes (main duct)	Yes (side branch)	No	No	No
Malignancy risk	High (60%)	Low-moderate (10-30%)	Moderate (15-30%)	Very low (<3%)	Low-malignant (~15%)
Key imaging	MPD ≥5 mm, "fish-mouth" papilla	Grape-like cysts	Unilocular, eggshell Ca++	Honeycomb, central scar/Ca++	Mixed solid-cystic, capsule

1. Intraductal Papillary Mucinous Neoplasm (IPMN)

Most common resected pancreatic cystic neoplasm.

Main duct IPMN (MD-IPMN):

Main pancreatic duct ≥5 mm (up to 20+ mm) with mucin
"Fish-mouth" ampulla (mucin extruding from papilla)
High-grade dysplasia/malignancy rate ~60%
Mandatory resection in fit patients

Branch duct IPMN (BD-IPMN):

Cystic lesion communicating with duct (key differentiator from MCN)
Usually head/uncinate
"Bunch of grapes" or "cluster of cysts" appearance
Main duct remains normal or minimally dilated
Worrisome features (Fukuoka guidelines): mural nodule, septations, rapid growth >5mm/yr, MPD ≥5 mm, jaundice, size ≥3 cm

MRI/MRCP: Best for showing duct communication (pathognomonic), mural nodules, septations

2. Mucinous Cystic Neoplasm (MCN)

Almost exclusively in women (>95%), median age 40
Body and tail in >97% of cases - this is diagnostic!
Single, unilocular or septated cyst; NO communication with pancreatic duct
Thick wall; "eggshell" peripheral calcification (~15%)
Ovarian-type stroma in wall (pathognomonic histologically)
CEA high in cyst fluid; KRAS mutation present
Malignancy risk: up to 15-30% (MCN with associated carcinoma)
CT/MRI: Uni- or multilocular cyst in body/tail, peripheral ± eggshell calcification, no duct communication, thick wall

3. Serous Cystadenoma (SCN)

Benign (serous cystadenocarcinoma extremely rare)
Older women (60+); associated with Von Hippel-Lindau (VHL) disease (multiple SCNs)
Head predominance
"Honeycomb" appearance: dozens of tiny cysts (<2 cm) separated by thin fibrous septa
Central stellate scar with calcification (50% have central calcification) - pathognomonic on CT
VHL gene mutation; KRAS negative
CEA <5 ng/mL in cyst fluid; PAS-positive cuboidal cells on cytology
Management: Observation unless symptomatic; does not recur after resection

CT: Lobulated, honeycombed lesion, central scar + sunburst/stellate calcification MRI: Multiple T2-bright tiny cysts; central low-signal scar

4. Solid Pseudopapillary Neoplasm (SPN / Frantz Tumor / Hamoudi Tumor)

Rare (<4% of cystic tumors), predominantly young women (90%), median age 30-38
"Frantz tumor" (Frantz 1959) - also called solid-cystic tumor or papillary-cystic neoplasm
Mixed solid-cystic (60%), pure solid (15%), or pure cystic (25%)
Location: 60% body/tail, but can occur anywhere; head in pediatric cases
Well-demarcated with fibrous capsule (peripheral capsule that calcifies in some)
Low malignant potential (~15% have metastases at diagnosis; 5-year survival >95% after resection)

CT features:

Well-encapsulated, heterogeneous mass (hemorrhage + necrosis)
Calcification in capsule (peripheral - opposite of SCN)
Variable enhancement; solid portions enhance
Older lesions more cystic due to necrosis

MRI features:

T1: Intrinsic high signal from hemorrhage (key feature)
T2: Mixed signal
DWI: Diffusion restriction
Post-gadolinium: Progressive peripheral enhancement

RARE CYSTIC LESIONS (Non-neoplastic mimics)

Lesion	Key feature
Pseudocyst	Post-pancreatitis; no epithelial lining; unilocular; near pancreas
Lymphoepithelial cyst	Men, 50s; keratinous material; no malignant potential
Retention cyst	Communication with duct; post-inflammatory/obstructive
Mucinous non-neoplastic cyst	Rare; no ovarian stroma; lower malignancy risk
Epidermoid cyst in intrapancreatic spleen	In tail; accessory spleen on Tc-99m scan

PART 4 - PANCREATITIS

Classification Systems

Atlanta Classification (Revised 2012):

Acute Pancreatitis

Mild - No organ failure, no local/systemic complications
Moderately severe - Transient organ failure (<48h) and/or local complications
Severe - Persistent organ failure (>48h) - single or multiple organ failure

Morphological types:

Interstitial edematous pancreatitis (~80-90%): Diffuse or focal gland enlargement, homogeneous enhancement, peripancreatic fat stranding
Necrotizing pancreatitis (~10-20%): Non-enhancement of parenchyma on CECT

Fluid Collections (by timing and content):

Collection	Timing	Content	Wall	Outcome
Acute peripancreatic fluid collection (APFC)	<4 weeks; interstitial pancreatitis	Fluid only	No defined wall	Most resolve
Pseudocyst	>4 weeks; interstitial pancreatitis	Fluid only	Well-defined capsule	May persist or need drainage
Acute necrotic collection (ANC)	<4 weeks; necrotizing	Fluid + necrotic debris	No defined wall
Walled-off necrosis (WON)	>4 weeks; necrotizing	Fluid + solid necrotic debris	Well-defined wall	Most serious; endoscopic/surgical necrosectomy

Key distinction: Pseudocyst = pure fluid; WON = contains solid material (fat + tissue debris) - critical because WON cannot be drained by simple aspiration alone

Balthazar CT Severity Index (CTSI)

Modified CTSI = Inflammation score + Necrosis score + Extrapancreatic complications

Parameter	Score
Normal pancreas	0
Intrinsic abnormality ± peripancreatic fat changes	2
Pancreatic or peripancreatic fluid or fat necrosis	4
Necrosis - None	0
Necrosis ≤30%	2
Necrosis >30%	4
Extrapancreatic complications (effusion, ascites, vascular, GI)	2

Total 0-2: Mild; 4-6: Moderate; 8-10: Severe
CT best performed at 48-72h (not within first 24h - underestimates necrosis)

Chronic Pancreatitis

Irreversible progressive inflammatory disease with fibrosis
Most common cause: Alcohol (70%)
Classification: TIGAR-O (Toxic-metabolic, Idiopathic, Genetic, Autoimmune, Recurrent/severe acute, Obstructive)

CT findings:

Parenchymal atrophy (late)
Parenchymal calcifications (70% - punctate, often in head) - most specific sign
Intraductal calculi (chain of stones)
Duct dilatation ("chain of lakes" pattern on MRCP)
Pseudocysts

MRI/MRCP:

T1: Loss of normal bright T1 signal (loss of secretory proteins)
T2: Heterogeneous
MRCP: Ductal changes (beaded duct, strictures, dilatation), side-branch ectasia
Secretin-enhanced MRCP: Best for assessing exocrine function

Duct-penetrating sign on MRCP: Pancreatic duct traverses through a mass = inflammatory (mass-forming CP); duct is obstructed/cut-off = carcinoma

Autoimmune Pancreatitis (AIP)

Type 1 (IgG4-related):

Systemic disease; extrapancreatic manifestations: sclerosing cholangitis, retroperitoneal fibrosis, salivary gland swelling, orbital pseudotumor
CT: Diffuse sausage-shaped pancreatic enlargement, loss of lobulation, capsule-like peripheral halo (hypodense rim on CT = peri-pancreatic inflammatory rind)
Responds dramatically to steroids (diagnostic/therapeutic)

Type 2:

Confined to pancreas; associated with IBD
No IgG4 elevation

Key differentiator from PDAC (HISORt criteria):

Duct-penetrating sign (duct visible through mass)
Diffuse involvement
IgG4 elevation (>twice normal = highly specific)
Steroid response

Complications of Pancreatitis

Local:

Pseudocyst, WON (walled-off necrosis)
Infected necrosis (gas bubbles on CT = pathognomonic)
Pancreatic abscess
Pseudoaneurysm (splenic artery most common, then GDA) - CT angiography; treat by embolization
Splenic vein thrombosis - leads to segmental (left-sided) portal hypertension, gastric varices
Portal/SMV thrombosis
Hemorrhage (hemosuccus pancreaticus = bleeding into duct)
Fistula (pancreatic-pleural fistula, pancreatico-cutaneous fistula)
Colonic necrosis/fistula (transverse colon most vulnerable)
Bile duct obstruction (compression by head pseudocyst)

Systemic:

ARDS, respiratory failure (most common systemic)
Acute kidney injury
Cardiovascular shock
DIC
Hypocalcemia (Ca++ saponification in fat necrosis)
Hyperglycemia
Fat necrosis (subcutaneous nodules - Grey-Turner panniculitis)
Retinopathy (Purtscher's retinopathy)
Psychosis

Grey Turner sign: Flank ecchymosis (retroperitoneal hemorrhagic extension) Cullen sign: Periumbilical ecchymosis (anterior extension)

PART 5 - MULTIDISCIPLINARY IMAGING PROTOCOLS

Ultrasound (USG/CEUS)

Transabdominal US:

First-line for patients with jaundice or upper abdominal pain
Best for: biliary dilatation, gallstones (pancreatitis etiology), large pancreatic masses
Limitations: Gas in bowel overlies pancreas (difficult visualization in up to 40%)
Normal pancreas: homogeneous, slightly hyperechoic; duct <3mm
Pancreatitis: Edematous, hypoechoic pancreas; peripancreatic fluid
Mass: Hypoechoic, poorly defined margins

CEUS (Contrast-Enhanced US):

Can delineate necrotic areas that don't enhance (alternative to CT when CECT contraindicated)
Vascular complications assessment (pseudoaneurysm)

Endoscopic US (EUS):

Gold standard for small pancreatic lesions (<2 cm insulinoma)
Sensitivity ~90% for PanNETs, small PDAC, cyst characterization
FNA/biopsy guidance (EUS-FNA): CEA, mucin, cytology from cyst fluid
Essential for gastrinoma triangle
Best for ampullary/periampullary lesions

CT Protocol (Multi-detector CT / MDCT)

Pancreas protocol CT (3 or 4-phase):

Phase	Timing (post-contrast)	Purpose
Non-contrast	Pre-IV contrast	Calcifications; baseline; hemorrhage detection
Pancreatic (Late arterial)	35-50 sec	Tumor detection (PDAC as hypodense vs. enhancing parenchyma); arterial anatomy
Portal venous	70-80 sec	Liver metastases; venous staging (SMV, PV); parenchymal assessment
Delayed (optional)	3-5 min	Isoattenuating tumors; confirms delayed enhancement

IV contrast: 300 mg I/mL; 1.5 mL/kg at 3-5 mL/s; 20 mL saline flush
Oral contrast: Water (neutral) - 500 mL over 10 min before scan (distends duodenum)
Thin-slice volumetric acquisition ≤1 mm; MPR (coronal/sagittal); MIP for vascular anatomy
Monoenergetic reconstructions (40 keV on DECT) increase lesion conspicuity

Pancreatitis CT: Single portal venous phase (70s) is sufficient; minimize radiation in young patients; delay CT to 48-72h for accurate necrosis assessment

MRI / MRCP Protocol

Standard sequences:

Sequence	Information
T1 fat-suppressed (pre-contrast)	Normal parenchyma bright; loss of brightness = fibrosis/chronic pancreatitis; hemorrhage detection (SPN)
T2 (HASTE/TSE)	Fluid content of cysts; edema; duct visualization
MRCP (3D/2D)	Ductal anatomy; duct communication; strictures; IPMN; choledocholithiasis
DWI (b 0, 500, 1000)	PDAC detection (restricted diffusion); small tumors; post-treatment response
Dynamic gadolinium (VIBE/LAVA/THRIVE) - arterial, venous, delayed	Tumor enhancement pattern; vascular involvement; PanNET (hypervascular)
EPI/FIESTA (optional)	Motility; small bowel

Gadolinium: 0.1 mmol/kg at 2 mL/s
Secretin-enhanced MRCP: Secretin IV → stimulates bicarbonate secretion → dilates duct transiently; best for exocrine function, small side branches, duct communication

MRI advantages over CT for pancreas:

Better soft-tissue contrast
DWI for small/isoattenuating tumors
MRCP without radiation
No iodinated contrast (renal failure)
Better characterization of cystic lesions (internal architecture, hemorrhage, communication)
Better liver metastasis detection (hepatocyte-phase with Primovist/Eovist)

Plain X-ray

Limited utility; mostly historical
Sentinel loop sign: Localized ileus of jejunum in left upper quadrant - indicates adjacent inflammation (acute pancreatitis)
Colon cut-off sign: Abrupt termination of gas at splenic flexure due to colonic spasm from transverse mesocolon inflammation
Pancreatic calcifications: Stippled calcifications in chronic pancreatitis (best seen on non-contrast CT but visible on plain film)
Annular pancreas: "Double bubble" sign in neonate (gas in stomach and duodenum only)
Retroperitoneal gas: Emphysematous pancreatitis (rare, surgical emergency)

Nuclear Medicine

Somatostatin receptor scintigraphy (Octreoscan): PanNETs (especially gastrinoma, non-functional); 70-80% sensitivity
68Ga-DOTATATE PET/CT: Superior to Octreoscan for well-differentiated PanNETs; sensitivity >90%
FDG-PET: Higher-grade/poorly-differentiated NETs; PDAC (moderate utility); post-treatment surveillance

PART 6 - CLASSIC RULES, SIGNS, AND SYNDROMES

Famous Rules and Classic Signs

Sign/Rule	Description
Whipple's Triad	Diagnosis of insulinoma: (1) Symptoms of hypoglycemia, (2) Glucose <50 mg/dL at time of symptoms, (3) Relief after glucose administration
Courvoisier's Law	Painless jaundice + palpable non-tender gallbladder = malignant biliary obstruction (gallbladder distends when CBD obstructs slowly from distal tumor, but NOT in gallstones because of chronic cholecystitis/fibrosis)
Double Duct Sign	Simultaneous dilatation of CBD and main pancreatic duct on imaging = periampullary/pancreatic head carcinoma until proven otherwise
Duct-Penetrating Sign	MPD traverses through a mass on MRCP = inflammatory mass (chronic pancreatitis), favors against carcinoma
Fish-Mouth Sign	Patulous ampulla with mucin extruding = MD-IPMN
Grey Turner Sign	Flank ecchymosis = retroperitoneal hemorrhagic pancreatitis
Cullen Sign	Periumbilical ecchymosis = hemorrhagic pancreatitis with anterior spread
Sentinel Loop	Localized jejunal ileus adjacent to inflamed pancreas on X-ray
Colon Cut-Off Sign	Gas terminates at splenic flexure on X-ray in acute pancreatitis
Teardrop Sign	Deformity of SMV/PV on CT = venous invasion by PDAC
Christmas Tree Pattern	Ventral duct in pancreas divisum (side branches diminish in size)
Honeycomb Pattern	Multiple tiny cysts = serous cystadenoma (SCN)
Eggshell Calcification	Peripheral calcification = MCN; central/stellate calcification = SCN
Balloon Dilatation of MPD	MPD ≥5 mm = main-duct IPMN - high risk lesion

Classic Syndromes Associated with the Pancreas

Syndrome	Key Pancreatic Association
MEN-1 (Multiple Endocrine Neoplasia type 1)	Pituitary + Parathyroid + Pancreas (3 Ps); PanNETs (gastrinoma most common)
MEN-2a	Medullary thyroid Ca + Pheochromocytoma + Parathyroid; rare pancreatic involvement
Von Hippel-Lindau (VHL)	Multiple SCNs, cystic PanNETs (up to 15%), pheochromocytoma, hemangioblastoma, RCC
Zollinger-Ellison Syndrome	Gastrinoma (60% in gastrinoma triangle); multiple peptic ulcers; high gastrin
Verner-Morrison (WDHA)	VIPoma; watery diarrhea, hypokalemia, achlorhydria
Glucagonoma Syndrome	Necrolytic migratory erythema, DM, weight loss, anemia
Insulinoma Syndrome	Whipple's triad; most common functioning PanNET
Autoimmune Pancreatitis	IgG4-related (Type 1); sclerosing cholangitis, retroperitoneal fibrosis
Cystic Fibrosis	Exocrine insufficiency, fat replacement, CFTR mutations
Shwachman-Diamond Syndrome	Lipomatous pseudohypertrophy; bone marrow failure
Hereditary Pancreatitis	PRSS1 (trypsinogen) mutation; chronic pancreatitis risk, PDAC risk (40x)
Purtscher's Retinopathy	Retinal emboli/occlusion complicating severe acute pancreatitis

PART 7 - MNEMONICS

Mnemonic: Causes of Acute Pancreatitis - "I GET SMASHED"

I - Idiopathic
G - Gallstones (most common overall)
E - Ethanol (most common in males)
T - Trauma
S - Steroids
M - Mumps (viruses)
A - Autoimmune
S - Scorpion sting / Hypercalcemia
H - Hyperlipidemia (hypertriglyceridemia)
E - ERCP (post-procedure)
D - Drugs

Mnemonic: MEN-1 - "3 Ps" (or Pit-Para-Pan)

Pit - Pituitary adenoma
Para - Parathyroid hyperplasia/adenoma
Pan - Pancreatic PanNET (gastrinoma most common)

Mnemonic: VHL - "HIPPEL"

H - Hemangioblastoma (cerebellum, spinal cord, retina)
I - Increased RCC (renal cell carcinoma) and renal cysts
P - Pheochromocytoma
P - Pancreatic cystic lesions (SCN) and PanNETs
E - ELST (Endolymphatic sac tumors); eye (retinal hemangioblastomas)
L - Liver cysts

Mnemonic: Whipple's Triad - "SLR"

S - Symptoms of hypoglycemia
L - Low blood glucose (<50 mg/dL)
R - Relief with glucose

Mnemonic: Cystic Pancreatic Lesions - "SIMS"

S - Serous (benign honeycomb, central scar, VHL)
I - IPMN (duct communication, head, older men)
M - Mucinous MCN (body/tail, women, no duct communication, eggshell Ca++)
S - SPN/Solid-pseudopapillary (young women, mixed, peripheral Ca++, hemorrhage on T1)

Mnemonic: PanNET functional tumors - "IGVS"

I - Insulinoma (most common, benign)
G - Gastrinoma (most malignant, ZE syndrome)
V - VIPoma (WDHA)
S - Somatostatinoma / Glucagonoma

Mnemonic: Complications of pancreatitis - "PHASHOP"

P - Pseudocyst / Pseudoaneurysm
H - Hemorrhage (hemosuccus pancreaticus)
A - Abscess / Ascites
S - Splenic vein thrombosis
H - ARDS / Hypocalcemia (systemic)
O - Obstruction (biliary/colonic)
P - Portal vein thrombosis / Pleural effusion

Mnemonic: TIGAR-O Classification of Chronic Pancreatitis

T - Toxic-metabolic (alcohol, tobacco, hypercalcemia)
I - Idiopathic
G - Genetic (PRSS1, SPINK1, CFTR)
A - Autoimmune
R - Recurrent/severe acute pancreatitis
O - Obstructive (stricture, divisum, tumor)

Quick Radiology Summary Table

Tumor	CT enhancement	T1 MRI	T2 MRI	Key distinguishing feature
PDAC	Hypovascular	Hypointense	Iso/mildly hyper	Double duct sign, DWI restriction
PanNET	Hypervascular	Iso/hypointense	Hyperintense	Arterial phase bright; EUS needed for small
SCN	Honeycomb, thin septa enhance	Hypointense tiny cysts	Hyperintense tiny cysts	Central scar/Ca++, VHL association
MCN	Variable; thick wall	Hypointense	Hyperintense	Body/tail only, women, no duct communication
MD-IPMN	-	-	-	MPD ≥5 mm; fish-mouth papilla
BD-IPMN	-	-	T2 bright	Duct communication; grapes sign
SPN	Progressive enhancement	T1 bright (hemorrhage)	Mixed	Young women; peripheral capsule Ca++
Pseudocyst	No enhancing wall	Hypointense	Hyperintense	Post-pancreatitis; pure fluid
WON	Heterogeneous; no internal enhancement	Mixed	Mixed with debris	Post-necrotizing; solid + fluid

Key References:

Grainger & Allison's Diagnostic Radiology, 6e (Imaging in Acute & Chronic Pancreatitis, Pancreatic Neoplasms)
Yamada's Textbook of Gastroenterology, 7e (Pancreas anatomy, cystic neoplasms)
Clinical Gastrointestinal Endoscopy, 3e (Pancreatic cysts classification table)
Mulholland & Greenfield's Surgery, 7e (Pancreas anatomy & physiology)
AJCC 8th Edition TNM Staging
Revised Atlanta Classification 2012
Fukuoka Guidelines for IPMN management

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