Mistakes in ... Booklet 2020 - 27

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Mistakes in... 2020

Figure 8 | Pancreas divisum. a | 2D MRCP displays the pancreatic duct anatomy in a selected plane, which does
not correctly identify pancreas divisum. b | An additional plane shows the pancreatic duct crossing the common
bile duct (arrow) to reach minor papilla and confirms pancreas divisum.

lesions may involve the side branches (branch
type), the main pancreatic duct (main duct type)
or both (mixed type).20 The risk of developing
cancer is significantly different when
comparing main duct/mixed type IPMN with
branch duct type IPMN. In patients who have
undergone surgical resection, the mean rate
of invasive cancer is 43% for main duct/mixed
type IPMN compared with 16.5% for branch
duct type IPMN.20 Therefore, it is important to
accurately diagnose IPMN and provide adequate
management.
MRI/MRCP is the imaging technique of choice
to confirm the diagnosis of IPMN, as well as
defining the presence of high-risk stigmata
(mural nodules, thickened cyst wall, main
pancreatic duct dilation >5mm) (figure 9).1
Finally, DWI can increase diagnostic accuracy
for the presence of solid malignant components
within IPMN (such as mural nodules), with
invasive lesions having a lower ADC.1

Mistake 10 Missing vascular abnormalities

Figure 9 | Main duct IPMN mimicking obstructive chronic pancreatitis. Irregular dilatation of corporeo-caudal
main pancreatic duct with parenchymal atrophy as shown by axial 2D MRCP imaging (a) and T2-weighted
imaging (b).

communicating dual drainage of the main
pancreatic duct, either with a patent or
obliterated minor papilla. Variations during the
embryological process regarding fusion of the
dorsal and ventral pancreas can lead to various
congenital variants of the pancreatic ducts.19
Pancreas divisum is the most common
congenital variation and occurs when the
ventral and dorsal ducts fail to fuse together. This
finding presents with an incidence of 3-7% in
patients who are undergoing ERCP and is found
in approximately 9% of autopsy cases.19 MRCP
can demonstrate ductal anatomy with precision,
and visualization can be enhanced by
intravenous secretin, which increases fluid
within the duct and therefore better delineates
anatomy.1 It is important to determine pancreatic
duct anatomy before pancreatic endotherapy,
such as pancreatic sphincterotomy and pancreatic
duct drainage in patients with chronic pancreatitis,
as preprocedural imaging allows the decision to be
made with regards to accessing either the major
papilla or the minor papilla (figure 8).2

features include parenchymal atrophy, the
presence of calcifications, cysts and pancreatic
duct irregularity characterized by strictures and
dilations.2 Both CT and MRI provide accurate
diagnosis, but pancreatic duct dilation and cysts
can be encountered in other pancreatic diseases.
Intraductal papillary mucinous neoplasms
(IPMN) of the pancreas are potentially malignant
intraductal epithelial neoplasms that are
composed of mucin-producing columnar cells
and harbour varying degrees of atypia. The

Abdominal pain is a symptom that frequently
leads to admittance to the emergency
department. Indeed, acute pancreatitis presenting
with abdominal pain is one of the leading causes
of hospitalization. For patients in whom acute
pancreatitis is suspected, contrast-enhanced CT
should be performed on admission if there is
diagnostic doubt.21
Although rare, acute splanchnic venous
thrombosis can occur in noncirrhotic patients
and is frequently associated with abdominal
infections (such as acute pancreatitis),
myeloproliferative diseases, or pre-existing
coagulation disorders.22,23 Furthermore,
abdominal pain is the most frequently reported
symptom in case of acute splanchnic vein
thrombosis. Therefore, it is important to fully
study vascular structures and their permeability
with CT in patients with abdominal pain of
unclear aetiology and pre-existing conditions,

a

Mistake 9 Considering every pancreatic
duct dilation as chronic pancreatitis
Chronic pancreatitis is an inflammatory process
of the pancreas characterized by progressive
parenchymal destruction.2 Typical morphological

Figure 10 | Acute portal vein thrombosis. a | Non-contrast CT imaging of a patient with acute abdominal pain
and renal function impairment in the coronal plane in shows peri-hepatic hilar infiltration and a spontaneously
hyperdense portal vein (arrow), suggestive of the presence of an intravascular clot. b | T1-weighted contrast
enhancement MR confirms acute portal vein thrombosis (arrow).

15
Mistakes in ... Booklet 2020

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