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Improved US Visualization of the Pancreatic Tail with Simethicone, Water, and Patient Rotation¹

¹ From the Department of Radiology, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA 52242. From the 1999 RSNA scientific assembly. Received January 5, 2000; revision requested February 22; revision received May 10; accepted May 22. Address correspondence to M.M.A.Y. (e-mail: monzer-abu-yousef@uiowa.edu).

View larger version (79K): [in a new window]   Figure 1a. (a) Baseline transverse sonogram of the pancreas poorly depicts the pancreatic tail (between arrowheads and large arrow). Slightly decreased pancreatic echogenicity suggests pancreatitis. Calipers 1 and 2 mark the pancreatic head and separation between the distal body and proximal horizontal segment of the tail, respectively. Arrowheads and small arrows mark the beginning of the proximal and distal descending segment, respectively. Note that the distal horizontal segment is totally obscured before the technique is applied. (b) Transverse sonogram obtained after ingestion of water and simethicone and rotation completely depicts the tail, with normal echotexture (between short black arrows). A = aorta, black arrowheads = pancreatic body, C = inferior vena cava, curved arrow = superior mesenteric artery, D = fluid-filled duodenum, K = left kidney, S = stomach filled with the hyperechoic water-simethicone mixture, solid straight arrow = left renal artery, open black arrows = pancreatic head, open white arrow = splenic vein, white arrowhead = superior mesenteric vein.

View larger version (87K): [in a new window]   Figure 1b. (a) Baseline transverse sonogram of the pancreas poorly depicts the pancreatic tail (between arrowheads and large arrow). Slightly decreased pancreatic echogenicity suggests pancreatitis. Calipers 1 and 2 mark the pancreatic head and separation between the distal body and proximal horizontal segment of the tail, respectively. Arrowheads and small arrows mark the beginning of the proximal and distal descending segment, respectively. Note that the distal horizontal segment is totally obscured before the technique is applied. (b) Transverse sonogram obtained after ingestion of water and simethicone and rotation completely depicts the tail, with normal echotexture (between short black arrows). A = aorta, black arrowheads = pancreatic body, C = inferior vena cava, curved arrow = superior mesenteric artery, D = fluid-filled duodenum, K = left kidney, S = stomach filled with the hyperechoic water-simethicone mixture, solid straight arrow = left renal artery, open black arrows = pancreatic head, open white arrow = splenic vein, white arrowhead = superior mesenteric vein.

View larger version (21K): [in a new window]   Figure 2a. Bar graphs show the mean grades of visualization and gas interference (indicated by the number above each bar) before and after technique application in both groups. (a) Remarkable improvement of pancreatic tail visualization resulting from use of the water-simethicone-rotation technique. (b) Remarkable decrease in gastric air resulting from use of the water-simethicone-rotation technique. (c) Limited improvement of pancreatic tail visualization resulting from use of the water-only technique. (d) Limited decrease in gastric air resulting from the use of the water-only technique.

View larger version (21K): [in a new window]   Figure 2b. Bar graphs show the mean grades of visualization and gas interference (indicated by the number above each bar) before and after technique application in both groups. (a) Remarkable improvement of pancreatic tail visualization resulting from use of the water-simethicone-rotation technique. (b) Remarkable decrease in gastric air resulting from use of the water-simethicone-rotation technique. (c) Limited improvement of pancreatic tail visualization resulting from use of the water-only technique. (d) Limited decrease in gastric air resulting from the use of the water-only technique.

View larger version (17K): [in a new window]   Figure 2c. Bar graphs show the mean grades of visualization and gas interference (indicated by the number above each bar) before and after technique application in both groups. (a) Remarkable improvement of pancreatic tail visualization resulting from use of the water-simethicone-rotation technique. (b) Remarkable decrease in gastric air resulting from use of the water-simethicone-rotation technique. (c) Limited improvement of pancreatic tail visualization resulting from use of the water-only technique. (d) Limited decrease in gastric air resulting from the use of the water-only technique.

View larger version (21K): [in a new window]   Figure 2d. Bar graphs show the mean grades of visualization and gas interference (indicated by the number above each bar) before and after technique application in both groups. (a) Remarkable improvement of pancreatic tail visualization resulting from use of the water-simethicone-rotation technique. (b) Remarkable decrease in gastric air resulting from use of the water-simethicone-rotation technique. (c) Limited improvement of pancreatic tail visualization resulting from use of the water-only technique. (d) Limited decrease in gastric air resulting from the use of the water-only technique.

View larger version (86K): [in a new window]   Figure 3. Transverse image of the upper abdomen obtained after the ingestion of the water-simethicone mixture and rotation completely depicts the pancreas (arrowheads), with multiple calcifications (black arrows) that enable diagnosis of chronic pancreatitis. The pancreas was totally obscured at initial US. Note the hypoechoic, mildly speckled echotexture of the fluid in the stomach (S). A = aorta, white arrow = superior mesenteric artery.

View larger version (79K): [in a new window]   Figure 4a. (a) Transverse US images of the upper abdomen show hypoechoic enlargement of the tail of the pancreas (between calipers). (b) Transverse image of the upper abdomen obtained after ingestion of water with simethicone and rotation shows a normal-appearing pancreatic tail (arrows). S = stomach with anechoic fluid mix.

View larger version (75K): [in a new window]   Figure 4b. (a) Transverse US images of the upper abdomen show hypoechoic enlargement of the tail of the pancreas (between calipers). (b) Transverse image of the upper abdomen obtained after ingestion of water with simethicone and rotation shows a normal-appearing pancreatic tail (arrows). S = stomach with anechoic fluid mix.

View larger version (86K): [in a new window]   Figure 5a. (a) Initial transverse US image of the pancreas obtained in a patient with upper abdominal pain shows an ill-defined area (solid arrows) thought to be behind the head (open arrows). The nature of this area was undetermined, since it was not certain whether it was anechoic with debris or intensely hypoechoic. (b) Repeat transverse image of the pancreas obtained after administration of the water-simethicone mixture and rotation more clearly depicts this area as a mildly hypoechoic pancreatic head (between calipers). This finding is more indicative of focal pancreatitis than carcinoma, which is usually focal and more intensely hypoechoic, and excludes a pseudocyst as a possibility. Focal pancreatitis was proved at US-guided biopsy. Arrows = pancreatic body, S = stomach.

View larger version (92K): [in a new window]   Figure 5b. (a) Initial transverse US image of the pancreas obtained in a patient with upper abdominal pain shows an ill-defined area (solid arrows) thought to be behind the head (open arrows). The nature of this area was undetermined, since it was not certain whether it was anechoic with debris or intensely hypoechoic. (b) Repeat transverse image of the pancreas obtained after administration of the water-simethicone mixture and rotation more clearly depicts this area as a mildly hypoechoic pancreatic head (between calipers). This finding is more indicative of focal pancreatitis than carcinoma, which is usually focal and more intensely hypoechoic, and excludes a pseudocyst as a possibility. Focal pancreatitis was proved at US-guided biopsy. Arrows = pancreatic body, S = stomach.