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This is Pediatrics week 5 case 2 and

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our diagnosis under consideration is pancreatitis. This

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is a teenage patient with an MRI.

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MRI wouldn't be the first Diagnostic Imaging

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to perform on a patient with suspected pancreatitis,

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but

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It offers a lot of value especially for

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some of the rarer causes of pancreatitis, which we see in

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children. So initially perhaps an ultrasound

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right upper quadrant ultrasound or maybe a

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CT scan might have identified some of

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the concerning features and MRI can add some

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specificity.

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To our diagnosis in children in addition

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to traumatic pancreatitis and congenital

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causes of pancreatitis and

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maybe even for older teenagers alcohol-induced pancreatitis. There's

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also the category of autoimmune pancreatitis, which

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is

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something that we have to be mindful of.

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and it's still not the most common cause

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of pancreatitis, but

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relatively speaking. It is a more significant

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cause in the Pediatric population partly because many of

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the cases that we see in the adult world are

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less common in children such as alcoholism.

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So here's an MRI sequence, we've

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got an axial fluid sensitive image here a

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T2 weighted image. And as I scroll down through

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you can see that the liver appears pretty normal that portal

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Triads were coming into the port of hepatis. We've got a little fluid in

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our stomach and here's the spleen. We're just getting

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the top of the left kidney and we're coming down to the epigastrium sure

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enough. Here's the pancreas coming across the midline. The

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first thing we notice about that pancreas is how dark it is. We

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don't expect to see the pancreas this

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dark relative to the liver.

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And as we come around the other thing, I hope you'll notice about the

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pancreas is how featureless the surface Contour is

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it looks bulging swollen. Some

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people might even say sausage like we do see

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the pancreatic duct coming along the center

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of the body, but it's not particularly dilated. So

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this isn't an obstructive pancreatitis and

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this isn't a chronic pancreatitis where

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we get that.

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Progressive enlargement after repeated cases of

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pancreatitis enlargement of the duct but we do see a

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dark edematous swollen pancreas

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no significant ductal enlargement and the

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signal intensity is low. Let's go ahead and look

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at the same region after the administration of IV

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contrast.

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Here's our post contrast image and notice that in

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this very early post contrast image arterial phase.

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Look at the cortex of those kidneys and the aorta.

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We really aren't seeing much enhancement.

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That's not quite right the pancreas loves doing hands. Let's

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give it a little bit more time and look after a minute.

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So now we're more of a Venus phase again, not

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all that much enhancement here. You can see the splenic vein

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coming over and joining with the mesenteric and giving us the portal.

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And the pancreas is just not that bright. Let's go ahead and give

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it a two-minute delay and here is

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Just a tiny bit of enhancement. So we're getting slow

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Progressive enhancement of the pancreatic

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parenchyma. Not as much as is expected and

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not as quickly as is expected. So all of

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these findings put together are very suggestive of autoimmune

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pancreatitis and just to take you back to the fluid sensitive

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sequence. Here's the t2. There's a

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little bit of free fluid you can see in the Perry hepatic

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region over here and maybe a little

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bit on the left percolic gutter Perry splenic region, but

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look at the pancreas, it is not surrounded by a lot

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of Perry pancreatic fluid like you might expect to see if there

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had been some sort of a traumatic.

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or acute pancreatitis, so

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These are some of the features to be on the lookout for with autoimmune

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causes.

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Low, signal intensity poor initial enhancement swollen

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appearance almost sausage, like and

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lack of significant dilatation of the main pancreatic duct.

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That's the end of the case.