0:00

Okay, so we're going to keep on

0:02

going down pancreatitis a bit.

0:04

And I know this is a bit of a rabbit hole, but

0:06

I have to say, if you're a radiologist, you love

0:09

the harder cases, like that is where the glory is.

0:12

So I'm going to take you down two cases that have a little

0:14

bit more glory because I think that that's what really

0:17

intrigues us, and we'll get you to want to learn more.

0:20

So.

0:21

Here's a patient.

0:21

We can see a nice fatty liver here.

0:23

Actually see a nice little differentiation

0:24

of the fatty, um, infiltration.

0:26

And you can see this liver comes all

0:27

the way around and hugs the spleen.

0:28

This is one of my more favorite variants of liver.

0:31

Um, on ultrasound, it can be kind of

0:32

confusing because it can look like a peri

0:34

splenic hematoma, so be careful of that.

0:36

Anyway, so as we come down, yes, we have a nice

0:38

large liver there, and we're going to see again

0:42

a lot of fluid in that anterior pararenal space.

0:45

All the fluid around that pancreas here.

0:48

It's pretty impressive.

0:51

Fluid down into the paracolic gutters as well.

0:53

So let's talk about the next part

0:55

of your search pattern, right?

0:56

You're going to look to see if you think

0:57

that the parenchyma is enhancing or if

0:59

there's any definite areas of necrosis.

1:02

I would say this one has some necrosis

1:04

definitely in the pancreatic tail, some

1:06

decreased enhancement in that location.

1:08

And then on your search pattern, I

1:09

want you to look for splenic vein

1:11

thrombosis.

1:12

The splenic vein is in the worst neighborhood possible.

1:16

It goes posterior to the pancreas.

1:18

I already decided that the pancreas

1:19

isn't well layered in fascial planes.

1:22

So frequently you can get splenic vein thrombosis,

1:25

and as you can see here, we lack enhancement of the

1:29

splenic vein. Here's the splenic

1:30

vein, and that is thrombosis.

1:31

Now, as we come down on the portal vein

1:34

into the SMV, you're going to notice also

1:37

a large filling defect in the SMV as well.

1:40

Let's go coronal on that.

1:41

I always think that the SMV is much better evaluated

1:44

on coronal, and you would never miss that thrombosis.

1:47

Be careful with mixing artifact.

1:49

I know that can be a little bit difficult,

1:51

but here you're a good radiologist.

1:52

You're going to be fine.

1:53

You're going to call that SMV and splenic vein thrombosis.

1:58

These can be hard cases because these are hard

2:00

patients to anticoagulate given their pancreatitis

2:03

and the risk for hemorrhagic conversion.

2:05

But it is something our clinicians want to know

2:07

about because at times, if it's really extreme

2:10

thrombosis, they may go for catheter lysis,

2:12

or if not, they will decide whether or not

2:14

the patient can safely be anticoagulated.

2:17

So always look on your acute pancreatic

2:20

cases, not only for the enhancement pattern

2:22

of the pancreas itself, for that necrosis.

2:24

Probably necrosis of the head here as well, but look

2:27

for those portal vein, splenic vein, SMV thrombosis.