Magnetic resonance (MR) in the diagnosis of pancreatic disease.

New methods of examination are measured in terms of the efficiency of their predecessors. The introduction of endoscopic retrograde cholangiopancreatography (ERCP) and computerised tomography (CT) constituted a turning point in the diagnosis of pancreatic disease. In its incipient stages as a clinical diagnostic method, the question is raised whether or not there is evidence that magnetic resonance (MR) can supplement, improve upon or replace the customary methods. It must, however, be taken into account that the technical development of MR is still in progress and that clinical experience with MR in the diagnosis of pancreatic disease, as in other areas, is still insufficient. At this point it is only possible to survey the trends.

Efficiency of different radiodiagnostic techniques in pancreatic disorders.

Using figures from the literature and from our own case material, the diagnostic efficiency of the barium meal, computerized tomography, angiography, ERPC and biopsy have been compared in acute and chronic pancreatitis, pancreatic and papillary carcinoma and islet cell tumour. In acute pancreatitis, CT is the method of choice. In chronic pancreatitis, ERPC has the highest diagnostic accuracy. Furthermore, it is capable of giving an indication for operative intervention, and facilitating the choice of operative method. In pancreatic carcinoma, combination of ERPC, angiography and/or biopsy provides the highest diagnostic accuracy. Angiography and ERPC can provide early diagnosis, and angiography and CT can predict the operability of a tumour. CT is also the most important of the non-invasive diagnostic techniques. Carcinoma of the papilla is easily and reliably recognized by endoscopy. For islet cell tumours, angiography still remains the method of choice.

Evaluation of the cruciate ligaments by CT.

Delineation of the cruciate ligaments in 112 patients using the computed tomography under arthrographic conditions was reported. Special position were used allowing for the demonstration of both cruciate ligaments in their complete lengths. In 6.2% of the examinations a reliable demonstration of the cruciates was not possible for technical reasons. Demonstration of normal cruciate ligaments in CT arthrography was described and normal values were tabulated. Recent cruciate ligament injuries were seldom examined by CT arthrography since the clinical symptoms were mostly unequivocal. The old ruptures of the ACL were divided into 4 different types: Type I: Rupture of the femoral origin that adjoins the PCL. Type II: Attenuation of the intraligamentary ruptured ligament with a preservation of origin and insertion. Type III: Complete rupture with shrinking and retraction of the fragments. Type IV: Osseous involvement of the femoral origin or tibial insertion. In 36 old cruciate ligament ruptures, the sensitivity of this method of investigation was 97%, the specificity 100%. After reconstructive surgery, CT arthrography allows for an objective analysis of the operative results and permits the comparison of different techniques of surgical repair.

[Standard report forms in radiological diagnosis (author's transl)]. / Befundformulare in der Röntgendiagnostik.

Standard report forms have been designed for excretion urography, gastro-intestinal examinations, cholecystography, myelography, trauma and surgical emergencies; the findings, which are printed on the form, are marked and the conclusion is then written by hand. If used for a limited number of examinations with recurring problems, these report forms results in a considerable reduction in effort and simplifies routine diagnosis.

[Algorithms in the radiological diagnosis of malignant disease (author's transl)]. / Algorithmen in der röntgenologischen Malignomdiagnostik.

Algorithms in the diagnosis of malignant disease have the aim to produce a diagnosis as quickly, as certainly and as simply as possible. The first phase consists of general non-invasive methods which should be as simple as possible. If the results are positive this should be followed immediately by percutaneous biopsy in order to produce cytological confirmation of the diagnosis as quickly as possible. If the original investigations were negative, those special methods of investigation should be used which are most likely to make a diagnosis. This is followed by investigations which throw light on the most appropriate form of treatment. This scheme has been illustrated by special algorithms for carcinoma of the bronchus, the pancreas and the breast.

[Computed tomographic morphometry of the normal pancreas in adults]. / Computertomographische Morphometrie des normalen Pankreas bei Erwachsenen.

The relationship of the morphology of the normal pancreas, as seen on CT, and age was studied in 200 normal people aged between 19 and 87 years. The A.P. diameter, vertebral body/pancreas ratio, cranio-caudal diameter, contour and structure of the pancreas were analysed. The most marked age-related changed occurred in the vertebral body/pancreas ratio, but all other measurements showed a reduction dependent on age. With increasing age, the contour of the pancreas becomes more lobulated and, at the same time, the structure changes from an homogeneous to an inhomogeneous appearance. These findings correspond with pathological-anatomical observations.

[Pancreatic carcinoma on endoscopic retrograde pancreatico-cholangiogram (author's transl)]. / Das Pankreaskarzinom im endoskopischen retrograden Pankreatiko-Cholangiogramm

The pancreaticographic appearances of carcinoma of the pancreas have been divided into two types: 1. Canalicular carcinoma arising from the duct system. If arising from the main pancreatic duct, it occludes this, or causes displacement or deformity of its branches in the immediate neighbourhood. If arising from branches, it causes cystic ectasia of the minor ducts; these appear fragmented and deformed while there is stenosis and displacement of the main duct. Simultaneous origin from the main and smaller ducts, as in the Gallert carcinoma, causes extreme lacunar ectasia of the minor ducts and occlusion of the main duct. 2. Carcinoma arising from the acinar epithelium. This causes primarily displacement and the secondarily stenosis of the main duct. Accuracy of ERCP is satisfactory. It is limited by technical failure or difficulties due to the pathology preventing demonstration of the pancreatic duct. It is increased by cytological examination of aspirated pancreatic secretion. Difficulties in the differential diagnosis from chronic pancreatitis can be overcome. The possibility of an early diagnosis of the carcinoma presented by this method loses some of its impact because the patients are seen at a late stage and because of the lack of early symptoms of this disease.

[Carcinoma of the pancreas: angiographic diagnosis (author's transl)]. / Pankreas-carcinom--angiographische diagnostik

Morphologic changes seen in angiographs and ductographs (endoscopic retrograde pancreaticographs) in the presence of carcinoma of the pancreas are described. The average diagnostic accuracy of angiography is currently 75 to 95 percent, while that of endoscopic retrograde pancreaticography is 90 to 95 percent. The combination of both methods increases the accuracy. The main problem with pancreatic carcinoma now is not early diagnosis, while is now possible, but early examination of the patient.

[Computed tomography of the pancreas (author's transl)]. / Die Computer-Tomographie des Pankreas

The computed tomography gives direct visualisation of the pancreas in a transverse section. Form, size, and changed consistency of the organ can be diagnosed. Being a non-invasive technique it does not stress the patient, and can be applied to the severly ill with acute haemorrhagic pancreatitis. Other indications are chronic pancreatitis, pancreatic abscess, pseudo-cyst and cancer. The differential diagnosis of cancer, especially from chronic pancreatitis, may be difficult. Further methods of investigation such as arteriography or endoscopic retrograde pancreatography may also have to be used.

The diagnosis of necrotizing pancreatic lesions by means of duodenoscopic pancreatography.

Direct demonstration of intrapancreatic abscesses and pseudocysts can be made by means of duodenoscopic retrograde pancreatography. The most important findings are escape of contrast medium from the duct system into a cavity and its visualization, the tryptic perforation of one or more ducts and the concomitant deformity which may be general or limited to the vicinity of the lesion. The differential diagnosis of pancreatic abscess and carcinoma with penetration of contrast medium in the tumor tissue is supported by the fact that the contours of a necrotic cavity are rather well defined, whereas in carcinoma the extraductal opacification is diffuse. As a rule in a necrotic lesion the ductal system is distorted locally or the whole excretory duct system may be involved. In carcinoma the ductal system generally appears normal distally to the tumor. Accurate demonstration of the necrotic lesion, the assessment as to its localization and size are of decisive importance for indication and choice of the surgical procedure.

Endoscopic retrograde pancreaticocholangiography in chronic diseases of the pancreas and in papillary stenoses.

The extensive experience of the authors in endoscopic retorgrade pancreaticography is correlated with data in the literature to illustrate the spectrum of characteristic changes and diagnostic accuracy in several entities. These include chronic pancreatitis, calculous pancreatitis, necrotizing lesions and pseudocysts, carcinoma of the pancreas, and papillary stenosis, spasm, and carcinoma.

[Basic pressure in the pancreatic duct and in the bile duct: results from 50 standardized duodenoscopic transpapillary pressure measurements (author's transl)]. / Der Basisdruck im Ductus pancreaticus und Ductus choledochus. Ergenbnisse von 50 standardisierten duodenoskopisch transpapillär durchgeführten Druckmessungen

In 90 patients pressure measurements in the pancreatic duct (50 cases) and in the common bile duct (20 cases) were performed endoscopically. In the normal pancreas an averaged basis pressure in Wirsung's duct of 22.2 cm H2O was found with a range of 9.6 to 37.0 cm H2O. In two cases of marked chronic pancreatitis and in one case of pancreatic carcinoma the secretion pressure was considerably diminished. The mean basic pressure of the common bile duct amounted to 12.0 cm H2O with a range of 7.3 to 17.0 cm H2O. The pressure values in the duodenum were found to be considerably lower than in the pancreatic duct and the bile duct; they amounted to 5.3 cm H20 with a range of 0.6 to 10.9 cm H20. In both ducts two different patterns of ondulations were found: tracings of slight ondulations, i.e. slow pressure changes with a constant average pressure and tracings of coarse ondulations with quick increase and drop in pressure. It will be discussed, how these findings can be related to physiology and pathophysiology of the pancreatic and biliary duct system. The clinical relevance for detection of excretory insufficiency of the pancreas and of pathologic changes leading to stenosis of the duct system are considered.

[Accuracy of endoscopic retrograde pancreatico-cholangiography in the diagnosis of pancreatic disease: an analysis of three thousand investigations (author's transl)]. / Die Treffsicherheit der endoskopischen retrograden Pankreatiko-Cholangiographie in der Diagnostik der Pankreaskrankheiten. Eine Analyse von 3000 Untersuchungen.

Endoscopic retrograde pancreatico-cholangiography (ERPC) gave the correct diagnosis in 83% of 269 cases of pancreatitis confirmed by operation, clinical features, laboratory findings and course. It provided the correct diagnosis in 85% of 82 cases of necrosis of the pancreas and pseudocysts confirmed at operation. ERPC is one of the most important methods of investigation in papillary stenosis, because it can demonstrate both ducts and can reveal functional changes, especially delayed emptying. The correct diagnosis of carcinoma of the pancreas, confirmed at operation or histologically, was made in 88% of 107 cases. Endoscopy correctly diagnosed 26 of 27 cases of papillary carcinoma. Biopsy with subsequent histological study and cytological analysis of pancreatic secretion further served to confirm the diagnoses established by ERPC.

[Pancreaticography and its correlation with angiography and ultrasonography in diagnosis of the pancreas (author's transl)]. / Die Pankreatikographie und ihre Korrelation mit der Angiographie und der Ultrasonographie in der Pankreasdiagnostik

The endoscopic retrograde pancreaticography demonstrates - when suspecting "pancreas anulare" - the part of the pancreatic duct system that forms a ring around the duodenum, helping to recognize this anomaly. In chronic pancreatitis deformities of the pancreatic ducts may be visualized 2-3 years after the onset of the disease. There are deformities of the outlining and the course of the ducts as well as solitary and multiple stenosis and -most important- dilatation of the main duct and its branches. In pancreas abscess, necrotic cavities, and pseudocysts the retograde pancreaticography visualizes solitary or multiple perforations of the duct and pooling of contrast medium in cavities. Carcinoma of the pancreas presents stenosis, occlusion and deviation of the main duct and its branches and sometimes with lakes of contrast medium in ares of necrosis. Pancreaticography following trauma demonstrates similar to chronic pancreatitis laking of contrast medium following perforation. The endoscopic retrograde pancreatico-cholangiography has - like angiography and ultrasound - its special indications in diagnosis of the pancreas. They are important in cases which have affected primarily or secondarily the duct system. Its reliability in confirming and differentiating a disease increases with more accurate indication. In this journal in 1965 a critical review of roentgenologic examinations of the pancreas presumed that development of a valid preoperative pancreaticography would lead to priority of this method. This priority has become true in chronic pancreatitis, calculous pancreatitis and visualization of necrotic cavities. In those examples the endoscopic retrograde pancreatico-cholangiography is still not dominating all cases.

[Cartilage injuries of the femoro-patellar joint in the computerized tomogram]. / Knorpelschäden des Femoro-Patellar-Gelenks im Computer-Tomogramm.

The conventional arthrographic methods for demonstration of the femoro-patellar joint are not sufficiently reliable. Through the use of CT-arthrography a cross-sectional image free of superimposition and possessing a high density resolution is available thus facilitating a direct demonstration of the joint cartilage. Traumatic and degenerative lesions of the cartilage can be clearly shown by CT-arthrography. Damage of cartilage in patients with chondromalacia patellae can be differentiated in its different stages. The shape of the patella and its relation to femoral condyles can be evaluated more accurate than by conventional axial x-rays.