Posted on September 15, 2017February 17, 2023 by Ashley Davidoff

Pancreas – Hermit of the Abdomen

Ashley Davidoff MD

O’ Dear pancreas

You have been called the hermit of the abdomen
By whom I do not know
But in your dark and hidden way, you have
spoken without a word
from the gurgling depths of the abdomen
Yes – you have earned this lonely title
and a coin should be tossed
to the person who coined the phrase

But it took a long time to understand who this hermit was – and what he was doing in the darkness of the abdomen

From the day of antiquity
You have been looked upon by many
Herophilus, the father of anatomy had the first incisive insights into you
As he was one of very few who had the guts to explore the guts in open fashion

Aristotle at the same time seemed to have known something about you
But then you lay unharmed and unexplored for almost 500 years
Until Rufus mistook you for a piece of meat –
You must have laughed at the “pan kreas” thing
How wrong he was – you evasive little trickster

And then the Talmud – always seeming to be right
Thought you were the finger of the liver –
Little did they know how independant you were

While Vesalius was up to your “hide and seek” game
The magical eyes of da Vinci missed you completely
Even though he saw the serpiginous splenic artery snake right above you

Your ducts seemed to have intrigued the next generation, Wharton, Wirsung, and de Graaf
As you sustained the pain of the quill penetrating your inner gut
(I forget you were already dead but it must of hurt just watching!)

A little later it was that man called Vater and the little Italian Santorini found your minor duct and your nipple
And so by this time we had a good understanding of you in your nakedness
But of course, as said – you were dead

And so young Bernard explored your factories, and got a sense of your canine workings,
But you were able to hold on to your sweet secret for just a little longer
Until the Langerhans found the family jewels in the famous 2% of your population-
The islets – those beautiful eyelits – governess of all things sweet in the body

Eberle Bernard Danilevsky, and Kuhne joined up across the world to expose your antacid and enigmatic enzymatic brew
And once again your wonderful workings for a better world were exposed –
And we knew then, that you were the quiet and effective type –
A hermit who did good
But did not want the limelight

To see you as you lived and breathed in the flesh
was the mission of Wilhelm the X-Ray man
who crusaded the path to visualise 40,000 Angstroms under the skin

abdomen, pancreas, liver, gallbladder, kidneys, CT scan, Art in Anatomy, Ashley Davidoff MD

And then there was a slew of heroes who learned to slew your sickened parts – including the famous Whipple who was able to Whipple you in an inimitable way

And then a bone guy – for God’s sakes – a bone guy! – called Banting and his student Best
Exposed the insular chemistry of you insulin that had given you the power over the sweet
Never mind – in the end it was for the good of all –
And a new era was borne

And so we try to understand your form as our scans explore you as you live and breathe
And we stare in awe at your odd shape – why oh why did you choose that shape?
What are you supposed to look like? – we have no clue
And we are happy – so happy for you that you are well nourished by a double blood supply
And we wonder why you have no skin – we thought all the organs had a skin
Except for your tail – almost a foreskin

And you are off axis on two planes – what is that all about? – kinda crooked

And your twin origins and the intimacy with the duodenum, of the ventral twin
And the strange fusion of the Wirsung guy excluding the little Italian Santorini
It seems to me that your matrimonial fusion with Wirsung and the bile duct has led to more problems than the merger was worth
It does not seem in the long run, to have been a marriage made in heaven
What was that all about? Is there a grand plan to come?

And so we try to understand your diseases
And in some way we understand that the guy glugging down the bottle
Could be punished by your reaction
But why Oh why are you so nasty to those whose misfortune it is to have stones roll down and get no satisfaction.. down the green vile bile route
Have you not learned to live with the green secretion by now
And did you not know that by reacting the way you do, that you are cutting off your nose to spite you head?

While type 2 seems remote from you
We don’t know about this Type 1 business
Why are you made to suffer so much at the hands of your own body on your own body?
We feel sorry for you – to have your own buddies reject you – must be awful
And then to see so many young ones suffer because you don’t work
And we once again see and understand what power you control from that deep dark hermit home of yours

And the cancer thing … so silently it creeps on you causing your collagen to counter
And only making things worse as it strangles nerve, blood vessel, and your spouse duct – the green one, – without regard

And then I think of you in your prime and in your happiness
When you are with you two buddies – the splenic vein and the renal vein
And you all look so much alike, and happy swimming in that deep ocean where you hide
And I wish this was forever

Posted on March 17, 2016February 17, 2023 by Ashley Davidoff

Anatomy of Endometriosis and Adenomyosis

Ashley Davidoff MD

Endometriosis is a disease caused by misplaced or ectopic endometrial tissues located beyond the uterus most commonly resulting in pain at the time of menstruation. The ectopic endometrial tissue is controlled by the oestrogen and progesterone cycles. The ectopic tissue bleeds at the time of menstruation and causes pain. Since neither the ectopic endometrium nor the blood can be extruded from the body, recurrent bleeding eventually results in scar formation which may cause non cyclical chronic pain.

Chronic Pelvic Pain is Unbearable

Endometriosis and adenomyosis cause horrific pain. For some the pain may only occur during the menstrual cycle but for others it can be constant, day and night, excruciating in nature, invading every aspect of normal daily life . Pain is a common symptom defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” This statement characterizes the evolved nature of pain as a warning system and feedback mechanism that influences how we adapt to our environment. However, pain at its core it is suffering and its persistence can be insufferable for people and diagnostically problematic to those who care for the sick, as well being a burdensome cost to society.

The cause of endometriosis is not truly known. Long standing hypotheses include spillage of endometrial tissue into the peritoneal cavity via the fallopian tubes or transvascular spread to remote areas . More recent hypotheses include spillage of stem cells during embryonic development, metaplasia of coelomic epithelium, abnormal vasculogenesis, and environmental factors

Endometriosis occurs in 5-10% of women. When endometrial tissue is located outside of the uterus, it can cause pelvic and back pain, as well as pain with sexual intercourse (dyspareunia). It is also associated with infertility by distorting anatomy, (for example Fallopian tube adhesions) , or physiological changes that result in altered immune and hormonal environments with consequent impairment of ovum implantation .

From a structural standpoint, endometriosis most commonly affects the ovaries and Fallopian tubes but can affect any of the pelvic organs including the peritoneal cavity, bladder, ureters, bowel, broad ligaments, uterosacral ligaments, cul de sac and even the nerves. Implants range in size from small microscopic implants, but are are commonly about 1-2cm.

The Intraperitoneal Aspect of the Pelvic Cavity

The peritoneal cavity or coelomic cavity is a large cell lined space via which almost all the abdominal organs are connected . It may be considered the suburban space around which the houses of the town are positioned. The ova are released from the ovary into the peritoneal space, but they are quickly directed by the fimbriae into the Fallopian tubes.

Endometriomas

Endometriomas are large hemorrhagic cysts that occur on the ovary and may be up to to 20cms in size. They are usually round in shape, much like a large blood blister after they have bled. The nodules can be red-blue to yellow-brown in color, (chocolate cysts) and occur just below the serosa of the organ to which they are attached. As the lesions undergo recurrent hemorrhage, they can become associated with fibrosis as stated. Rarely they may be associated with malignant transformation.(<1%).

MRI of an Endometrioma

A T2 weighted image of the pelvis (left) with an overlay of colors on the right shows a 10cms endometrioma (overlaid in red) with internal debris better appreciated in the left image. The large ‘chocolate cyst” lies above the uterus (pink) and compresses the bladder (yellow)

MRI has a 90% specificity and 90% sensitivity for endometriomas. On T1 weighted images the endometriomas may be bright and do not lose signal on fat suppressed sequences. Heterogeneity is due to the presence of degraded products. Septations may also be present. Both these features are present in the above image . On T2 weighted sequences “shading” is caused by repeated episodes of bleeding reflecting hemorrhagic contents in various stages of degradation. The wall of the endometrioma may contain hemosiderin which leads to a loss of signal on the T2 weighted sequence.

Unusual Locations

Endometriosis is rarely can be more far reaching and may involve the kidneys, brain, diaphragm, and pleura. When it involves the diaphragm or pleura, shoulder pain may be associated with the entity. Pleural disease can cause life threatening catamenial pneumothorax induced by the menstrual cycle .

Endometriosis on the Bladder

A CT scan through the pelvis (left) shows an endometriotic implant on the bladder wall. The image on the right shows the endometriotic implant overlaid in maroon on the right anterior surface of the bladder (yellow overlay). The implant measures about 1.1cms. The fornix of the vagina is overlaid in pink. Most peritoneal implants are too small to be visualized by conventional imaging and require laparoscopic evaluation for diagnosis.

Endometriosis in the Skin of the Groin

A CT scan through the pelvis (left) shows an endometriotic implant in the subcutaneous region of the skin in the left inguinal region (image a, circled). The region is magnified in image b and the endometriotic deposit is labelled “e” with maroon overlay. An ultrasound of the left groin(c) shows the implanted endometriosis (black) medial to the artery (red) and vein (blue). In image d, the region of endometriosis (e) is overlaid in maroon.

Clinically the entity more commonly occurs in nulliparous women and the degree of pain is variable. As endometrial tissue, it is responsive to the cyclical hormonal fluxes, and thus may bleed in response to hormonal changes. Pain commonly occurs at the time of the menses. The volume of ectopic endometrial tissue does not correlate with the severity of the pain, but rather with the depth of infiltration into the tissue, or the degree of distension that might occur. The pain is usually recurring and commonly but not necessarily occurs during the menses. With induction of fibrosis, pain may be caused by other structural changes that are unrelated to the menses.

Diagnosis is suspected clinically and confirmed by ultrasound. When a woman in the reproductive phase of her life presents with pain, the imaging study of choice is a pelvic ultrasound. Hemorrhage into evolving follicles is a common cause of pelvic pain and these could be also quite large. This entity has to be differentiated from an endometrioma that has a characteristic ultrasonographic appearance shown below

ovary, ovaries, genitourinary tract, genitourinary system, woman, Art in Anatomy, Ashley Davidoff MD, endometriosis, endometrioma, chocolate cyst, ultrasound,

Endometrioma on Ultrasound

A transvaginal ultrasound of the adnexa shows an endometrioma with characteristic low level echoes reminiscent of the texture of the testes on ultrasound. The image on the right is an overlay in a biloculate cyst. Some through transmission is present.

Chocolate Cyst on US and CT

A 25 year old female presents with painful menses. The ultrasound shows a cystic mass in the pelvis with a large amount of debris in the cystic cavity consistent with a chocolate cyst (a). Image b is an overlay showing the fine granular appearance of the sediment. When the patient is in decubitus position (c) , the sediment settles to the dependant portions with a clear supernatant. Image (d) is a CT scan of the same patient, showing a non specific cyst in the left ovary. In this instance CT has little diagnostic value in the characterization of the abnormality other than localising a large cyst, and excluding other causes for the pain. Although the appearance on the ultrasound is consistent with endometriosis, a hemorrhagic cysts is possible and the distinction may only be made pathologically.

When a female patient in the reproductive age presents with pelvic pain and ultrasound or MRI are negative, laparoscopy is indicated both for diagnosis of small or flat lesions lesions as well as for therapy. Microscopic deposits which may cause symptoms will not be identified by imaging techniques and will only be seen laparoscopically. The reluctance to undergo an “invasive” procedure is understandable, but delaying or worse still missing the diagnosis will cause unnecessary long term suffering.

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Laparoscopy

Laparoscopic image of small blood blisters characteristic of endometriotic lesions of the pelvic wall in the peritoneum

Courtesy Author Hic et nunc. Acknowledged work is in public domain

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Blood Blisters in the Cul De Sac and Sacrouterine Ligament

Laparoscopic image of endometriotic lesions in the pouch of Douglas and on the sacrouterine ligament.
Courtesy Author Hic et nunc. Acknowledged work is in public domain

Treatment options depend on patient preference, including whether fertility is desired, but include both medical and surgical options. Medical management frequently involves suppression of regular menses/hormones . Surgical options include removal of implants or surgical induction of menopause (i.e. oophorectomy and hysterectomy).

Adenomyosis

Adenomyosis is a disease of the myometrium caused by misplaced or ectopic endometrium in the myometrium resulting in myometrial hyperplasia and smooth muscle hypertrophy clinically manifesting as pelvic pain and uterine enlargement. The entity can be focal or diffuse

Enlarged and Painful Uterus of Adenomyosis

The exact cause of the displacement is not known but it is presumed that a breach in the endometrial myometrial barrier enables a small amount of endometrium to translocate and remain viable. There is a high prevalence rate with about 40% of hysterectomy specimens displaying the entity.

The junctional zone of the uterus is the epicenter of the structural abnormality The junctional zone is subendometrial smooth muscle that is more compacted, and contains less water in comparison to the outer myometrium. (McCarthy) The junctional zone is functionally different from the outer myometrium.

The Normal Junctional Zone on MRI

The normal sagittal view of the uterus is a T2 weighted MRI from a 16 year old female with pelvic pain. The myometrium consists of an outer part (dark red) and an inner more homogeneous part called the junctional zone (light maroon) Since a T2 weighted image is sensitive to water, we understand from this image that the outer part has greater white signal and therefore contains more water, and likely more vascularity. The junctional zone (light maroon) on the contrary has less water and therefore is blacker. The endometrial canal, cervical canal and vaginal cavity are outlined in yellow and the vaginal wall is overlaid in pink.

Clinically the patient presents with pelvic pain, dysmenorrhea, menorrhagia and may contribute to infertility. On exam the uterus is enlarged.

The diagnosis is best made by MRI which shows a thickened junctional zone (>10-12mms) s. The deposition of acute blood, blood degradation products such as iron, or the presence of fluid filled microglandular deposits in the junctional zone make the MRI findings highly specific for the diagnosis.

Treatment options include pain management with NSAIDS, and hormonal manipulation. Surgery and hysterectomy is the only current option for cure.

MRI

Adenomyosis with a Thickened Junctional Zone and Enlarged Uterus

A T2 weighted MRI (a) shows fluid in the endometrial cavity, surrounded by a thick dark layer of the junctional zone, and then surrounded with a slightly brighter outer myometrium. The color overlay in b, shows a small amount of fluid in the endometrial cavity (yellow) surrounded by a thickened subendometrial junctional zone (light maroon) measuring up to 13 mms characteristic of adenomyosis. The outer myometrium (dark maroon) is normal

The junctional zone thickening is key to the diagnosis of adenomyosis on MRI. The junctional zone normally measures 8mm or less. Between 8-11mm it is considered indeterminate, and when it measures 12mm or greater, it is considered diagnostic for the disease. The junctional zone may thicken normally in the first few days of the menstrual cycle or during myometrial contractions. Cystic changes in the junctional zone are also characteristic and relatively common and represent small blood blisters. Linear striations radiating from endometrium to myometrium are also seen but these are not as easy to discern. These probably reflect a breech in the endometrium reflecting microscopic tears extending into the myometrium.

Ultrasound

The Normal Junctional Zone on Ultrasound

A transvaginal ultrasound of a premenstrual woman in the sagittal plane (left) reveals a normal view of the uterus with characteristic premenstrual appearance. Image on the right is an overlay showing the components of the endometrium and subendometrial layers. The stripe is almost homogeneously echogenic and thick but also shows a hypoechoic halo of the junctional zone or inner myometrium. (salmon) The homogeneous stripe is made up from two histological layers (barely distinguished by this ultrasound)– the inner stratum functionalis (deep orange) that will shed once the spiral arteries vasoconstrict, and the outer stratum basalis (deep yellow) that will not shed, and will be the basis for regenerating the endometrium in the next cycle. The next layer as stated above is the compact myometrium – the junctional zone (aka inner myometrium) , and is followed by the thicker outer myometrium (maroon).

The junctional zone is hypoechoic due to decreased water content, and is formed by smooth muscle cells that are tightly packed. The extracellular matrix and water content are sparse. It usually measures less than 8mm.

Adenomyosis with Ectopic Deposits in the Junctional Zone

Two echogenic nodules (overlaid in green in image on the right) are present in the subendometrial layer, (junctional zone) in a woman with menorrhagia. The nodules are in close proximity and have appositional relationships with the endometrial stripe (yellow overlay). They distort the endometrial lining. These findings likely account for the menorrhagia. Included in the differential diagnosis are dystrophic changes in prior foci of adenomyosis and submucosal fibroids. An MRI would assist to characterize the lesions in the subendometrial layer.

Posted on November 19, 2015February 17, 2023 by Ashley Davidoff

Art of Anatomy of the Pancreas

Introduction

Pancreas in the Sky

is a photograph that shows a cloud formation embodying the shape of a pancreas

The anatomy of the pancreas is unusual and the physiology is multifaceted. It is a gland and is part of both the digestive and hormonal systems of the body. Structurally it is characterised by its unusual shape and position and the absence of a capsule. Functionally it is involved in the digestion of food as well as in the metabolism of glucose. The most common diseases include pancreatitis, pancreatic carcinoma and diabetes. Serum tests, ultrasound, CT scan, MRI and endoscopy are most commonly used in diagnosis of pancreatic disease. Treatment options include medical treatment (eg insulin in type 1 diabetes) minimally invasive procedures, and surgery.

“Pancreas in Pink”

is artwork derived from a CT scan and shows the upper abdominal cavity with the pancreas in bright pink surrounded by the liver, gallbladder, and kidneys. The aorta and inferior vena cava are the major transport vessels and serve to connect the organs.

Structure

Unusual Shape

“…and we stare in awe at your odd shape – why oh why did you choose that shape?
What are you supposed to look like? – we have no clue”

from “Hermit of the Abdomen”

Shapes of the Pancreas

The pancreas has been compared to many objects including an elongated comma on its side, an elongated number 9 on its side, a prism, a banana, an inverted and curved upside down tobacco pipe, and even an old fashioned revolver. Placing a seahorse or a woodpecker with head down and tail up probably brings us closest to the complex shape of the pancreas. The objects used for description are so varied and disparate, that one wonders if we truly have a grasp of the shape of this organ. A more practical way to look at the shape of the organ is to define the shape of its component parts.

Structure – Position

Deep in the Abdomen in the Retroperitoneum

The pancreas lies in the anterior pararenal space of the retroperitoneum surrounded by a vertebral body and kidneys posteriorly, the liver and gall bladder to its right, the spleen to its left, and the stomach and left lobe of the liver in front. This AiA rendering shows the pancreas cycling through the seasons. In the spring it is in shades of pink, the summer in blue, the fall in red, and in the winter in ice blue and white.

Function

The pancreas has dual functions in the the metabolism of the body. It acts as an as both an exocrine gland (secretes into ducts) and an endocrine gland (secretes into the circulation).

As an exocrine gland it secretes enzymes into ducts that lead to the duodenum. These enzymes aid in the digestion of fat, proteins, and carbohydrates. As an endocrine gland it is a key player in the control of glucose metabolism which it accomplishes by secreting insulin into the circulation.

The acini are the microscopic glands making up 98% of the parenchyma and they function as the exocrine component.

“Blueberries of the Glands of the Pancreas”

is a rendering of the histological appearance of the pancreatic acinar glands. The artpiece illustrates the ductules that subtends the acini which are the exocrine glandular cells. The shape of the acinar cells and ductules are reminiscent of grapes or berries on a stalk.

“Histology of the Glands of the Pancreas”

The exocrine hormones of the pancreas that aid in the digestion of fats, proteins and carbohydrates are produced in the acinar cells in the glandular unit called the acinus. The art piece shows the acinus with acinar cells and the duct that transports the secretions to the pancreatic duct and eventually to the duodenum where they aid in the digestion of proteins fats and carbohydrates.

The islets of Langerhans secrete insulin into the blood stream, very soon after ingestion of a meal in order to control blood sugar and intracellular glucose concentrations. The endocrine cells called the islets of Langerhans represent only 1-2% of the tissue volume of the pancreas, but play a vital role in body function and well being. They are most numerous in the tail of the pancreas.

Islets of Langerhans

Immunohistochemistry on mouse pancreas for insulin shows the brown stained Islets of Langerhans that secrete insulin among the acinar cells. They represent only 2% of the population of pancreatic cells.

(Modified Image – Courtesy Billyboy Wikipedia Public Domain)

Diseases

Acute Necrotic Pancreatitis

This is a CT of an elderly man who had severe pancreatitis. Within the retroperitoneum there is necrotic pancreas (asterisk). It is enlarged and consists mostly of air (arrow), fluid, and high density hemorrhagic components. The findings are consistent with a gangrenous pancreatic abscess. The surgeon noted that the pancreas looked and smelled like a “dead fish…. that had been dead for quite a long time.” Other structures including the gallbladder(gb), liver, kidneys, spleen and stomach surround the pancreas

Pancreatic Cancer with Spread to the Liver

The CT scan shows a primary pancreatic cancer (red asterisk) with metastases to the liver. Four of many metastases are identified with white asterisks

Normal Pancreatic Cells and Pancreatic Cancer Cells

In the upper image the cellular makeup of the acinar cells of the pancreas manifest with a normal nuclear to cytoplasmic ratio reflecting the relative size of the nucleus to the cytoplasm. The 2nd image show cancerous cells of the exocrine pancreas. The blue nuclii are far too large for the amount of the cytoplasm of the cell (abnormal nuclear to cytoplasm ratio). The malignant cells are also too dark (hyperchromatic) and lack uniformity and organization. These are all features of malignant cells . Cancerous cells do not obey the rules of the body and have no regard for the body at large. Malignant cells are equivalent to rebels in the community. They destroy and do not contribute to the wellbeing of the society. They also invade the territory of neighboring structures.

Ravages of Diabetes

The foot of a person with diabetes following amputation of the 2nd, 3rd, and 4th digits as a result of poor circulation of the tissues. The magnified view shows the calcification and hardening of the arteries.

Diagnosis

“Doppler Ultrasound of the Pancreas-Hermit of the Abdomen”

shows the pancreas in black in front of the splenic vein

“ERCP – Ductal Skeleton of the Pancreas”

is from an ERCP with an injection into normal the dorsal pancreatic duct of Wirsung with contrast also noted in the distal common bile duct

“Arteries of the Pancreas”

is from an angiogram of the celiac axis and shows the multiple arteries that supply the pancreas. The head of the pancreas is supplied by the superior pancreatico-duodenal vessels which arises from the gastroduodenal artery, and inferior pancreatico-duodenal artery which arises from the SMA. The body is supplied by the splenic artery and the superior mesenteric artery.

Treatment

Treatment options include medical treatment (eg insulin in type 1 diabetes) minimally invasive procedures for drainage and relief of obstruction, and surgery.

3D Nuclear Magnetic Resonance Structure of Insulin Dimer

(Modified from public domain image from Wikipedia and Courtesy Jawahar Swaminathan Jawahar Swaminathan and MSD staff at the European Bioinformatics Institute)

“And then a bone guy – for God’s sakes – a bone guy! – called Banting and his student Best
exposed the insular chemistry of your insulin that had given you the power over the sweet
Never mind – in the end it was for the good of all –
And a new era was born

from “Hermit of the Abdomen” Davidoff

Pancreas and Buddies

This aquatic scene shows the relationship of the pancreas to its neighbours particularly the splenic vein and left renal vein which run a parallel course, almost like a bunch of buddies romping in the water. The arching bodies with heads all in the same direction is quite beautiful

And then I think of you in your prime and in your happiness
When you are with your two buddies – the splenic vein and the renal vein
And you all look so much alike, and happy swimming in that deep ocean where you hide
And I wish this was forever”

from “Hermit of the Abdomen” Davidoff

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ART IN ANATOMY

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Pancreas – Hermit of the Abdomen

Pancreas – Hermit of the Abdomen

Anatomy of Endometriosis and Adenomyosis

Anatomy of Endometriosis and Adenomyosis

Ashley Davidoff MD

Endometriomas

Adenomyosis

MRI

Art of Anatomy of the Pancreas

Art of Anatomy of the Pancreas

Introduction