Answer to the question 1 from page 361.

Prawidłowa odpowiedź: C.

Correct answer: C.

The Doppler examination decided about the diagnosis (fig. 2) and at the same time forced the establishment of the reason of these lesions. As it should have been thought, a blocked portal vein was responsible for the image presented (fig. 3). The problem probably appeared in the period of the abdominal cavity infection after relaparotomy, which the patient had undergone because of the large intestine cancer relapse. In the US examination the lesions in the pancreas were described as cysts. It is another proof that currently the ultrasound examinations should not be performed if there are no accessory Doppler options in the apparatus equipment and if they are not used. All the lesions: solid, cystic and solid-cystic should be assessed with regards to their vascularization. This is the 15th case of pancreatic varices in my collection. Lately I have observed a shunt-circulation located in such a way in a 6-year-old girl (fig. 4), who experienced not only portal vein blockage but the pancreatic segment of the splenic vein and the terminal fragment of the superior mesenteric vein as well. From the medical interview obtained from the mother results only that the newborn experienced an extended jaundice after the birth, the etiology of which was not established. It should be explained why in some patients with portal vein blockage pancreatic varices form, while others do not have this complication. The correct answer to this problem is the individual body structure of a given person. Anatomical variability is the constant feature of living organisms and that is why the same reason may lead to different morphological effects. Among the accessory portal veins in this area hepatogastric veins have the particular meaning. They can lead the blood from the stomach to the liver, disemboguing directly to the parenchyma of this gland and this situation is most common. In the second rare case the ostium of these vessels is located in the left branch of portal vein. Moreover, as the constant blood drainage element of the area, there is a left gastric vein in the lesser omentum. Its ostium is very variable. As Ibukuro at al.( have shown, basing on the spiral computed tomography, this vein terminates in the splenomesenteric confluence in 46% of the examined patients, in 32% in the splenic vein and in portal vein only in 22%. Another important tributary in this region is the inferior mesenteric vein. It fuses with the splenic vein in 46% of patients, with splenomesenteric confluence in 25% and with superior mesenteric vein in 29%. These various types of connections cause that in almost each patient with portal system veins thrombosis depending on the blockage area (full or partial) different routes of shunt-circulation develop. Nevertheless, in all of them the varices localize in the head and head and the body. I have not encountered varices located in the tail most probably because of the activity of the short splenogastric connections. Moreover, it should be remembered that an abundant anastomose system in the head of the pancreas is formed by three veins: anterior superior pancreaticoduodenal vein, posterior superior pancreaticoduodenal vein and inferior pancreaticoduodenal vein. In the differentiation of pancreatic varices with other pathologies one should take into account arteriovenous fistula of the pancreas, which manifests itself with pronounced portal hypertension symptoms. The pulsed Doppler examination will give the deciding result – pulsating character of the flow in the vascular malformation and in a part of the portal system(.

Fig. 2

Head and body varices

Fig. 3

Blocked hepatic portal vein

Fig. 4

Varices of the pancreas in 6-year-old girl