Surg Radiol Anat (2010) 32:853–858

DOI 10.1007/s00276-010-0630-8

ORIGINAL ARTICLE

Short pancreas: evaluation with multi-detector row CT

Murat Acar · Bumin Degirmenci · Servet Tatli

Received: 17 December 2009 / Accepted: 27 January 2010 / Published online: 18 February 2010© Springer-Verlag 2010

AbstractPurpose The purpose of this study was to analyze thelength variations of the pancreas using computed tomogra-phy (CT) and establish a database for short pancreas.Methods We retrospectively reviewed CT examinationsof 228 adults and rated pancreatic lengths qualitatively on ascale of 1–3 using transverse images. 1, normal pancreaslength; 2, mildly short pancreas; and 3, markedly shortpancreas. The length of the pancreas from head to tail wasalso measured using the “curved line tool” through themidline of the organ on curved planar reconstructed (CPR)images. The pancreatic neck–tail length and the abdominalradius were measured on transverse images, and the ratio ofpancreatic neck–tail length to abdominal radius was calcu-lated to avoid the eVect of body mass diVerences. All datawere analyzed statistically.Results The pancreas length was normal (group 1) in 180(78.9%) patients, mildly short (group 2) in 38 (16.7%), andmarkedly short (group 3) in 10 (4.4%). The average pancre-atic length on CPR evaluation was 207.5 § 19.1 mm ingroup 1, 168.9 § 8.5 mm in group 2, and 135.1 § 10.7 mmin group 3. There were statistically signiWcant diVerencesbetween three groups. Although it was not statistically sig-niWcant, percentage of diabetes mellitus was higher in

group 3 (20%) than other two groups (13.2% in group 2,and 8.9% in group 1).Conclusions CT examination of the pancreas is an eVec-tive imaging method to classify the pancreatic length and todetect short pancreas. We suggest that pancreatic lengthvariations should be reported on routine abdominal CTexaminations.

Keywords Short pancreas · CT · CPR · MPR · Pancreas length

Introduction

The pancreas is an elongated organ located across the backof the abdomen, posterior to the stomach. Its head lies inthe concavity of the duodenum to the right of the vertebralcolumn, and its tail extends left side, slightly upward, andtapers and ends near the spleen.

The average length of the pancreas is 15–20 cm accord-ing to the autopsy series [13, 16]. Short pancreas, alsoknown as agenesis or hypoplasia of the dorsal pancreas, is arare congenital anomaly and results from congenital partialor total defective pancreas formation. Total agenesis of thedorsal pancreas consists of absence of the pancreatic bodyand tail, on the other hand, partial agenesis results fromhypogenesis of the body and tail or only tail [20–22].Although it can remain asymptomatic, partial agenesis of thepancreas has been associated with malabsorption and failureto thrive in children, and diabetes mellitus in adults [3, 19].

Because of oblique orientation of the pancreas, trans-verse or coronal CT images provide only visualization of itslimited anatomical part per section. Recent developments inmulti-detector row CT (MDCT) technology have allowedacquisition of submillimetric thin sections which can be

M. Acar (&) · B. DegirmenciDepartment of Radiology, Faculty of Medicine, Afyon Kocatepe University, 03200 Afyon, Turkeye-mail: drmacar@hotmail.com

S. TatliDivision of Abdominal Imaging and Intervention, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

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further reconstituted to high-resolution images in anydesired plane and three-dimensional reformations. Theevaluation of the pancreas and accurate measurements of itslength from the head to the tip of tail are much simpler pro-cessess when curved planar reformat (CPR) images areused. Although there are many publications related to thick-ness, density, and volume of the pancreas [4, 5, 7, 11, 12],to the best of our knowledge, there has not been any reportin length measurement of the pancreas using imaging inEnglish medical literature. The aim of this study was toanalyze the length variations of the pancreas using contrast-enhanced MDCT and establish a database for the length ofthe pancreas in adults.

Materials and methods

This study conformed to Helsinki Declaration. Patients whoreferred to our Radiology Department for various reasonsfor abdominopelvic CT scan between November 2007 andJuly 2008 were included in this study. To avoid measure-ment mistakes, patients with pancreatic diseases includingpancreatic neoplasm and pancreatitis, and scoliosis, andpatients with a large mass or adjacent organ compressingon or displacing the pancreas were excluded. AbdominalCT examinations of 228 subjects (111 men and 117women; mean age, 60 § 15 and 54 § 14 years, respec-tively), were performed with a 6-detector-row MDCT scan-ner (Philips Brilliance 6, Philips Medical Systems,Amsterdam, The Netherlands) after oral (composed of1,000 ml of water and 250 ml of lactulose; Osmolac,Biofarma, Ãstanbul, Turkey) and intravenous contrast material(1.6 ml/kg body weight, rate 3 ml/s, delay 65 s; Omnipaque350, iohexol, GE Healthcare, Ireland), and reconstructed tocontiguous 5 mm transverse sections. In addition, 2 mmthinner sections were also obtained to create high-resolutionCPR images.

Hypoplasia of pancreas has been classiWed into threetypes in medical literature: (1) total agenesis of the dorsalpancreas, (2) hypogenesis of body and tail, and (3) hypo-genesis of the tail only [3]. In this perspective, two radiol-ogists (MA and BD) who had more than 5 years ofabdominal imaging experience, and blinded each othersreading, independently evaluated the transverse abdomi-nal CT images of each patients on the picture archivingand communication system (PACS) (Enlil, Eskisehir,Turkey), and rated the pancreatic length qualitatively on ascale of 1–3. 1, normal pancreas length (the pancreatic tailends near the spleen), 2, mildly short pancreas (hypogene-sis of the tail only), and 3, markedly short pancreas (hypo-genesis of the body and tail). We did not classify totalagenesis of dorsal pancreas agenesis cases because of theabsence of such cases in our series. There was complete

agreement on the rating of normal pancreas, however,there was disagreement between mildly and markedlyshort pancreas in two subjects. Both radiologists reevalu-ated the images of these two subjects together and anagreement was obtained.

A workstation (Philips Brilliance CT, V.2.3.0, Amster-dam, The Netherlands) was used to obtain CPR images ofthe entire pancreas by one (MA) of the radiologists and thepancreatic lengths from the head to the tail were measuredusing the curved line tool through the midline of the longaxis of the organ as shown in Fig. 1. The other radiologist(BD) who blinded to the CPR measurements selected a sec-tion of the transverse images that showed the farthest pointof the pancreatic tail, and drew an anteroposterior line (APline) through the spinous process and/or mid vertebral

Fig. 1 A 62-year-old male. The pancreatic length from the head to thetail was measured using “curved line tool” through the midline of thelong axis of the organ on CPR image, S stomach, D duodenum

Fig. 2 A 60-year-old male. Contrast-enhanced transverse CT imageshows normal pancreas. Measurement technique of the pancreaticlength (short measurement line) and the abdominal radius (long mea-surement line). K kidney, VB vertebral body, S spleen

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body. The pancreatic neck–tail length was then measured atright angle from this line to the farthest point of the pancre-atic tail. In addition, radius of abdomen was measured atthe same section by drawing a line from the midline at rightangle to the farthest inner surface of the abdominal wall(Fig. 2). The ratio of the pancreatic neck–tail length to theradius of abdomen was obtained to avoid the eVect of bodymass diVerences.

Weights and heights of all patients were recorded, andbody mass index (BMI) was calculated by dividing eachpatient’s weight (in kilograms) by the square of his or herheight (in meters). All parametric results were expressed asmean § SD for each group. Data were analyzed by descrip-tive statistics, independent-sample t and one-way ANOVAtests. The diVerences were assessed using �2 test in case ofnominal variables. For determining the correlation betweentwo variables, Pearson’s coeYcient was calculated. Localstatistical signiWcance was assumed as P < 0.05 for allparameters.

Results

Out of 228 adults, 180 (78.9%) had normal pancreas (group1), 38 (16.7%) mildly short pancreas (group 2), and 10(4.4%) markedly short pancreas (group 3) (Figs. 2, 3, and4). No complete agenesis of dorsal pancreas was detected.The average pancreatic length was 207.5 § 19.1 mm ingroup 1, 168.9 § 8.5 mm in group 2, and 135.1 § 10.7 mmin group 3. These diVerences were found to be statisticallysigniWcant between all groups (P < 0.05). Also, there werestatistically signiWcant diVerences between the pancreasneck–tail measurements and the pancreatic length–abdomi-nal wall ratios in all groups. Age, weight, and BMI showedno signiWcant diVerences between all groups. Baseline clin-ical characteristics and measurement results of subjects aresummarized in Table 1.

CPR evaluation revealed that the pancreatic length washigher in males than females in group 1 and group 3whereas, there was no signiWcant diVerence between

Table 1 Pancreatic lengths in all 3 groups (n = 228)

Values are means § SD

NP Normal pancreas, SP Short pancreas

** P value between NP–Mildly SP, NP–Markedly SP, and Mildly SP–Markedly SP respectivelya Pancreas neck–tail measurement on transverse images

NP Mildly SP Markedly SP P

n (%) 180 (78.9%) 38 (16.7%) 10 (4.4%) <0.01

Age 58 § 15 55 § 15 57 § 17 1

BMI 28.2 § 5 27.6 § 6.3 27.8 § 3.4 1

CPR Pancreas length (mm) 207.5 § 19.1 168.9 § 8.5 135.1 § 10.7 <0.01

Pancreas length (mm)a 90.5 § 12.2 74.8 § 11.9 59.5 § 6 <0.01

Abdominal radius (mm) 138 § 13.3 126.7 § 12 138.6 § 13.6 0.001, 1, 0.03**

Neck-tail length/Abdominal radius ratio 0.66 § 0.8 0.59 § 0.9 0.43 § 0.6 <0.01

Table 2 Pancreatic lengths for both genders in all three groups

Values are means § SD

NP Normal pancreas, SP short pancreas

* P < 0.05 vs. male

** Pancreas neck-tail measurement on transverse images

NP Mildly SP Markedly SP

Female Male Female Male Female Male

n 85 95 26 12 6 4

Age 54 § 15* 60 § 15 54 § 14 59 § 14 54 § 15 62 § 22

BMI 29.9 § 5.4* 27 § 3.9 29 § 6.4* 24.5 § 5 28.3 § 3.8 27.1 § 3.2

CPR Pancreas length (mm) 200.9 § 17* 213.3 § 19 169.5 § 8.3 167.7 § 9.2 129.6 § 10* 143.3 § 5.4

Pancreas length (mm)** 85.1 § 9.8* 95.3 § 12.2 74.3 § 13.2 76.1 § 8.9 57.7 § 6.7 62.2 § 4.1

Abdominal radius (mm) 132.2 § 12* 143.1 § 13 124.6 § 11 131.3 § 14 137.2 § 10 140.7 § 4

Neck-tail length/Abdominal radius ratio 0.65 § 0.8 0.67 § 0.8 0.59 § 0.1 0.58 § 0.9 0.42 § 0.7 0.44 § 0.4

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genders in group 2. In group 1 between genders, statisti-cally signiWcant diVerences were present for the pancreaticlength and the abdominal radius but absent for the pancre-atic length/abdominal radius ratio. No statistically signiW-cant diVerences of the pancreatic length, the abdominalradius, and the pancreas length/abdominal radius ratio weredetected between genders in group 2 and group 3. All datarelated with genders were summarized in Table 2.

Correlation analysis showed a signiWcant correlationbetween the length of the pancreas and weight (r = 0.17;P = 0.01), height (r = 0.3; P < 0.01), and the abdominalradius (r = 0.33; P < 0.01) of subjects. Although it was not

signiWcant, percentage of diabetes mellitus was higher ingroup 3 [2 of 10 patients (20%)] than group 2 [5 of 38patients (13.2%)] and group 1 (16 of 180 patients (8.9%));(P = 0.4).

Discussion

The pancreas develops by the ventral and dorsal endoder-mal buds. While the dorsal bud forms the body and tail ofthe pancreas, the ventral bud forms the most of the headand uncinate process [10]. Embryologically absence or

Fig. 3 A 42-year-old female. a Contrast-enhanced transverse CTimage shows a short pancreas. Note markedly short pancreas withhypogenesis of the body and absence of the tail. A abdominal aorta Kkidney, SV splenic vein, P pancreas. b CPR measurement of the samepatient revealed that the pancreas was 132.5 mm in length, S stomach,D duodenum

Fig. 4 A 55-year-old male. a Contrast-enhanced transverse CT imageshows mildly short pancreas. Note hypogenesis of the tail, K kidney,SV splenic vein, P pancreas. b CPR measurement of the same patientrevealed that the pancreas was 173.1 mm in length, D duodenum,K kidney

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regression of the dorsal bud results in dorsal pancreaticagenesis, which can be partial or total. In total agenesis ofthe dorsal pancreas, the neck, body and tail is absent.Whereas, in partial agenesis, body and tail, or only the tailis absent [8]. In our series, approximately one out of Wvesubjects had short pancreas corresponding partial dorsalpancreatic agenesis. Markedly short pancreas was detectedin 10 (4.4%) of 228 adults. CPR measurements in thisgroup revealed the average length of pancreas as 135.1 §10.7 mm. Mildly short pancreas was seen in 38 (16.7%)subjects, and the average pancreatic length in this groupwas 168.9 § 8.5 mm. The remaining 180 (78.9%) of 228subjects had normal pancreatic length (207.5 § 19.1 mm).We did not detect any complete agenesis of dorsalpancreas. Statistically signiWcant diVerences between thepancreas neck–tail measurements and the pancreaticlength–abdominal radius ratios were found in all threegroups. In a few cases, although CPR measurements

revealed normal pancreatic length, the pancreas neck-taildistance was small. This was likely due to the curved shapeand course of the pancreas, which tend to lie toward poster-ior rather than lateral (Fig. 5).

Partial agenesis of the pancreas can remain asymptom-atic because of the functional reserves of the exocrine andthe endocrine pancreas [19]. The most common clinicalpresentation of pancreatic hypoplasia in children is severeexocrine insuYciency accompanied by malabsorption andfailure to thrive. In review of the literature, diabetes melli-tus has been noted mostly in adults with partial or completedorsal agenesis of pancreas [3, 8, 19, 22]. Joo et al. [8] sug-gested that, because the body and the tail of the pancreashave the most of islet cells, the absence of the body and thetail with this anomaly contributes to the development ofdiabetes mellitus. In our study, although there were not sta-tistically signiWcant diVerences, percentage of diabetes mel-litus was more in markedly short pancreas group than theother groups. Pancreatitis has been reported as anothercommon associated disease with agenesis of dorsal pan-creas [15, 17, 19, 22]. However, it is still unclear whetherthe high frequency of pancreatitis is due to frequent imag-ing required in patients with pancreatitis or whether pancre-atitis is simply a frequent comorbidity with agenesis [19].

Dorsal pancreatic lipomatosis and distal pancreatectomyshould be considered in the diVerential diagnosis of shortpancreas. Distal pancreatic bed can be Wlled by adjacentstomach, intestine or intraabdominal fat tissue after distalpancreatectomy similar to what is seen in subjects withshort pancreas. However, splenic vein is absent in theformer [9]. Fat replacement of the distal pancreas is patho-logically characterized by the replacement of pancreaticparenchymal cells with normal adipose tissue, and occursas a result of the atrophy of the distal pancreas, particularlyin pancreatic head tumors or chronic pancreatitis [1, 2]. CTimaging can be used to demonstrate the presence of fatreplacement in the distal pancreas. The diVerentiation ofdorsal pancreatic agenesis and fat replacement of the distalpancreas depends on the detection of the presence of thedorsal pancreatic duct [6, 9, 14, 15].

The available data suggest that there are eVects of bodysize and sex on the volume of the pancreas [18]. In ourstudy, there was a correlation between body size andpancreas length in both sexes. The abdominal radius andpancreas length of males were greater than females. Saishoet al. [18] reported that pancreas volume tended to besmaller in females than in males which is consistent withour results. In contrast to our study, their data showedsmaller BMI in females compared with males. This opposi-tion may arise from their subject’s age distribution. How-ever, similar to our results, they reported a positivecorrelation between abdominal radius and pancreaticlength.

Fig. 5 Contrast-enhanced transverse CT images of 57 (a) and 35 (b)year-old patients. a Although the pancreas appeared normal in length,the neck to tail measurement from the mid vertebral line revealed ashort pancreas because of the orientation of the pancreas, which wastoward posteriorly rather than laterally, VB vertebral body, S spleen,b Normal pancreas length measurement, note the pancreas courseslaterally toward the splenic hilum, S spleen

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Our study has several limitations. It included relativelysmall number of subjects and without any subject withcomplete dorsal pancreatic agenesis. In addition, it was notplanned to investigate any correlation between pancreaticsize and its exocrine-endocrine function which appears asan important limitation.

Conclusions

CT examination of the pancreas is an eVective imagingmethod to classify the pancreatic length and to detect shortpancreas. Although the technique described here on trans-verse images gives an idea about the length of the pancreas,it is limited and CPR evaluation is essential to obtain accu-rate pancreatic length measurements. We suggest thatpancreatic length variations should be reported on routineabdominal CT examinations. However, further studieswith higher number of subject are needed to documentrelationships between the pancreatic length and pancreaticdisorders.

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