This case illustrates several findings which are commonly seen in patients with chronic pancreatitis. The pseudocyst presents an acute superimposition of pancreatitis on the underlying chronic disease. It should be noted that the patient is only 34 years old and that these severe changes may even occur in younger individuals.

Pancreatic ductal enlargement is common in chronic pancreatitis and may be caused by ductal obstruction secondary to a calculus or fibrosis of the pancreatic head. It is often difficult to recognize the pancreatic duct as enlarged, and it may be mistaken for the splenic vein or even fluid within a collapsed gastric antrum. However, this sign is important to recognize because it clearly indicates that the pancreas is abnormal and helps to differentiate chronic from acute pancreatitis. Pancreatic ductal dilatation is frequently seen in chronic pancreatitis yet is very uncommon in acute inflammation.

Small calculi are also recognized in this case, again confirming the chronic nature of disease. In this case, the calculi were small and easier to visualize on the real-time examination. Due to their small size, acoustic shadowing was not detected. Notice that the common bile duct is normal in caliber. Despite the severe changes present in this case, there is no biliary obstruction. This is usual. Acute pancreatitis rarely causes significant biliary dilatation. Even chronic pancreatitis may not cause it. When biliary obstruction is also present, it may be caused by pancreatic carcinoma, common bile duct stone or cancer, or fibrosis and stricture from the chronic inflammatory disease.

The pancreatic pseudocyst itself, while representing an acute superimposition of disease on chronic pancreatitis, may persist for some time. The presence of hyperechoic debris does not necessarily determine its exact age or whether it is complicated by infection.

Acute and chronic pancreatitis are essentially discrete entities which may at times have common findings such as the presence of pseudocysts. Some of the signs mentioned above may be difficult to recognize unless specifically searched for. These can, however, be extraordinarily helpful in making the appropriate sonographic diagnosis.