Fig. 23.31 Insulinoma: demonstrated by intra-arterial digital subtraction angiography (DSA). Selective or superselective arterial catheterisation is required together with gas distension of the stomach and paralysis of the bowel. Multiple projections may be necessary, as in this patient where the small insulinoma in the tail of the pancreas (confirmed surgically) was only clearly shown on DSA films obtained in the 45¡ left anterior oblique projection. Angiography may produce a false positive 'blush' from the gut or splenunculus and this problem can be resolved by combining angiography with CT, which will show whether the 'blush' is truly pancreatic (see Fig. 23.32).
