CT Imaging of Acute Pancreatitis

Erin Rikard Radiology December 2007

Outline
Definition Epidemiology Causal Factors Pathophysiology CT Evaluation and Findings Normal and abnormal Complications Management Prognosis

Definition

Definition

Epidemiology

Epidemiology
79.8/100,000 per year 185,000 new cases annually in U.S. Peak incidence in 6th decade

Causal Factors

Causal Factors
Etiology Cholelithiasis Alcohol Iatrogenic Incidence 30-60% 15-30% 2-5%

Trauma/Surgery
Metabolic Disorders Viral Infection

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Pathophysiology

Pathophysiology
Pancreatic autodigestion, with activated pancreatic enzymes escaping the ductal system and lysing tissue of pancreas and adjacent structures Lack of capsule facilitates spread

Normal CT Findings

Normal Anatomy by CT
Pancreas arcing anteriorly over spine Head adjacent to duodenum Tail extending toward spleen Splenic vein posterior to body and tail Portal vein confluence immediately posterior & left of pancreatic neck

Normal Morphology by CT
Pancreatic acini lobulated contour No capsule AP dimensions
Head 2-2.5 cm Body and tail 1-2 cm

Pancreatic duct
Maximal diameter 3 mm in adults (5 mm in elderly) Empties into ampulla of Vater, along medial aspect of 2nd portion of duodenum

50 year-old woman
Bennett, W. F. et al. Am. J. Roentgenol. 2000;175:882-883

Stomach
Liver V A L Kidney Spleen

R Kidney

CT scans of normal kidneys and pancreas

Evaluation by CT

Evaluation of Acute Pancreatitis

Contrast-enhanced CT is imaging modality of choice Oral and IV contrast differentiate pancreatic tissue from adjacent blood vessels and duodenum

Recommendations for ContrastEnhanced CT

Clinical diagnosis in doubt Severe clinical pancreatitis Ranson score > 3 APACHE score > 8 Failure to rapidly improve within 72 hours of beginning conservative medical therapy Initial improvement with later deterioration

Ranson Criteria
At admission After 48 hours

Age > 55 WBC > 16,000 Blood glucose > 200 Serum AST > 250 Serum LDH > 350

Hematocrit > 10% BUN 1.8 after rehydration Serum calcium < 8.0 PO2 < 60 Base deficit > 4 Estimated fluid sequestration > 6L

Abnormal CT Findings

Abnormal CT Findings
Peripancreatic inflammation Diffuse or focal pancreatic edema Poor definition and heterogeneity of gland Fluid collections Necrosis Thickening of pararenal fascia

Spectrum of Disease
Mild Cases
May be normal or show only mild gland enlargement

Severe Cases
May reveal peripancreatic fluid &/or pancreatic necrosis and phlegmon

Peripancreatic Inflammation/ Pancreatic Edema/ Fluid Collections

Gallstone-induced pancreatitis in 27 year-old woman

Balthazar, Emil J. Radiology. 2002; 223: 603-613

Copyright 2002 by RSNA

Transverse CT scan obtained with intravenous and oral contrast material reveals a large, edematous, homogeneously attenuating (73-HU) pancreas (1) and peripancreatic inflammatory changes (white arrows). Although the attenuation values are low, there is no pancreatic necrosis. Calcified gallstones are seen in gallbladder (black arrow). 2 = liver (140 HU).

Infection?
Gallium-67 SPECT (perfusion studies) ? with (+) findings had infection at intervention 78% of all patients No false (+) No correlation between gallium uptake and presence or absence of necrosis

47-year-old man with severe pancreatitis

Copyright 2007 by the American Roentgen Ray Society

Fluid collection replacing pancreatic body and tail

47-year-old man with severe pancreatitis

Copyright 2006 by the American Roentgen Ray Society

West, J. H. et al. Am. J. Roentgenol. 2002;178:841-846

47-year-old man with severe pancreatitis who had true-positive finding for infection on gallium study. Fusion image of CT scan and gallium study was helpful in localizing infection.

Necrosis

57-year-old man with acute necrotizing pancreatitis and severe back pain

Large region of unenhancement (necrosis) involving most of body and tail of pancreas. Inflammatory fluid is present in anterior pararenal space. Note ascites around liver.

50 year-old woman with acute pancreatitis (1st view)

Balthazar, Emil J. Radiology. 2002; 223: 603-613

(a, b) Transverse CT scans obtained with intravenous and oral contrast material reveal an encapsulated fluid collection associated with liquefied necrosis (large straight arrows) in the body of the pancreas. The head, part of the body, and the tail of the pancreas are still enhancing (small straight arrows). N = liquefied gland necrosis, S = stomach.

Copyright 2002 by RSNA

50 year-old woman with acute pancreatitis (2nd view)

Balthazar, Emil J. Radiology. 2002; 223: 603-613

(a, b) Transverse CT scans obtained with intravenous and oral contrast material. The head, part of the body, and the tail of the pancreas are still enhancing (straight arrows). Residual fluid collections and areas of soft-tissue attenuation (curved arrow) consistent with fat necrosis are seen adjacent to the pancreas. f = fluid, N = liquefied gland necrosis.

Copyright 2002 by RSNA

Complications

Complications
Pancreatic Pseudocysts Abscess Hemorrhagic Pancreatitis Splenic Artery Pseudoaneurysm formation or rupture/ Splenic Venous Thrombosis

Pancreatic Pseudocyst
Fluid collection surrounded by fibrous capsule but not lined by epithelium Occurs in 10% of cases Significant % will not resolve spontaneously Seen within pancreas and potential spaces with which gland is continuous (lesser sac and left pararenal space)

28 year-old man with pseudocyst

Cohen-Scali, Frack, et a;. Radiology. 2003; 228: 727-733.

Copyright 2003 by RSNA

Image demonstrates a pseudocyst (arrow) in the tail of the pancreas surrounded by a thick enhancing wall. The lesion appears heterogeneous with central areas of higher attenuation, which is suggestive of fresh hemorrhage. Note infiltration (arrowheads) of the peripancreatic fat.

44 year-old man with acute abdominal pain hemorrhagic pseudocyst

Copyright 2000 by RSNA

Axial CT scan obtained with intravenous contrast material demonstrates calcifications from chronic pancreatitis in the head of the pancreas. A high-attenuation focus of blood (arrow) is seen within the low-attenuation pseudocyst, a finding that is consistent with hemorrhage.

Abscess
1 in 20 cases and fatal in of cases Suspected clinically with fever and septicemia Pathognomonic finding presence of gas bubbles in pancreatic bed

Pancreatic abscess containing gas in 54-year-old man

Copyright 2006 by the American Roentgen Ray Society

Demos, T. C. et al. Am. J. Roentgenol. 2002;179:1375-1388

Large fluid collection containing gas bubbles in pancreatic bed due to abscess complicating acute pancreatitis. Note infiltration of peripancreatic fat and calcified gallstones.

Hemorrhagic Pancreatitis

Rare Noted clinically by in hematocrit

70 year-old woman with hemorrhagic pancreatitis

Urban, Bruce A., et al. Radiographics. 2000; 20: 725-749.
Copyright 2000 by RSNA

CT scan demonstrates hemorrhagic pancreatitis as a heterogeneous mass in the area of the pancreatic bed (*). Arrow indicates active extravasation (hemorrhage).

Splenic Artery Pseudoaneurysm

Presents similarly to hemorrhagic pancreatitis with a in hematocrit

Pseudoaneurysm
Copyright 2005 by The Society of Interventional Radiology

Tang, Linda J. J Vasc Interv Radiol. 2005; 16: 863-866

Axial CT scan with intravenous contrast material reveals a pseudoaneurysm (arrow) projecting from the splenic artery.

Management

Management
Acute pancreatitis usually self-limited
Inflammation within 3-7 days in 90% of cases

Medical therapy
Analgesics IV hydration Decrease PO intake Decreased pancreatic secretion Antimicrobials in severe necrotizing pancreatitis

Management
Presence of abscess or necrosis indicates need for intervention Percutaneous drainage of abscess Surgical debridement (necrosectomy) of infected necrotic tissue when conservative treatment has failed

Prognosis

Prognosis
Mortality over last 20 years
5% for all cases 20% for severe cases

Reasons for Reduced Mortality

Initially - Recognition and application of severity signs 1990s More selective endoscopic or surgical debridement of infected tissue, endoscopic cyst drainage, and angiographic control of GI bleeding Later Improved nutritional support by jejunal feeding, earlier use of antibiotic therapy, gut sterilization, early ERCP for common bile duct stones, and necrosectomy for necrotic tissue

Resources

Resources
Balthazar, Emil J. Acute Pancreatitis: Assessment of Severity With Clinical and CT Evaluation. Radiology. 2002; 223: 603-613. Banu, S., P. Singh, N. Pooran, and B. Stark. Evaluation of Factors That Have Reduced Mortality from Acute Pancreatitis Over the Past 20 Years. Journal of Clinical Gastroenterology. 2002 July; 35: 5060. Bennett, William F., Kuldeep Vaswani, and Kenneth Vitellas. Case 1: Parenchymal Lymphoma. American Journal of Roentgenology. 2000; 175: 882-883. Cohen-Scali, Frank, et al. Discrimination of Unilocular Macrocystic Serous Cystadeoma from Pancreatic Pseudocyst and Mucinous Cystadenoma with CT: Initial Observations. Radiology. 2003; 228: 727-733. Demos, Terrence C., et al. Cystic Lesions of the Pancreas. American Journal of Roentgenology. 2002; 179: 1375-1388. Gore, Richard M., et al. Helical CT in the Evaluation of the Acute Abdomen. American Journal of Roentgenology. 2000; 174: 901913.

Resources Continued
Gunderman, Richard B. Essential Radiology. 1998. Greenberger, Norton J. and Phillip P. Toskes. Acute and Chronic Pancreatitis. Harrisons Internal Medicine. Mitchell, RM, MF Byrne, and J. Baillie. Pancreatitis. Lancet. 2003 Apr 26; 361: 1447-1455. Novelline, Robert A. Squires Fundamentals of Radiology. 6th ed. 2004. Pretorius, E. Scott and Jeffrey A. Solomon. Radiology Secrets. 2nd ed. 2006. Ranson, JH, et al. Prognostic Signs and the Role of Operative Management in Acute Pancreatitis. Surgery, Gynecology, and Obstetrics. Tang, Linda J., Stan Zipser, and Young S. Kang. Temporary Spontaneous Thrombosis of a Splenic Artery Pseudoaneurysm in Chronic Pancreatitis During Intravenous Octreotide Administration. Journal of Vascular Interventional Radiology. 2005; 16: 863-866.

Resources Continued
Urban, Bruce A. and Elliot K. Fishman. Tailored Helical CT Evaluation of Acute Abdomen. Radiographics. 2000; 20: 725-749. West, Jeffrey H., Stephen B. Vogel, and Walter E. Drane. Gallium Uptake in Complicated Pancreatitis. American Journal of Roentgenology. 2002; 178: 841-846.