.

4,

Emil J. Baithazar, M.D. John H.C Ranson, BM., B.Ch. David P. Naidich, M.D. Alec J. Megibow, M.D. Robert Caccavale, M.D. Matthew M. Cooper, M.D.

Acute of CT1

Pancreatitis:

Prognostic

Value

In 83 patients with acute pancreatitis, initial computed tomographic (CT)

A

the ex-

.4

F
I

aminations were classified by degree of disease severity (grades A-E) and were correlated with the clinical follow-up, objective prognostic signs, and complications and death. The length of hospitalization correlated well with the severity of the initial CT findings. Abscesses occurred in 21.6% of the entire group, compared with 60.0% of grade E patients. Pleural effusions were also more common in grade E patients. Grades A and B patients did not have abscesses, and none died, regardless of the number of prognostic signs. Abscesses were seen in 80.0% of patients with six to eight prognostic signs, compared with 12.5% of those with zero to two. The use of prognostic signs with initial CT findings results in improved prognostic accuracy. Early CT examination of patients with acute pancreatitis is a useful prognostic indicator of morbidity and mortality.
Index terms: Pancreas, 77.1211 #{149} Pancreatitis, Radiology 1985; computed 77.291 tomography,

degree, duration, and type of treatment of acute pancreatitis based on the early evaluation of the initial attacks severity. Until recently, this evaluation relied mainly on the presence on absence of varied clinical parameters such as tachycardia, fever, dyspnea, oligunia, protracted ileus, and tense abdomen. Several methods of a more objective evaluation have been reported (1-7) that potentially improve prognostic ability and prediction of complications. Among them, the statistical analysis of early objective measurements of multiple risk factors, described by Ranson (2, 3), has received wide attention and has been considered a reliable prognostic indicator of the diseasess severity. These objective prognostic signs (grave signs or risk factors) have significantly improved the initial assessment based on clinical criteria alone and are used as guidelines in the decision-making process of selecting proper medical or surgical treatment in our institution. Since morbidity and mortality depend in great measure on the local pancreatic and penipancreatic complications (i.e., abscess, pseudocyst, hemorrhage), computed tomographic (CT) examination could play an important role in the initial assessment of the severity of acute pancneatitis. For this reason, in the past 4 years we have embarked on a comprehensive study designed to assess the prognostic value of the initial CT examination in patients with acute pancreatitis. Our objectives are (a) to describe, classify, and analyze the early CT findings in acute pancreatitis; and (b) to assess their predictive value based on correlation of early CT findings with clinical and objective prognostic signs.
HE

are

156:767-772

MATERIALS
Our study is based findings of 83 patients the past 4 years. There mean such levels

AND

METHODS
in a

on a detailed analysis of CT, clinical, and laboratory with acute pancreatitis admitted to our institution were 63 men and 20 women, aged 17-79 years, with clinical abdominal units. diagnosis was based on typical symptoms pain, and elevation of serum amylase The etiology of pancreatitis was chronic in 11, gallstones or unknown and in

age of 45 years. The as nausea, vomiting, above 200 Somogyi

alcohol abuse in five, hyperlipidemia

51 patients, in two,

cholelithiasis and miscellaneous pancreatitis reported

alcohol in 14. There (2, 3, 6, 7), compliintravecollections others treatment, death as or

were no cases of traumatic We used the previously listed in Table 1, to assess patients were and supportive in 18 patients developed. to treatment cations. All nous fluid, (abscesses) complications and response discharge

included objective of the treated We

in this prognostic attack and

series. signs its possible suction, fluid and until

the

severity

initially therapy. (21.7%), The were

by nasogastric drained infected

some clinical recorded

upon initial evaluation course, complications, for all individuals,

From the Departments of Radiology (E.J.B., D.P.N., A.J.M.) and Surgery (J.H.C.R., R.C., M.M.C.), New York University Medical Center, Bellevue Hospital Medical Center, New York City. Received January 10, 1985; accepted and revision requested March 18, 1985; revision received April 3. 1985. c RSNA, 1985

from the hospital. CT examinations were performed using standard technical parameters. E-Z-EM, Westbury, N.Y.) was used

on a GE 8800 scanner (Milwaukee) Diluted 2% barium sulfate (E-Z-CAT, as oral contrast material, and a rapid (Reno-M-DIP contraindicated. examination 2 weeks. or as The

intravenous drip infusion of 30% diatrizoate meglumine [Squibb]) was started immediately before scanning unless Bolus injections were not used in this study. A total of 152 CT scans were obtained, either as a single consecutive, follow-up examinations approximately every

767

Figures

1, 2, and

4,

2.

1.
2.

3.

CT scan of normal pancreas in patient with clinical pancreatitis (grade A). Diffuse enlargement of the pancreas without peripancreatic inflammatory changes (grade B). Enlarged pancreas associated with haziness and increased density of peripancreatic fat (grade C). Note presence of diffuse fatty infiltration of liver.

initial within tients tients. and In

examinations the first between general, 3 hospital day severely

were days 4 and ill

performed in 10 in patients 40 43 papameof adprior objec-

ceived priority for CT examination, making this sample unrepresentative all patients with acute pancreatitis mitted to our institution.

CT scans knowledge

were interpreted without of clinical findings or The fatty

tive prognostic signs. ditions were specifically recorded: presence of den pathology, pleural effusions. In addition, pancreatic into based five on peritoneal we

following conlooked for and liver, gallbladeffusion, the seen on type CT of scans was size, permeaand of

8.

classified This

inflammation categories. an overall and

classification assessment

contour, ipancreatic surements ment.

density of the abnormalities. were used not the

gland and Specific this

We

used in following

assessgrades, in the pancreas enlarge-

which are similar to those reported literature (8): grade A, normal (Fig. 1); grade B, focal or diffuse

ment of the pancreas (Fig. 2) (including contour irregularities, nonhomogeneous attenuation of the gland, dilatation of the pancreatic duct, and foci of small fluid collections within the gland, as long as there was no evidence of peripancreatic disease); malities grade C, intrinsic associated with pancreatic haziness abnorand

.#, (Fig. 5) or presence of gas the pancreas (Fig. 6). in or adjacent to

RESULTS
Of the 83 patients covered with medical and were discharged,
tients (21.7%) became

streaky densities representing tory changes in the peripancreatic 3); grade D, single, ill-defined tion (phlegmon) multiple, poorly (Fig. defined 4); grade fluid

inflammafat (Fig. fluid collecE, two collections or

abscesses. One patient underwent surgery to memove a persistent pseudocyst. Five patients with abscesses died, and one other patient died of hepatic and
quired surgical drainage of renal failure without evidence of pan-

surveyed, treatment while

septic

63 mealone 18 paand me-

creatic abscess. the objective

clinical course

The prognostic
is shown

relationship signs
in Table

to
2.

of the

768

#{149}

Radiology

September

1985

Figure

a.

b.

CT scan

of enlarged

body

and

tail of the pancreas

(a) with

associated

fluid

collection

in left anterior

pararenal

space

(b) (arrows)

(grade

D).

Figure

a.
CT scan
.

b.
showing large fluid
of the

collections
duodenum

with

partial

obstruction

in the lesser and slight

sac and
thickening

anterior pararenal of gallbladder

space in patient wall (arrows).

with

grade

E pancreatitis.

Note

compression

cholelithiasis on sonognams or during surgical exploration. We observed gallbladdens with thickened walls in five patients, none of whom had gallstone pancreatitis (Fig. 5). Six patients
(7.2%) had free fluid in the pemitoneal

cavity, five with grade D or E pancreatitis. We detected pleural effusions in 27 patients (32.5%). Effusions were present in 41% of the 12 patients with grade D and 65% of with grade E pancreatitis. fusions were seen in with grade E pancreatitis. 23 patients Bilateral ef22% of patients the

Secondary

CT

Findings

Secondary CT findings that may correlate with the severity of acute pancreatitis were recorded. We observed fatty infiltration of the liver in

21 patients (25.3%) (Fig. 3) from all five grades of pancreatitis. Gallstones were seen on CT scans in 12 patients (14.5%), but were missed in a number of other patients who proved to have

In our morphologic evaluation, we noted a diffuse involvement of the pancreas in 68 of 83 cases and a segmental distribution in the remaining 15 cases (18.1%). In nine patients

Volume

156

Number

Radiology

#{149}

769

Figure

..

44

a.
b.

CT

scan

showing

increased

density

of the

peripancreatic

retroperitoneal with multiple gas

fat bubbles

associated in patient

with with

extraluminal abscess (grade

air E).

(arrow)

in

patient

with

pemipancreatic abscess. Bilateral, ill-defined, retroperitoneal

fluid

collections

(10.8%), the inflammatory process involved exclusively or predominantly the head of the pancreas (Fig. 7); in five, the body and tail; and in one, only the tail of the pancreas. Swelling of only the head of the pancreas was present in three of the 1 1 patients with gallstone pancreatitis (27.3%) but in only six cases of all other types of pancreatitis (8.3%). Two patients with histories of previous pancreatitis had pancreatic ductal calcifications demonstrated on CT scans. The patients were divided according to the five grades, and the melationships between different grades and the clinical course and prognostic signs were analyzed. There were 12 patients (14.5%) in grade A, 19 (22.9%) in grade B, 17 (20.5%) in grade C, 12 (14.5%) in grade D, and 23 (27.7%) in grade E. CT and Clinical Course

I-

.4

The relationship between early CT findings and clinical course is summanized in Table 3. The average numben of fasting days (nothing by mouth) and days in the hospital comelated roughly with the severity of the initial CT findings. Exceptions to the general trend, however, occurred, with some patients in grade B requiring 4 weeks of hospitalization and some in grade D requiring less than 2 weeks of treatment. No patient with grade A pancreatitis was seriously ill, and all five patients who died because of local complications (abscesses) mitially had grade D or E pancmeatitis. Retropemitoneal, extraluminal air was seen in four patients (Fig. 5) who all proved at surgery to have infected

abscesses. In three cases, gas bubbles were detected on CT scans in patients with only one to three prognostic signs within the first 24 hours of hospitalization. Fluid collections were initially seen in 35 patients in grades D and E (or 45.7% of these combined grades). Follow-up CT scans showed that in 19 patients (54.3%), fluid collections mesolved without further complications, while in 16 patients (45.7%), they did not and eventually became infected. Fluid collections developed in only three patients who did not have them

initially and were classified as grade C pancreatitis. One of these patients ended up with a pseudocyst and two with abscesses. In 15 patients, the infected fluid collections were drained between the 5th and 50th day hospitalized after an average stay of 25 days.

.I

CT and
The findings shown between

Prognostic

Signs
early signs relationship prognostic CT is

relationship and in

between prognostic The of

Table 4. the number

770

#{149}

Radiology

September

1985

Figure

pa

signs and grades of pancreatitis varies widely in patients with zero to five prognostic signs. All patients with more than five prognostic signs were in grade E; however, a few patients with four and five signs were in grades A and B. When the number of patients with abscesses or those that died were analyzed as a function of combined CT findings and prognostic signs (Table 5), the complication rate and prognosis could be better assessed. The numben of patients with abscesses in grades C and D is significantly larger if the number of prognostic signs is higher. In addition, the percentage of deaths correlated well with the numbem of prognostic signs.

Secondary

CT Findings

.,

DISCUSSION
The
. -.

radiologic

features

and

role

of

CT

scanning

in

initial

diagnosis

of

.3

acute pancreatitis and its complications are well established in the literature (8-18). The CT appearance of clinical forms of mild (edematous, interstitial) or severe (necrotizing, hemomnhagic) pancreatitis has been descnibed (8, 19, 20). To our knowledge, however, a comprehensive evaluation of the prognostic value of the mitial CT examination based on clinical follow-up, surgical findings, and conrelation with prognostic signs has not been performed. This study attempts to fill this gap and establishes the value of CT scanning, not only in the initial diagnosis of pancreatitis, but as a prognostic indicator of the diseases severity and its expected complications.

Our search of the literature did not disclose a previous assessment of the secondary CT findings evaluated in this study. Fatty infiltration of the liven was seen in 21% of our patients (Fig. 3) and occurred about equally in patients with mild, moderate, or sevene pancreatitis. Gallbladders with thickened walls were seen in five cases (Fig. 5), and the significance is unknown since the condition was present in patients without clinical evidence of cholecystitis. It may mepresent nonspecific edema associated with alcoholic liver disease or nonspecific inflammation related to pancreatitis. Pleural effusions were larger and more commonly seen in patients with severe pancreatitis. In this series, they were present in 65% of grade E patients and in only 10% in grades A and B. Bilateral pleural effusions were seen almost exclusively in grade E patients. There was no correlation between the severity of pancreatitis and its cause in this series. Five of the 11 cases of gallstone pancreatitis were classified as grade E, while the other six were grade A, B, or C. While acute pancreatitis is generally considered a diffuse disease, in this series a segmental form of pancreatitis was observed in 18.1% of the cases. (Fig. 7). Specifically, the head of the pancreas was enlarged in a larger proportion of patients with gallstone pancreatitis (27.3%), compared with the proportion of the total series (8.3%).

tion can be established between the severity of pancreatitis, as determined at the initial CT examination, and the clinical course. We noted a steady trend toward an increased average number of fasting days and days hospitalized in patients with more severe grades of pancreatitis (Table 3). Five of six deaths and 88.8% of all abscesses occurred in patients initially classified as having grades D and E pancreatitis. No patients originally classified as having grade A or B pancreatitis had subsequent abscesses. All patients with a normal pancreas on CT scan (grade A) had a mild clinical course without complications and were discharged in less than 2 weeks. Although the clinical course was consistent with the grade of pancreatitis, some grade A patients may not have had pancreatitis at all. Therefore, the exact percentage of patients with acute pancreatitis and a normal CT scan is difficult to assess. This percentage depends mainly on the severity of acute pancreatitis and the time of the pected examination to vary from and should be series to series. ex-

CT and Abscesses

Development

of

CT and
The presented

Clinical

Course
statistical a clear data comrela-

survey of the shows that

A strong relationship exists between the initial presence of pemipancreatic fluid collections (grades D and E) and the development of abscesses. Abscesses occurred in 18 patients in this series (21 .7%), but they developed in only two patients without initial fluid collections. The presence of poorly encapsulated pemipancneatic fluid collections in
patients with acute pancreatitis

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771

should not be regarded casually. id collections resolved spontaneously in 54.3% of patients who had them

Flubut

Prognostic Clinical

Signs, Course

CT,

and

5.

lingered on and eventually became infected in the remaining 45.7%. Follow-up CT examinations should be performed in these patients to assess the presence, size, and location of these collections until they resolve. Previously, extravasated pancreatic secretions and the development of large pemipancreatic fluid collections were considered an escape mechanism, leading to a beneficial decompression of the pancreatic duct system (12). In our study, however, based on short-term CT and clinical follow-up evaluation, we failed to detect any advantages of large fluid collections for this group of patients. While we did not conduct long-term evaluations, we found that extravasated fluid was associated with a protracted and sevene clinical course. In patients without such fluid, the course of pancreatitis was mild or significantly shorten and less complicated. The diagnosis of abscess in most of our cases was based on the presence of a persistent fluid collection plus sepsis unresponsive to antibiotic themapy. Because of debris and necrotic tissue, the density of fluid collections was variable (5-30 HU) and not helpful in this diagnosis. The roles of percutaneous aspiration and drainage of pancreatic abscesses have been meported in the literature (21, 22), but these procedures were not used in this series. Retmopemitoneal air was seen in four patients, all of whom had proved abscesses at surgery. As reported in the literature (23, 24), fluid collections containing air may develop secondamy to entemic fistulas and may not always indicate an abscess. However, this CT finding, particularly when seen during the initial attack, strongly suggests a gas-forming infection and is extremely valuable in quickly identifying this potentially lifethreatening complication. In three patients, metropemitoneal aim visualized on CT scan in the first 24 hours led to a correct diagnosis that was not suspected clinically. Surgery was performed without delay, and all three patients survived.

The relationship between prognostic signs and severity of pancreatitis is documented in Table 2. Infected abscesses occurred with an increased incidence in patients with several prognostic signs. Abscesses were seen in 80.0% of patients with six to eight signs, compared with 12.5% of patients with zero to two signs. We found that using prognostic signs and CT findings led to a better estimation of the risk of death in this series. In grades A and B patients, none of the patients died, regardless of the numben of prognostic signs, which varied between zero and five. On the other hand, the mortality of patients initially classified as grades C, D, on E comelated with the increasing number of prognostic signs (Table 5). We conclude that initial CT examination in cases of acute pancreatitis is very helpful in establishing on confirming the clinical diagnosis, as well as in depicting associated abnonmalities. CT can also be used as an early indicator of the diseases severity and its expected morbidity and mortality. We found a good correlation between the grades of mild, moderate, or sevene pancreatitis as established by CT appearance and the clinical course, development of abscesses, and death. The use of objective prognostic signs with initial CT findings improves the original prognostic estimation and identifies patients in whom lifethreatening complications may develop. CT examinations should be penformed in all patients with moderate or severe clinical forms of pancreatitis to evaluate the presence and severity of the initial attack and to assess its clinical evolution. U
Send correspondence and reprint requests Emil Balthazar, M.D., NYU Medical Center, levue Hospital, Department of Radiology, Street and 1st Avenue, New York, New 10016. to: Bel27th York

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

Berry AT, Taylor TV, Davies CC. Diagnostic tests and prognostic indicators in acute pancreatitis. J R Coil Surg Edinb 1982; 27:345-52. Ranson JHC, Spencer FC. The role of peritoneal lavage in severe acute pancreatitis. Ann Surg 1978; 187:565-575. Ranson JHC, Rifkind KM. Turner JW. Prognostic signs and nonoperative peritoneal lavage in acute pancreatitis. Surg Gynecol Obstet 1976; 143:209-219. Hill MC, Barkin J, Isikoff MB, et al. Acute pancreatitis: clinical vs. CT findings. AJR 1982; 139:263-269. Silverstein W, Isikoff MB, Hill MC, Barkin J. Diagnostic imaging of acute pancreatitis: prospective study using CT and sonography. AJR 1981; 137:497-502. Mendez G Jr., Isikoff MB, Hill MC. CT of pancreatitis: interim assessment. AIR 1980; 135:463-469. Williford ME, Foster WLJr., Halvorsen RA, Thompson WM. Pancreatic pseudocyst comparative evaluation of sonography and computed tomography. AJR 1983; 140:5357. Siegelman 55, Copeland BE, Saba GP, et al. CT of fluid collections associated with pancreatitis. AJR 1980; 134:1121-1132. Jeffrey RB, Fedemle MP, Cello JP, Crass RA. Early computed tomographic scanning in acute severe pancreatitis. Surg Gynecol Obstet 1982; 154:170-174. Pningot J, Dardenne AN, Lousse JP, et al. Contribution of computed tomography in the diagnosis of severe acute pancreatitis. In: Hollender LF, ed. Controversies in acute pancreatitis. Berlin: Springer, 1981; 64-71. Dembner AG, Jaffee CC, Simeone J, Walsh J. A new computed tomographic sign of pancreatitis. AJR 1979; 133:477-479. Jeffrey RB, Federle MP, Laing FC. Cornputed tomography of mesentemic involve-

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1983; 147:185-188. Federle MP, Jeffrey RB, Crass RA, Dalsern vv. Computed tomography of pancreatic abscesses. AJR 1981; 136:879-882. Segal I, Epstein B, Lawson HL, et al. The syndrome of pancreatic pseudocysts and fluid collections. Gastrointest Radiol 1984; 9:115-122. Darnmann HG, Grabbe E, Eichfuss HP, Flashoff D. Computed tomography and clinical severity of acute pancreatitis. In: Hollender LF, ed. Controversies in acute pancreatitis. Berlin: Springer, 1981; 72-77. Kivisaari L, Somer K, Standertskjold-Nordenstam CC, Schroeder T, Kivilaakso E, Lempinen M. A new method for diagnosis of acute hemorrhagic-necrotizing pancreatitis using contrast-enhanced CT. Gas-

trointest
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Jacobs ML, Daggett WM, Civetta JM, et al. Acute pancreatitis: analysis of factors influencing survival. Ann Surg 1977; 185:43-51. Ranson JHC, Pastemnak BS. Statistical methods for qualifying the severity of clinical acute pancreatitis. J Surg Res 1977; 22:79-91. Ranson JHC. Etiological and prognostic factors in human acute pancreatitis: a meview. Am J Gastroenterol 1982; 9:633-638. McMahon MJ, Pickford IR, Playforth MJ. Early prediction of severity of acute pancreatitis using peritoneal lavage. Acta ChirScand 1980; 146:171-175.

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Hill MC, Dach JL, Barkin J, et al. Role of percutaneous aspiration in diagnosis of pancreatic abscess. AJR 1983; 141:10351038. Karlson KB, Martin EC, Fanuchen El. Percutaneous drainage of pancreatic pseudocysts and abscesses. Radiology 1982; 142:619-624. Alexander ES, Clark RA, Federle MP. Pancreatic gas: indication of pancreatic fistula. AJR 1982; 139:1089-1093. Torres WE, Clements JL Jr., Sones PJ, Knopf DR. Gas in the pancreatic bed withoutabscess. AJR 1981; 137:1131-1133.

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