CT maging of Acute

Pancreatitis
Erin Rikard
Radiology
December 2007
utline
Definition
Epidemiology
Causal Factors
Pathophysiology
CT Evaluation and Findings Normal and
abnormal
Complications
Management
Prognosis
Definition
Definition
5idemioIogy
Epidemiology
79.8/100,000 per year 185,000 new
cases annually in U.S.
Peak incidence in 6
th
decade
CausaI Factors
Causal Factors
Etiology ncidence
Cholelithiasis 30-60%
Alcohol 15-30%
atrogenic 2-5%
Trauma/Surgery --
Metabolic Disorders --
Viral nfection --
!atho5hysioIogy
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 2
nd
portion of duodenum

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50 year-oId woman
CT scans of normal kidneys and pancreas
Spleen
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Kidney
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Kidney
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Stomach
Liver
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;aIuation by CT
Evaluation of Acute Pancreatitis
Contrast-enhanced CT is imaging modality
of choice
ral and V contrast differentiate
pancreatic tissue from adjacent blood
vessels and duodenum
Recommendations for Contrast-
Enhanced 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
nitial improvement with later deterioration
Ranson Criteria
At admission
Age > 55
WBC > 16,000
Blood glucose > 200
Serum AST > 250
Serum LDH > 350
After 48 hours
Hematocrit > 10%
BUN < 1.8 after
rehydration
Serum calcium < 8.0
P2 < 60
Base deficit > 4
Estimated fluid
sequestration > 6L
Abnormal CT
Findings
!eri5ancreatic infIammation
Diffuse or focaI 5ancreatic edema
!oor definition and heterogeneity of
gIand
FIuid coIIections
Necrosis
Thickening of 5ararenaI fascia
Abnormal CT Findings
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 nflammation/
Pancreatic Edema/
Fluid Collections
Transverse CT scan obtained with intravenous and oral contrast material reveals a
large, edematous, homogeneously attenuating (73-HU) pancreas 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). = liver (140 HU).
aIIstone-induced 5ancreatitis in 27 year-oId woman

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nfection?
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
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47-year-oId man with se;ere 5ancreatitis
Fluid collection replacing pancreatic body and tail
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47-year-oId man with se;ere 5ancreatitis
47 47- -year year- -old man with severe pancreatitis who had true old man with severe pancreatitis who had true- -positive finding for positive finding for
infection on gallium study. Fusion image of CT scan and gallium study was infection on gallium study. Fusion image of CT scan and gallium study was
helpful in localizing infection. helpful in localizing infection.
Necrosis
57-year-oId man with acute necrotizing 5ancreatitis and se;ere back 5ain
Large region of unenhancement (necrosis) involving most of body and tail of
pancreas. nflammatory fluid is present in anterior pararenal space. Note
ascites around liver.
50 year-oId woman with acute 5ancreatitis (1st ;iew)
(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). = liquefied gland necrosis, $ = stomach.

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(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, = liquefied gland necrosis.
50 year-oId woman with acute 5ancreatitis (2
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;iew)

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Com5Iications
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
ccurs 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-oId man with 5seudocyst
mage 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.
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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.
44 year-oId man with acute abdominaI 5ain - hemorrhagic 5seudocyst
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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
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!ancreatic abscess containing gas in 54-year-oId man
Large fluid collection containing gas bubbles in pancreatic bed due to
abscess complicating acute pancreatitis. Note infiltration of
peripancreatic fat and calcified gallstones.
Hemorrhagic !ancreatitis
Rare
Noted cIinicaIIy by in
hematocrit
CT scan demonstrates hemorrhagic pancreatitis as a heterogeneous mass in
the area of the pancreatic bed (*). Arrow indicates active extravasation
(hemorrhage).
70 year-oId woman with hemorrhagic 5ancreatitis
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Splenic Artery Pseudoaneurysm
Presents similarly to hemorrhagic
pancreatitis with a in hematocrit
Axial CT scan with intravenous contrast material reveals a
pseudoaneurysm (arrow) projecting from the splenic artery.
!seudoaneurysm
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anagement
Management
Acute pancreatitis usually self-limited
nflammation within 3-7 days in 90% of
cases
Medical therapy
Analgesics
V hydration
Decrease P intake Decreased
pancreatic secretion
Antimicrobials in severe necrotizing
pancreatitis
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
Management
!rognosis
Prognosis
Mortality over last 20 years
5% for all cases
20% for severe cases
Reasons for Reduced Mortality
nitially - Recognition and application of
severity signs
1990s More selective endoscopic or
surgical debridement of infected tissue,
endoscopic cyst drainage, and
angiographic control of G bleeding
Later mproved 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 ver the Past
20 Years. Journal of Clinical Gastroenterology. 2002 July; 35: 50-
60.
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: nitial bservations. 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: 901-
913.
Resources Continued
Gunderman, Richard B. ssential Radiology. 1998.
Greenberger, Norton J. and Phillip P. Toskes. "Acute and Chronic
Pancreatitis. Harrison's Internal Medicine.
Mitchell, RM, MF Byrne, and J. Baillie. "Pancreatitis. Lancet. 2003
Apr 26; 361: 1447-1455.
Novelline, Robert A. $6uire's Fundamentals of Radiology. 6
th
ed.
2004.
Pretorius, E. Scott and Jeffrey A. Solomon. Radiology $ecrets. 2
nd
ed. 2006.
Ranson, JH, et al. "Prognostic Signs and the Role of perative
Management in Acute Pancreatitis. $urgery, Gynecology, and
Obstetrics.
Tang, Linda J., Stan Zipser, and Young S. Kang. "Temporary
Spontaneous Thrombosis of a Splenic Artery Pseudoaneurysm in
Chronic Pancreatitis During ntravenous ctreotide 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.