MultimodalityImagingin

AcutePancreatitis
MarshaLynch,HMSIII
GillianLieberman,MD
BIDMCCoreClerkshipinRadiology
March2009
OurPatientR:Introduction
52Mwith10dhistoryofnausea,vomitingand
abdominalpain.
PatientR:InitialPresentation
PRESENTATION
WBC19.1
ARF:Cr3.2(baseline1.2)
BG:235
Lipase:2211(060)
Amylase:804(0100)
ALT:10AST:9AP:79
Ca:7.9(8.410.2)
TGs:511(0149)
PMH
HTN
Hyperlipidemia
Congenitaldeafness
Gout
Obesity
PatientRdemonstratesatypical

presentationofacute

pancreatitis
AcutePancreatitis:Pathophysiology
INFLAMMATIONOFTHEPANCREAS
Inappropriateactivationofpancreaticenzymes
Intraparenchymal

andextraparenchymal

extravasation

ofenzymescauseautodigestion

ofpancreatic

parenchymaanddamagetoperipancreatic

tissuesand

vascularnetwork
Inflammatoryresponsetothisinjuryoutofproportion

tothatofotherorganstoasimilarinsult
Inflammatoryresponsecausesfurtherdamage
Fluidsequestration,fatnecrosis,vasculitis

leadingto

occlusionsandthrombosis,hemorrhage
Whitcomb, D C, Acute Pancreatitis. N Engl J Med 2006
Balthazar, E J, Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation. Radiology 2002
AcutePancreatitis:Etiologies
EtiologiesofAcutePancreatitis
Mechanical Gallstones(>45%),sludge,pancreaticmass,ampullary

stenosis

or

mass,duodenalstrictureorobstruction
Toxic Alcohol(>35%),methanol,steroids/drugs,scorpionvenom
Metabolic Hyperlipidemia,hypertriglyceridemia,hypercalcemia
Trauma Bluntorpenetrating,ERCP,s/p

abdominalsurgery
Infection Viral(mumps),parasitic,bacterial
Vascular Ischemia,embolism,vasculitis
Congenital Pancreasdivisum
Genetic CFTRmutation
Miscellaneous Autoimmune,renaltransplant,alpha1antitrypsindeficiency
Adapted from etiology of acute pancreatitis; Up-To-Date
AcutePancreatitis:Epidemiology
>200,000UShospital

admissionyearly
20%haveasevere

course
Associatedwithsystemic

andlocalcomplications

andincreasedmortality

(1030%)
SevereCourse
SYSTEMIC
COMPLICATIONS
Shock
DIC
Pulm.Insufficiency/ARDS
LOCALCOMPLICATIONS
Necrosis
Abscess
Pseudocyst
Pseudoaneurysm
Splenic

veinthrombosis
AcutePancreatitis:Severity

Assessment
Severityofacutepancreatitisiscommonlyassessedusing:
1.

RansonsCriteria
5clinicalsignsatpresentationand6at48hrs


3associatedwithseverecourse(systemiccomplicationsand/or

pancreaticnecrosis)
2.

APACHEII
12routinephysiologicmeasurement,ageandprevioushealthstatus


8associatedwithseverecourse
3.

CTSeverityIndex(CTSI)
Basedonextentofinflammationandpresenceofcomplicationson

CTscan.
Letsbrieflyreviewtheanatomy

ofthepancreas
PancreasAnatomy
Retroperitoneal organ stretching from
the curvature of the duodenum to the
spleen. Rich arterial supply from
vessels off the celiac artery superiorly
and the SMA inferiorly. Glandular
tissue with both endocrine and
exocrine function.
http://www.fairview.org/healthlibrary/content/pancreas.gif
PancreasAnatomy:AxialCTView
Image from: PACS, BIDMC
pancreas
pancreas
Companion Patient 1: Delayed Phase Axial CT
AcutePancreatitis
CLINICALDIAGNOSIS
Abdominalpain
Nausea/Vomiting
ElevatedPancreatic
Enzymes
MANAGEMENT
BowelRest/NPO
IVF
Analgesics
http://www.fairview.org/healthlibrary/content/pancreas.gif
Thediagnosisofpancreatitisislargelya

clinicalonebasedonphysicalsignsand

symptomsaswellasserumlevelsof

pancreaticenzymes.

WhatthenistheroleofRadiologyinits

management?
RoleofRadiologyinAcutePancreatitis
Ruleoutotherintraabdominalconditionsas
causeofabdominalpainorothersymptoms
Bowelobstruction,infarctionorperforation;acutecholecystitis;

appendicitis
ConfirmdiagnosisandIdentifycauses(e.g.
gallstones)
Evaluateandstagelocalpancreaticmorphology
Identifyandmanagecomplications
MenuofTests:US,PlainFilm,CT,MR
BacktoOurPatientR
PatientR:Ransons

Criteria
Ransons Score 3(Threshold)
AtPresentation
Age>55
BG>200
WBC>16,000
LDH>350
ALT>250
Within48Hours
Hct

>10%decrease
SerumCa<8
BaseDef>4
BUN>5increase
FluidSequestration>6L
PaO
2

<60
PATIENTXPRESENTATION
WBC19.1
BG235
Age52
ALT10
LDH15
Wearelessconcernedaboutourpatient

progressingdownanmoreseverepathbased

onhimhavingonly2/5Ransonscriteriaat

presentation.
However,wecanuseradiologytoassess

whetherhisacutepancreatitisisduetoone

ofthecommonestetiologies:gallstones.
Wethereforeproceedtoabdominal

Ultrasound
UseofAbdominalUltrasoundin

AcutePancreatitis
Indicatedearlyinacutepancreatitis
Pros
Inexpensive
Excellentforidentifyinggallbladderpathology,sludgeandgallstones

(Mostcommoncauseofpancreatitis!)
Evaluatebileductdilation
Mayvisualizemassesand

followupofpseudocyst
Cons
Notoptimalforpancreas;retroperitoneallocationeasilyobscuredby

bowelgasdistension
LesssensitiveforstonesindistalCBD
Limitedinearlyassessmentofpancreatitis
Balthazar, E J, Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation. Radiology 2002
PatientRAbdominalUS:Liver,GB
Image from: PACS, BIDMC
Gallbladder:
anechoic cystic
region with
increased through-
transmission
Liver parenchyma: no gross
intra-hepatic ductal dilitation
Abdominal Ultrasound: RUQ
PatientRAbdominalUS:GB
Image from: PACS, BIDMC
Absence of
hyperechoic foci
Non-distended GB with
normal wall thickness
No signs of acute cholecyctitis: lack of gallbladder wall
thickening, pericholecystic fluid or cholelithiasis
Abdominal Ultrasound: RUQ
Happily,oursuspicionofgallbladder

pathologyasthecauseofourpatientRs

acutepancreatitisisnowgreatlylowered.
Sowecontinuesupportive

managementwithbowelrest,IVF

andanalgesics.
OnHospitalDay5
ourPatientRdevelopsbowel

distensionandabdominalpain.
Weproceedimmediatelyto

AbdominalPlainFilm
UseofAbdominalPlainFilmin

AcutePancreatitis
Pros
Screen

for/excludeseparateoraccompanyingabdominalprocess
Signsofperitonitisorbowelischemia
Freeair
BowelObstruction
Ascites
Inexpensive,readilyavailableandfast
Cons
Poorvisualizationofthepancreasandretroperitoneum
Mayseecalcificationsduetochronicprocess
PatientR:

Abdominal

PlainFilm

HD5
Image from: PACS, BIDMC
residual contrast in asc.
and desc. colon
----- isolated segments of
dilated sm. bowel, up to
3cm luminal diameter
Transverse colon shows no
marked distention but with
no contrast
Abdominal Plain Film: Supine
spasm of the desc.
colon just distal to splenic
flexure
PatientR

Abdominal

PlainFilm

HD5
Image from: PACS, BIDMC
Abdominal Plain Film: L Lat Decubitus
Air fluid levels
Thepresenceofdistensioninthealongwith

airfluidlevelsconcernusforsmallbowel

obstruction.Wedecidetocloselyfollowour

patient.
OnHospitalDay6
Ourpatienthasworsening

abdominalpainanddistension.We

quicklyperformarepeatabdominal

plainfilm.
PatientX

Abdominal

PlainFilm

HD6
3.3 cm
8.5 cm
Distended stomach
Increased focal
distension of
small bowel
Abdominal Plain Film: Supine
Image from: PACS, BIDMC
Marked distension of
transverse colon, still
with no contrast in
lumen.
arrest of contrast (2 days)
Wearecertainlymoreconcernedabout

obstructionnow.Beforewecontinue,lets

reviewsomepossiblecausesofobstructionin

thispatient.
PossibleCausesofBowel

ObstructioninOurPatientR
Functional
Focalileus/Sentinelloops(Transversecolonand

segmentsofsmallbowel)duetoadjacent

pancreaticinflammatoryprocess
Mechanical
Pancreaticmass
Developingfluidcollectionsorpseudocyst
GBunseenonU/S
Wearemoreconcernedaboutyetunseen

causesofanymechanicalobstruction.

WenowproceedtoAbdominalCTtofurther

evaluatethecauseoftheincreasing

abdominaldistensionandtohaveabetter

lookattheinflamedpancreas.
UseofAbdominalCTinAcute

Pancreatitis
Pros
ReadilyavailableandFast
Aidindiagnosisandstagingofpancreatitis
Depict,

quantifypancreatic

parenchymal

injury
Abilitytoassessthepresenceorabsenceof:
Edema(focalordiffuse)
Peripancreatic

fluidandinflammation
Fluidcollections
Pseudocysts
Necrosis
Evaluatecommonbileductforstonesorotherobstructions
Cons
OurPatientRisinARFandthismaybeexacerbatedbyIVcontrast

administration
PatientRDelayedPhaseaxialCT:

Suprapancreaticfluidcollection
Image from: PACS, BIDMC
4x7cm fluid
collection just
superior to
the pancreas
Delayed Phase CT: Axial
Normalvs.AcutePancreatitis
Images from: PACS, BIDMC
Acute pancreatitis: swollen, edematous gland with
indistinct edges blurred into those of surrounding
structures
Axial Delayed Phase CT: Companion Pt. 1 Axial Delayed Phase CT: Patient R
Normal pancreas: Fluffy, macronodular gland
texture distinct from surrounding organs
PatientR:AbdominalCT

peripancreatic

fatstrandingand

patentsplenic

vein
peripancreatic fat stranding
patent splenic vein
Axial Delayed Phase CT: Patient R Axial Delayed Phase CT: Patient R
Images from: PACS, BIDMC
PatientRAbdominalCT:Focal

TransverseIleus

andArrestof

Contrast
arrest of contrast
adynamic transverse colon
Axial Delayed Phase CT: Patient R Axial Delayed Phase CT: Patient R
Images from: PACS, BIDMC
PatientRAbdominalCT:

Suspicioushyperattenuating

lesion
There is a round
hyperdensity
measuring 1.4cm with
similar attenuation as
the adjacent aorta.
We can also visualize
the IVC posterior and
the GDA adjacent
and just superior to
the lesion.
This could represent:
1.Pseudoaneurysm of
GDA
2.Gallstone
3.Reactive lymph
node.
Image from: PACS, BIDMC
Delayed Phase CT: Axial
WhatNow???

Weneedtofurtherexplorethislesionasour

laststudywaslimitedbythelackofbotha

noncontrastandarterialphase.

Luckily,wehaveanothertoolinourarsenal.
UseofMRinAcutePancreatitis
Increasinglyusedindiagnosisandmanagementofacutepancreatitis
Pros
NoninvasiveandnouseofIVcontrast
Abilitytobettercharacterizefluidcollections(acutecollectionvs.

abscess,necrosis,hemorrhage,pseudocyst)
Abilitytodelineatepancreaticandbileducts(detect

choledocholithiasis

missedonU/S)andothercomplications

comparabletoERCP
Greatersensitivityvs.CTindetectingmildpancreatitis
Cons
Expensiveandinmanylessseverecasesnotnecessaryfordiagnosis

andmanagement
Lessreadilyavailableinnontertiarymedicalcenters
PatientR:AbdominalMR
Image from: PACS, BIDMC
T2 MRI: flow-void sequence
Our lesion has
high signal
distinct from the
absence of signal
(flow-void
sequence) in the
other three
vessels of
interest: GDA,
IVC and aorta.
In particular, the
lesion is distinct
from the GDA,
significantly
reducing our
suspicion for
pseudoaneurysm.
PatientR:HighsignallesiononMR
In this sequence,
gallstones would
demonstrate no
signal and our
lesion is
consistent with a
reactive lymph
node.
Image from: PACS, BIDMC
T2 MRI: flow-void sequence
PatientR:ComparisonofCTversus

MRIfindings
The suspicious lesion on CT was further evaluated on MR and found to
be benign consistent with a reactive lymph nose Images from: PACS, BIDMC
T2 MR: flow-void sequence
Delayed Phase CT: Axial
AwordaboutPleuralEffusions
PleuralEffusions:acommon

complicationofAcutePancreatitis
Approx. 1/3 patients with acute pancreatitis will have will
have abnormal CXRs. The typical findings include
elevated hemidiaphragm, pleural effusions, atelectasis and
in more severe cases ARDS
Patient R: Delayed Phase CT
Low lung volumes,
Bibasilar atelectasis and
pleural effusions
Images from: PACS,
BIDMC
Patient R: Frontal CXR
Patient R: Lateral CXR
PatientR:RemainingCourse
HD6
EmesisandlargeBMthatlargelyrelievedabdominalpain
StartedonTPN
Dietslowlyadvanceduntiltoleratedregulardiet
Continuedonsupportivemeasuresaslabs

normalizedandsymptomsresolved
DischargedtoHomeonHD16
PatientRRemainingCoursecontd
PRESENTATION
WBC19.1
ARF:Cr3.2(baseline1.0)
BG:235
Lipase:2211(060)
Amylase:804(0100)
ALT:10(040)
AST:9(040)
AP:79(39117)
Ca:7.9(8.410.2)
TGs:511(0149)
DISCHARGE
WBC7.4
Cr0.9
BG:95
Lipase:59*(060)
Amylase:50*(0100)
ALT:18
AST:29
AP:79*
Ca:8.7(8.410.2)
TGs:112(0149)
* Last labs drawn before date of discharge
Summary
AcutePancreatitisisacommonillnesswith

manypotentialhighlymorbidcomplications.
Manycasesarediagnosedclinicallyand

managedsupportivelywithbowelrest,

aggressivefluidadministrationsandanalgesics.
Radiologyplaysimportantroleinconfirming

diagnoses,evaluatingseverityandidentifying

andmanagingcomplicationsofacute

pancreatitis.
References
Whitcomb,DC,AcutePancreatitis.NEngl

JMed

2006;354:214250.
Balthazar,EJ,AcutePancreatitis:Assessmentof

SeveritywithClinicalandCTEvaluation.Radiology

2002;223:603

613
Textbook of Gastrointestinal Radiology /
[edited by] Richard M. Gore, Marc S. Levine.
London : W. B. Saunders Co., c2000.
Up-To-Date, Clinical manifestations and
diagnosis of acute pancreatitis, etiologies of
acute pancreatitis
Acknowledgements
ErnestYeh,MD
MariaLevantakis,CourseCoordinator
GillianLieberman,MD