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OConnor et al.
Imaging of Acute Pancreatitis
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Residents Section
Structured Review Article
Residents
inRadiology
Owen J. OConnor 1
Sebastian McWilliams1
Michael M. Maher 1,2
OConnor OJ, McWilliams S, Maher MM
WEB
This is a Web exclusive article.
AJR 2011; 197:W221W225
0361803X/11/1972W221
American Roentgen Ray Society
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OConnor et al.
pancreatitis is unreliable. It is estimated that
experienced clinicians predict which pa
tients will develop severe acute pancreati
tis in less than 40% of cases [8]. Examples
of clinical systems that have been developed
to more accurately and reproducibly grade
the severity of acute pancreatitis include the
Acute Physiology and Chronic Health Evalu
ation II (APACHE II), Ransons criteria, and
the Glasgow original and modified systems
[9, 10]. A Ransons score of 3 or more and
an APACHE score of 8 or more suggest the
presence of severe acute pancreatitis [10].
Scoring systems also help predict the likely
course of acute pancreatitis at the time of pre
sentation. This helps guide treatment-related
decision making, such as the necessity for ad
mission into an ICU or transfer to a tertiary
referral center [3]. The sensitivity and speci
ficity of the APACHE II system for assessing
severe acute pancreatitis at the time of admis
sion are 75% and 79%, respectively [11]. Clin
ical grading systems, such as the APACHE II
system, indirectly estimate the degree of pan
creatic damage. To directly evaluate and es
timate the degree of parenchymal injury and
to improve the early prognostic value of CT
in acute pancreatitis, the CT severity index
(CTSI) was developed [11]. The CTSI grades
acute pancreatitis into five levels of increasing
severity (A to E) using a 10-point scale. Points
are awarded on the basis of the presence of
pancreatic enlargement, fat stranding, and flu
id collections and the amount of pancreatic
necrosis. The CTSI is discussed in more de
tail in the systematic review of the complica
tions of acute pancreatitis in an upcoming is
sue of the AJR.
A new subgroup of acute pancreatitis has
recently been described, termed moderate
ly severe acute pancreatitis, consisting of
patients with local complications similar to
those with severe acute pancreatitis but low
er morbidity, which is believed to be due to
more transient organ dysfunction [12].
Disease Epidemiology
The incidence of acute pancreatitis is ap
proximately 570 cases per 100,000 per year
[13, 14]. Gallstones and alcohol are respon
sible for approximately 70% of cases [15].
Among patients with gallstones, acute pancre
atitis has a higher incidence in men than wom
en, but overall, gallstone acute pancreatitis is
most frequent in women (generally between
40 and 50 years old) [16]. Gallstones and al
cohol have been implicated in the develop
ment of recurrent attacks of acute pancreati
W222
Causes
Mechanical
Metabolic
Drugs
Infections
Vascular
Idiopathic
Fig. 1CT in 54-year-old man with abdominal pain and raised serum amylase 3 days after blunt abdominal
trauma.
A and B, CT images show disruption and discontinuity of pancreatic neck (arrow, A) and extensive stranding of
retroperitoneal and intraperitoneal fat (arrowhead, B).
Indications
1. When the diagnosis of acute pancreatitis is uncertain
2. Patients with hyperamylasemia, severe clinical pancreatitis, abdominal distention
and tenderness, fever > 102, and leukocytosis for the detection of complications
3. Ranson score > 3 or APACHE score > 8
4. Patients who fail to improve after 72 hours of conservative medical therapy
5. Acute change in clinical status, such as new fever, pain, and shock after
successful initial medical therapy
Delayed CT
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Fig. 2CT of 35-year-old man with acute-on-chronic pancreatitis due to alcohol abuse.
A, Control phase CT image shows several calcifications in head of pancreas (arrowhead) suggesting chronic
pancreatitis.
B, Contrast-enhanced CT image (pancreatic parenchymal phase) shows heterogeneous enhancement of
pancreas, and pancreatic head appears edematous with associated stranding of peripancreatic fat. There are
small peripancreatic fluid collections (acute pancreatic fluid collections) (arrowhead).
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OConnor et al.
W224
Conclusion
Imaging plays an important role in the
management of the patient with acute pan
creatitis. CT in particular has revolutionized
pancreatic imaging, and what was once con
sidered a hidden organ may now be accurate
ly and noninvasively imaged.
References
1. Millar FH, Keppke AL, Balthazar EJ. Pancreati
tis. In: Gore GM, Levine MS, eds. Textbook of
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