Abdominal Imaging • Original Research

Lenhart and Balthazar

MDCT of Nonnecrotizing Pancreatitis

Abdominal Imaging
Original Research

MDCT of Acute Mild

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(Nonnecrotizing) Pancreatitis:
Abdominal Complications and
Fate of Fluid Collections
Dipti K. Lenhart 1 OBJECTIVE. The objective of our study was to describe the occurrence of local compli-
Emil J. Balthazar cations and the fate of fluid collections in milder forms of acute nonnecrotizing pancreatitis.
MATERIALS AND METHODS. Initial MDCT studies of 169 consecutive patients
Lenhart DK, Balthazar EJ with mild acute pancreatitis and 203 follow-up CT examinations were reviewed. The fate of
peripancreatic fluid collections was investigated, and the incidence and type of local compli-
cations were recorded and correlated to the CT grading system (A–E).
RESULTS. Complications developed in nine of 169 patients, for an incidence of 5.3%. All
morbidity occurred in the subgroup of 73 patients with initial fluid collections, for an inci-
dence of 12.3%. Follow-up CT examinations available in 51 of these 73 patients documented
rapid fluid resolution in 35 cases (68.6%) and persistence of fluid more than 2 weeks from
onset in seven asymptomatic patients (13.7%). Acute, life-threatening complications (hemor-
rhage, infection, perforation) occurred in five patients, for an incidence of 6.8% among the 73
patients with initial fluid collections, or 3.0% in the entire group of 169 patients. Five patients
developed acute pseudocysts. Long-term follow-up studies discovered two patients with
chronic pancreatitis and one with groove pancreatitis.
CONCLUSION. A small number of acute, life-threatening abdominal complications
and chronic complications are expected to occur in patients with milder forms of acute non-
necrotizing pancreatitis presenting with fluid collections. In these patients, clinical monitor-
ing and repeated imaging studies are recommended to document the resolution of fluid or the
development of complications.

Keywords: abdominal imaging, acute pancreatitis,
MDCT, pancreas
DOI:10.2214/AJR.07.2761
Received June 21, 2007; accepted after revision
September 28, 2007.
1
Both authors: Department of Radiology, NYU School
of Medicine–Bellevue Hospital Center, 462 First Ave., NB
3W33A, New York, NY 10016. Address correspondence
to D. K. Lenhart (dipti.kandlikar@med.nyu.edu).
CME
This article is available for CME credit.
See www.arrs.org for more information.
AJR 2008; 190:643–649
0361–803X/08/1903–643
© American Roentgen Ray Society
A
cute pancreatitis is a common dis-
ease in the developed world that
is characterized by a diffuse in-
flammatory process affecting the
pancreas and triggered by the leakage and ex-
travasation of activated pancreatic secretions.
Acute pancreatitis leads to a wide range of lo-
cal and systemic pathophysiologic alterations
and to a large variability in the clinical mani-
festation and prognosis [1–5]. For clinical
purposes, a useful simplified classification of
acute pancreatitis was proposed by the Atlanta,
Georgia International Symposium on Acute
Pancreatitis [6, 7].
According to this classification system, an
acute attack of pancreatitis is divided into two
major clinical forms: First, mild acute pan-
creatitis occurring in approximately 80% of
patients has no CT evidence of necrosis, ex-
hibits minimal or no distal organ dysfunction,
and shows rapid recovery without complica-
tions. It is a self-limiting disease previously
called “edematous” or “interstitial” pancreati-
tis. Second, severe acute pancreatitis, also
called “necrotizing pancreatitis;” occurs in
approximately 20% of patients; shows CT
evidence of parenchymal necrosis (lack of en-
hancement); and exhibits systemic manifesta-
tions, distal organ failure, a protracted clinical
course, and an increased incidence of morbid-
ity and mortality [6, 7]. Indeed, most patients
who develop local complications have necro-
tizing pancreatitis [8–11]. The mortality inci-
dence is less than 1% in mild pancreatitis,
with a striking increase to 10–23% in the
presence of pancreatic necrosis [3, 10, 11].
Furthermore, more than 50% of deaths do not
occur immediately, but rather within a few
weeks after an acute episode secondary to ab-
dominal complications and occur mainly in
patients with pancreatic necrosis [1, 11]. This
clinical classification emphasizes the impor-
tance of pancreatic necrosis as a predictive
indicator, while overlooking intermediary
forms of disease presenting with fluid collec-
tions but without necrosis.

AJR:190, March 2008 643


The purpose of this retrospective study was
to estimate whether and to what degree milder
forms of pancreatitis without necrosis contrib-
ute to the development of local abdominal
complications. We attempted to determine the
fate and outcome of extravasated peripancre-
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atic fluid collections and to assess the incidence
and type of local morbidity and patient out-
come as correlated with the CT grading scale
[12] in patients without pancreatic necrosis.
Materials and Methods
Subjects
A retrospective review of CT scans obtained in
patients with acute pancreatitis presenting to either
of our institution’s two large tertiary care centers
over a 2-year period (April 2004–April 2006) was
undertaken according to a protocol approved by our
institutional review board; patient informed consent
was waived. We identified 233 patients with acute
pancreatitis in our radiology database. By review of
their images, 28 patients were excluded because of
the presence of pancreatic necrosis (on either initial
or follow-up CT scans) and an additional 36 patients
were excluded because of either concomitant tumor,
complications from prior episodes of pancreatitis,
motion or streak artifacts on the CT scan that
limited evaluation, or unenhanced scans. A total
of 169 patients with acute mild (nonnecrotizing)
pancreatitis were included in our study. Clinical
staging criteria (Ranson’s signs [13]) were not used.
In addition to the 169 initial CT scans obtained
within 24 hours of patient presentation to the hospital,
we reviewed 203 follow-up CT examinations, for a
total of 372 studies or an average of 2.2 examinations
per patient. Among the 169 initial episodes, 82
patients (48.5%) had follow-up examinations, for an
average of 3.5 scans per patient in this subgroup. The
follow-up time ranged from 4 to 880 days, with an
average time to final CT examination of 124 days.
Seventy-three percent of patients with follow-up
studies underwent their first follow-up CT within 60
days of their initial CT examination.
Our series of 169 subjects was composed of 93
males and 76 females with an age range of 11–90
years (average age, 49 years). The cause of
pancreatitis was gallstones in 57 patients, alcohol
in 44 patients, gallstones and alcohol combined in
nine patients, other causes (including hyperlipidemia,
lupus, pancreas divisum, and post-ERCP) in 10
patients, and unknown in 49 patients.
CT Technique
Initial CT examinations were performed on
a 16-MDCT scanner (Sensation 16, Siemens
Medical Solutions) in 103 patients and on a
4-MDCT scanner (LightSpeed, GE Healthcare) in
66 patients.
644 AJR:190, March 2008
Lenhart and Balthazar
TABLE 1: CT Grading of Acute
Pancreatitis
Grade CT Finding
A Normal pancreas
B Enlarged edematous pancreas
C Pancreatic and peripancreatic
inflammation (peripancreatic
stranding)
D Single small peripancreatic fluid
collection
E Large or several fluid collections or
retroperitoneal air
One hundred twenty-five patients (74%) were
clinically suspected to have acute pancreatitis and
were scanned using our institution’s two-phase
acquisition pancreatic protocol. These patients
were instructed to drink 500 mL of water for
negative opacification of the gastrointestinal tract
immediately before imaging. The initial pancreatic
phase (late arterial dominant phase) of the
examination was performed over the upper
abdomen from T11 to L3 vertebral body levels
with a scanning delay of 40 seconds after the start
of IV administration of 1.5 mL/kg of contrast
material (300 mg I/mL, Ultravist [iopromide,
Bayer HealthCare] or Omnipaque [iohexol, GE
Healthcare]) at an injection rate of 4 mL/s. On the
16-MDCT scanner, the images were acquired at
120 kVp with a detector row configuration of 16 ×
0.75 mm and a table speed of 9.0 mm per rotation
with a reconstructed slice thickness of 3 mm. On
the 4-MDCT scanner, the images were acquired at
120 kVp with a detector row configuration of 4 ×
1.25 mm and table speed of 7.5 mm per rotation
with a reconstructed slice thickness of 2.5 mm.
The second portal-dominant phase of the
examination was performed from the diaphragm to
the symphysis pubis at an 80-second scanning
delay. On the 16-MDCT scanner, the images were
acquired at 120 kVp with a detector row configuration
of 16 × 1.5 mm, table speed of 18.0 mm per rotation,
and reconstructed slice thickness of 4 mm. On
the 4-MDCT scanner, the images were acquired at
120 kVp with a detector row configuration of 4 ×
2.5 mm, table speed of 15 mm per rotation, and
reconstructed slice thickness of 5 mm.
Forty-four patients (26%) were scanned using a
single-phase portal venous acquisition with an 80-
second scanning delay at an IV contrast injection
rate of 3 mL/s, using the same CT scanner
parameters as the second phase of the pancreatic
protocol. These patients drank 1.5 L of diluted
(2%) water-soluble contrast material (Gastrografin
[meglumine diatrizoate], Bristol-Myers Squibb)
beginning 1 hour before imaging.
Data Analysis
Reconstructed axial images were reviewed on
our PACS workstation (either PACS MagicView
1000, Siemens Medical Solutions; or Philips
PACS, Philips Medical Systems) and thinner
collimation and coronal or multiplanar reformation
were performed if needed. All images were
reviewed together by two radiologists, one with 40
years of experience in abdominal imaging and the
other a radiology resident, both of whom were
blinded to clinical follow-up information.
The initial episodes of pancreatitis were
stratified into five groups (grades A–E) according
to the previously described CT grading scale [12]
(Table 1). The follow-up studies were evaluated
for the number and type of local complications,
including pseudocysts, hemorrhage, infection, bowel
perforation, venous thrombosis, pseudoaneurysm,
and chronic and groove pancreatitis. The
complications were correlated with the initial CT
grade. Fluid collections that develop immediately
after an episode of pancreatitis due to leakage of
pancreatic secretions define grades D and E
pancreatitis. These are ill-defined nonencapsulated
collections to be distinguished from pseudocysts,
which are completely encapsulated fluid collections
that develop more than 4 weeks after the initial
episode of pancreatitis [6, 7].
A two-tailed Fisher’s exact test was used to
compare the difference in complication rate
between each grade of pancreatitis. It was assumed
that those patients without follow-up examinations
who clinically improved and became asymptomatic
did not develop complications. We reviewed our
hospital’s clinical electronic data repository for
follow-up findings, need for surgical intervention,
and final clinical outcome.
Results
Among the 169 attacks of acute pancrea­
titis, follow-up CT examinations depicted
local complications in nine patients, for an
overall incidence of 5.3%. There were a total
of 16 complications, with three patients show-
ing multiple complications. The number and
percentage of patients with complications,
number of complications, and number and
percentage of follow-up examinations were
calculated and correlated with the CT grad-
ing scale (Table 2). Follow-up CT examina-
tions were available for review in 48.5% of
the entire group and in 70% of patients pre-
senting with fluid collections (in 54.2% of
grade D and 100% of grade E patients). Lo-
cal complications occurred exclusively in
patients with fluid collections. The incidence
of complications among the 73 patients with
fluid collections was 12.3%, whereas no
 MDCT of Nonnecrotizing Pancreatitis

complications developed in the 96 patients
without fluid collections (Fig. 1). This inci-
dence of complications is based on clinical
evaluation and on CT follow-up studies in 51
of the 73 patients initially exhibiting peri-
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pancreatic fluid collections. A significantly
higher complication rate was seen in patients
with fluid collections (grades D and E) than
in patients without fluid collections (grades
A, B, and C) (p ≤ 0.001); indeed, no compli-
cations occurred in those patients without
fluid collections.
Follow-up CT studies in 51 of 73 patients
with retroperitoneal peripancreatic fluid col-
lections were available and revealed resolu-
tion of fluid within 2 weeks in 35 patients

TABLE 2:  Complications of Acute Pancreatitis in Patients Without Necrosis (68.6%), development of abdominal compli-
cations in nine patients (17.6%), and persis-
No. (%) of Patients with No. of Local No. (%) of Patients with
tence of unencapsulated or partially encap-
Grade No. (%) of Patients Local Complications Complications Follow-Up CT in ≥ 4 Days
sulated fluid collections in seven patients
A 12 (7.1) 0 (0) 0 1 (8.3) (13.7%) who were clinically asymptomatic at
B 24 (14.2) 0 (0) 0 11 (45.8) the time of hospital discharge (Fig. 2 and
C 60 (35.5) 0 (0) 0 19 (31.7) Table 3). Three of these seven patients were
lost to follow-up, whereas long-term clinical
D 48 (28.4) 6 (12.5) 7 26 (54.2)
follow-up in four patients with residual fluid
E 25 (14.8) 3 (12.0) 9 25 (100) collections revealed no complaints or abnor-
D and E 73 (43.2) 9 (12.3) 16 51 (69.9) mal physical findings.
Total 169 (100) 9 (5.3) 16 82 (48.5) The type and number of local complica-
tions in our series of 169 patients with acute
pancreatitis as correlated to the A–E grad­ing
Fig. 1—Development system are presented in Table 4. These com-
169 Patients of complications in
patients with and plications developed entirely in our patients
without peripancreatic with fluid collections (grades D and E). Acute
fluid collections on short-term life-threatening complications
initial CT examination.
(hemor­rhage, infection, or perforation) devel-
96 Patients 73 Patients oped in five of 73 patients with peripancreatic
No Fluid + Fluid fluid (6.8%), and chronic long-term morbidity
(A, B, C) (D, E) (chronic pancreatitis or groove pancreatitis)
31 had 51 had was seen in three of 73 patients (4.1%).
follow-up follow-up Among the 73 patients with initial fluid
CT CT collections, we detected five patients who de-
(32%) (70%) veloped single pseudocysts from 2 × 1 cm to
7 × 6 cm, for an incidence of 6.8% (Fig. 3).
No complications 9 complications Two of the pseudocysts developed hemor-
(0%) (12%) rhage and rupture with leakage of blood into

A B
Fig. 2—Grade E pancreatitis without necrosis in 24-year-old man.
A, Axial image from initial contrast-enhanced CT examination at admission shows multiple large peripancreatic fluid collections (arrows). Entire pancreatic gland shows
normal enhancement.
B, Axial image from last CT examination 27 days after A reveals development of 6 × 10 cm partially loculated fluid collection (arrows) in lesser sac, which may progress to
acute pseudocyst if it becomes fully encapsulated. Patient was lost to follow-up.

AJR:190, March 2008 645

 Lenhart and Balthazar

TABLE 3: Fate of Fluid Collections in 51 Patients with Follow-Up infection may develop [14]. In the initial 1–2
Examinations weeks after an acute attack, however, the natu-
No. (%) of Patients No. (%) of Patients with
ral evolution of sterile fluid collections remains
No. (%) of Patients with Local Partially Encapsulated or unpredictable, so we recommend that these
Grade No. of Patients with Rapid Resolutiona Complications Persistent Fluid collections be followed up with imaging ex-
D 26 18 (69.2) 6 (23.1) 2 (7.7) aminations in symptomatic patients.
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In our series of 169 patients, fluid collections

E 25 17 (68)
D and E 51 35 (68.6)
aWithin 2 weeks.
the peritoneal cavity (Fig. 4). One of these
patients also developed duodenal perforation
and required surgery, and the other recov-
ered without surgical intervention.
There were two other cases of acute retro-
peritoneal hemorrhage, for a total of four
cases of hemorrhage (5.5% in 73 patients
with fluid collections) (Fig. 5). One case of
duodenal perforation (1.4%) (Fig. 4), two
cases of infection (2.7%), and one case of
splenic vein thrombosis (1.4%) were also
diagnosed. Chronic pancreatitis developed
in two of 73 patients (2.7%) and groove pan-
creatitis in one patient (1.4%) on long-term
follow-up CT examinations. Two patients
with bleeding underwent diagnostic angiog-
raphy that was negative. Three patients with
complications, including hemorrhage, infec-
tion, and duodenal perforation, had surgical
interventions with drainage and débridement
and protracted clinical courses. All patients
in our series survived.
Discussion
The development of abdominal complica-
tions in patients with acute pancreatitis leads to
a prolonged hospitalization and, when life-
threatening and not detected in time, to an in-
creased mortality rate. Some of these compli-
cations may coexist, occur at any time after an
acute attack, and have different manifestations
and clinical repercussions. By and large, they
3 (12) 5 (20)
9 (17.6) 7 (13.7)
are closely related to the staging severity of an
acute attack of pancreatitis. Abdominal com-
plications occur predominantly between the
second and fifth week after one or several epi-
sodes of acute pancreatitis and with decreasing
frequency months to years later [14]. They are
mostly seen in patients with severe necrotizing
pancreatitis. However, a smaller number of pa-
tients with no CT evidence of pancreatic necro-
sis can manifest severe systemic alterations and
develop significant local complications. The
nature and incidence of complications in this
subset of patients, representing more than 80%
of cases of acute pancreatitis, have not received
much attention in the literature.
Digestion of the pancreatic gland or of peri-
pancreatic tissues after the leakage of activated
pancreatic secretions from acinar cells is re-
sponsible for the development of local compli-
cations [14]. Enzymatic fluid secretions dissect
fascial planes and have a deleterious effect on
vascular structures, adjacent hollow or solid
organs, and retroperitoneal fat, producing fat
necrosis. Extensive retroperitoneal fat necrosis
interferes with the rapid absorption of ex-
travasated, and sometimes hemorrhagic, fluid
collections. When these transitory collections
are not rapidly absorbed or continue to increase
in size, they tend to organize and loculate by
developing partial capsules. Because liquefied
necrotic tissue, blood products, and retained
fluid are excellent media for bacterial growth,
were detected in 73 patients (43.2%) and almost
totally resolved within 7–10 days in most pa-
tients. We were able to document resolution in
35 of the 51 patients (68.6%) in whom follow-up
CT studies were available for review (Table 3).
The remaining 22 patients in whom long-term
follow-up studies were not obtained all had
small fluid collections (grade D). These patients
had an uneventful clinical course and rapid im-
provement, and it may be presumed that be-
cause these patients remained asymptomatic,
their small fluid collections resolved as well.
The occurrence and fate of fluid collections
in acute pancreatitis have been previously re-
ported in a series of 48 patients with and with-
out pancreatic necrosis [15]. In that series,
fluid was found in 37% of patients. It resolved
spontaneously in about half the patients and
led to complications (pseudocyst, abscess, in-
fected necrosis) in the other half. As was also
seen in our collected data, the incidence of
spontaneous resolution of extravasated fluid is
substantially higher (70–80%) in patients
without pancreatic necrosis.
The overall incidence of acute and chronic
complications in our series of 169 acute at-
tacks of pancreatitis is 5.3%. As expected,
complications did not occur in the mild forms
of grades A, B, and C pancreatitis, but oc-
curred exclusively in the more severe forms,
grades D and E pancreatitis, after the extrava-
sation of pancreatic secretions. Even in this
subgroup of 73 patients with fluid collections,
the morbidity rate was relatively low in the
absence of pancreatic necrosis, with an inci-
dence of complications of 12.3%. Acute

TABLE 4:  Type, Number, and Incidence of Complications in 169 Patients with Acute Pancreatitis
Abscess or
Grade Pseudocyst Hemorrhage Infected Fluid Perforation Thrombosis Chronic Pancreatitis Groove Pancreatitis Total
A 0 0 0 0 0 0 0 0
B 0 0 0 0 0 0 0 0
C 0 0 0 0 0 0 0 0
D 3 2 1 0 0 1 0 7
E 2 2 1 1 1 1 1 9
D and E 5 4 2 1 1 2 1 16
Total 5 (3.0) 4 (2.4) 2 (1.2) 1 (0.6) 1 (0.6) 2 (1.2) 1 (0.6) 16 (9.5)
Note—Data are numbers of patients. Numbers in parentheses are percentages.

646 AJR:190, March 2008

 MDCT of Nonnecrotizing Pancreatitis
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A B
Fig. 3—Grade D pancreatitis without necrosis in 44-year-old man.
A, Initial contrast-enhanced axial CT image shows small fluid collection (arrows)
adjacent to tail of pancreas and in left anterior pararenal space. Entire pancreas
including tail (not shown) showed normal enhancement.
B, Axial CT image 2 months after A reveals development of 7 × 6 cm acute
pseudocyst (arrows) adjacent to tail of pancreas.
C, Axial CT image 2 years after A shows 5 × 4 cm pseudocyst (arrows) with
calcification in wall (arrowhead), indicating chronic pseudocyst.

A B
Fig. 4—Grade E pancreatitis without necrosis in 47-year-old man.
A, Axial image from contrast-enhanced CT examination performed 5 months after initial episode for abdominal pain and decrease in hematocrit level shows hemorrhagic
pseudocyst (white arrows) in wall of duodenum and leakage of blood (arrowheads) into peritoneal cavity. Additionally, small pseudocyst is present in head of pancreas
(black arrow).
B, Axial CT image 6 days after A shows that hemorrhagic pseudocyst (arrows) has eroded and perforated postbulbar duodenum, with leakage of free air (arrowheads)
into abdomen. Patient underwent surgery with unroofing and drainage of pseudocyst and pyloric exclusion. Hemorrhage and pseudocyst resolved on follow-up CT
examinations (not shown).

AJR:190, March 2008 647


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Fig. 5—Retroperitoneal hemorrhage in 25-year-old man with grade E pancreatitis without necrosis.
A, Initial contrast-enhanced axial CT image reveals large retroperitoneal hematoma (arrows).
B, Follow-up axial CT image 21 days later shows encapsulated, liquefied retroperitoneal hematoma (arrows). Resolution of hematoma was documented on follow-up CT
examinations (not shown).
life-threatening complications such as hem-
orrhage, infected collections, and duodenal
perforation were seen in only five patients,
representing 6.8% of the 73 patients with fluid
collections or 3.0% of 169 cases overall.
When the initial peripancreatic fluid collec-
tions are not absorbed, they tend to organize
and slowly evolve into fully encapsulated
collections called “acute pseudocysts.” This
evolution heralds the beginning of a poten-
tially more complex and uncertain clinical
course. The development usually takes more
than 4 weeks, but because the timing is some-
what variable, the diagnosis is established
only when a sharply defined circumferential
capsule is clearly detected. As opposed to
chronic pseudocysts, acute pseudocysts have a
thin friable capsule and an unstable natural
history. They can diminish or grow in size,
resolve, rupture, drain into the pancreatic
duct, or fistulize into the gastrointestinal
tract. Spontaneous resolution has been re-
ported in 40% of acute pseudocysts known
to be present for less than 6 weeks, whereas
they tend to remain stable when older than 12
weeks [16]. Complications such as rupture,
hemorrhage, or infection have been reported in
18–50% of cases [16–19]. A follow-up CT
series of 75 patients with acute pseudocysts
reported enlargement or complications requir-
ing surgery in about half and resolution or
stable size in asymptomatic individuals in
the other half [20].
Follow-up CT examinations in our 73
grades D and E patients with fluid collections
documented five patients with single pseudo-
648 AJR:190, March 2008
Lenhart and Balthazar
A B
cysts, for an incidence of 6.8%, or 3.0% of the
entire group of 169 cases. Hemorrhage from
rupture of a pseudocyst occurred in two pa-
tients, necessitating surgical intervention.
The prevalence of hemorrhagic pseudocysts,
similar to the two cases in our series, varies
in different reports from 2% to 31% of acute
pseudocysts [17, 21]. After an acute attack of
pancreatitis, hemorrhage is usually not associ-
ated with ruptured pseudoaneurysms, which
tend to occur later after an acute episode [22].
Rather, in the acute phase, hemorrhage most
often occurs secondary to capillary bleeding
in the wall of the pseudocyst or in the retroperi-
toneum. Because the natural history, clinical
significance, and surgical management are
uncertain, a conservative noninterventional
approach, particularly for asymptomatic
pseudocysts smaller than 5 cm, has been
accepted in clinical practice [20]. Surgical
or interventional drainage procedures are
reserved for complications (such as hemor-
rhage or infection) and for symptomatic en-
larging pseudocysts diagnosed by follow-up
imaging studies.
Three individuals in our series of 169 pa-
tients developed chronic complications (two
cases of chronic pancreatitis and one case of
groove pancreatitis), for an incidence of only
1.8%. Groove pancreatitis was diagnosed
when there was focal inflammation exclusive-
ly or predominantly involving the head of the
pancreas and associated fluid in the groove
between the head of the pancreas and the sec-
ond portion of the duodenum [23]. Although
these are important long-lasting, irreversible,
and clinically debilitating developments [23,
24], their true incidence rate is difficult to es-
tablish without close patient supervision and
repeated long-term follow-up examinations.
Our retrospective survey of 169 patients
with attacks of nonnecrotizing acute pancrea-
titis has several limitations that may affect the
veracity of our results. Because of its retro-
spective nature, this is not a controlled study,
and long-term follow-up examinations in
some of our patients with unresolved fluid col-
lections and acute pseudocysts were not al-
ways available. Follow-up imaging studies
were available for review in approximately
50% of our entire patient population and in
70% of patients with fluid collections, includ-
ing 100% of grade E patients with larger col-
lections and more severe and protracted clini-
cal presentations. We likely underestimated
the true incidence of acute and chronic com-
plications because longer-term follow-ups in
some of our patients with unresolved fluid col-
lections and acute pseudocysts may have
yielded additional complications. On the other
hand, long-term follow-up examinations could
have missed other unrecorded subliminal in-
tervening acute episodes of pancreatitis, par-
ticularly in alcoholic patients, that might have
contributed to the development of late compli-
cations. Patients may also have sought follow-
up care and undergone imaging at an outside
institution, and they may have developed
complications of which we were not aware. In
addition, despite the improved accuracy of
MDCT examinations, small superficial patchy
areas of pancreatic necrosis that might have

contributed to the severity of the acute attack
in the development of subsequent complica-
tions could have been missed.
In conclusion, in this series of 169 patients
with milder forms of acute pancreatitis, 16 ab-
dominal complications developed in nine pa-
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tients, for an incidence of 5.3%. All complica-
tions occurred in grades D and E patients with
fluid collections. Fluid was rapidly absorbed in
most patients but led to complications in 12.3%
in this subgroup of patients. Acute, life-threat-
ening complications (hemorrhage, infection,
perforation) were seen in five patients, for an
incidence of 6.8%, among 73 episodes with
fluid collections, or 3.0% of 169 total cases.
Single acute pseudocysts were seen in five pa-
tients, and long-term chronic complications
were documented in three patients. Severe ab-
dominal morbidity can occasionally occur after
an episode of acute pancreatitis in the absence
of necrosis. In patients with milder interstitial
forms of pancreatitis, routine follow-up CT ex-
aminations are indicated only in patients with
fluid collections to document resolution of fluid
or the development of complications.
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F O R YO U R I N F O R M AT I O N
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AJR:190, March 2008 649
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