Classification of Acute Pancreatitis– 2012: revision of Atlanta

Classification and definition by international consensus

(Banks et al.,2013)
Abstract
• Objective:
– Enabled standardized reporting of research
– Aided communication of clinicians
• Significance of the study:
– Allow consistent and worldwide classification
– Allow a consistent terminology across all studies
• Methods:
– Web-based consultation in 2007
– Draft documents sent to 11 national and
international pancreatic associations
– Final consensus reviewed
• Results:
– Two phases: early and late
– Severity: mild, moderate & severe
– Local complications: peripancreatic fluid collection
necrosis
pseudocyst
walled-off necrosis
• Conclusions:
– Provides clear definitions to classify acute
pancreatitis using easily identified clinical and
radiologic criteria
– This revision is not intended to be a management
guideline
 Acute pancreatitis
• Diagnosis:
– 2 of the following:
• Abdominal pain
• Serum lipase/ amylase activity
• Characteristic findings on CECT
• Onset:
– time of onset of abdominal pain and not the time
of admission to the hospital
• Types:
– 1. Interstitial Oedemetous Pancreatitis
– 2. Necrotizing Pancreatitis
• Infected Pancreatic Necrosis
Interstitial Oedemetous Pancreatitis
• Diffuse enlargement of pancreas due to
inflammatory edema
• Symptoms resolve within the first week
 Interstitial Oedemetous Pancreatitis

CECT:
- Relatively homogenous
enhancement
- Peripancreatic fat with
some inflammatory
changes of haziness or
mild stranding
- Some peripancreatic fluid
 Necrotizing Pancreatitis
• 5-10% of patients
• Necrosis involving both the pancreas and
peripancreatic tissues
• Natural history is variable
Necrotizing Pancreatitis

• CECT:
• - first few days: pattern of
perfusion of the pancreatic
parenchyma is patchy
• -after first week: a non-
enhancing area of pancreatic
parenchyma

• Peripancreatic necrosis:
pancreas enhances normally
but the peripancreatic tissue
develops necrosis
Necrotizing Pancreatitis
 Infected Pancreatic Necrosis
• Rare during the first week
• Antibiotic treatment
• No absolute correlation with extent of
necrosis
 Infected Pancreatic Necrosis
• CECT:
- presence of extraluminal gas in
the pancreatic and peripancreatic
tissues
- Pathognomonic sign: gas bubbles

• Percutaneous Image-
guided FNA:
- positive for bacteria and/or fungi
on Gram stain and Culture
• Complications:
– Organ failure (respiratory, cardiovascular, renal)
• A score of 2 or more for one of these three organ
systems using the Modified Marshall Scoring System

– Local and Systemic

• Local complications:
– Acute peripancreatic fluid collection
– Pancreatic pseudocyst
– Acute necrotic collection
– Walled-off necrosis
• Local complications:
– Recurrence of abdominal pain
– Secondary increase in serum pancreatic enzyme
– Increasing organ dysfunction
– Fever and leukocytosis

– CECT
• Systemic complications:
– Exacerbation of pre-existing comorbidity
– Precipitated by acute pancreatitis
• Phases:
– Early
– Late
• Early Phase:
- 1st to 2nd week
- SIRS > organ failure
- severity: presence and duration of organ
failure
• Transient Organ Failure
- organ failure resolves within 48 hours

• Persistent Organ Failure

- organ failure persists for more than 48 hours

• Multiorgan Failure
- organ failure affects more than 1 organ system
• Late Phase:
- persistence of systemic signs of inflammation
- presence of local complications
- seen only in moderately severe or severe acute
pancreatitis
• Severity:
– Mild
– Moderately Severe
– Severe
 Mild Acute Pancreatitis
• Absence of organ failure
• Absence of local or systemic complications
• Usually does not require imaging
• Mortality is rare
 Moderately Severe Acute Pancreatitis

• Presence of transient organ failure or local/

systemic complications
• Absence of persistent organ failure
• Mortality is less than that of severe acute
pancreatitis
 Severe Acute Pancreatitis
• Persistent organ failure
• Usually have one or more local complications
– If with infected necrosis -> extremely high
mortality
 Acute Peripancreatic Fluid Collection

• - develop on early phase

• - most acute fluid remain sterile and resolve
spontaneously without intervention
 Acute Peripancreatic Fluid Collection

• CECT:
– - do not have well defined wall
– - homogenous
– - confined by normal fascial planes in the
retroperitoneum
– -may be multiple
 Pancreatic Pseudocyst
• Fluid collection in the peripancreatic tissues
• Aspiration of cyst content -> markedly
increased amylase activity
 Pancreatic Pseudocyst
• Disruption of main pancreatic duct or its
intrapancreatic branches without any
recognizable pancreatic parenchymal necrosis
• Consequent leakage of pancreatic juice ->
persistent, localized fluid collection (after >
4weeks)
 Pancreatic Pseudocyst
• “Disconnected Duct Syndrome”
• Seen post-necrosectomy
Pancreatic Pseudocyst

• CECT:
-Surrounded by a well
defined wall
-Contains essentially no
solid material
 Acute Necrotic Collections
• Variable amounts of fluid and necrotic tissue
on the first 4 weeks
• Arises from a necrotizing pancreatitis and
contains necrotic tissue
 Acute Necrotic Collections
• Disruption of main pancreatic duct within the
zone of parenchymal necrosis and can become
infected
 Acute Necrotic Collections
CECT:
- varying amounts of solid necrotic
material and fluid
- may be multiple
- may appear loculated
 Walled-off Necrosis
• Necrotic tissue contained within an enhancing
wall of reactive tissue
• Mature, encapsulated collection of pancreatic
and/or peripancreatic necrosis
• Well defined inflammatory wall
• >/= 4 weeks after onset of necrotizinf
pancreatitis
 Walled-off Necrosis
• MRI
• Transabdominal Ultrasonography
• Endoscopic Ultrasonography

• Demonstration of the presence or absence of

pancreatic ductal communication
Walled-off Necrosis
Thank You!