ArticlePublisher preview availableLiterature Review

CT imaging, classification, and complications of acute pancreatitis

May 2020
Abdominal Radiology 45(4)

May 2020
45(4)

DOI:10.1007/s00261-019-02236-4

Authors:

Orysya Svystun

University of Alberta

Satomi Kawamoto

Johns Hopkins Medicine

Acute pancreatitis is an increasingly common condition and can result in significant morbidity and mortality. Contrast enhanced computed tomography (CECT) is the primary initial imaging modality in the characterization of acute pancreatitis. In this article, we provide sample CECT technical acquisition parameters for pancreatic imaging. We also review the classification systems for acute pancreatitis and give examples of common and uncommon complications of acute pancreatitis. © 2019, Springer Science+Business Media, LLC, part of Springer Nature.

Acute pancreatitis with early heterogeneous enhancement. 49-yo-F with chest pain and epigastric pain with 48 h duration. a Initial chest CT for PE protocol shows acute pancreatitis. Heterogeneous enhancement in tail of the pancreas raised possibility of pancreatic necrosis. b Follow-up contrast enhanced venous phase CT in 2 weeks shows improvement of heterogeneous enhancement, with no evidence of pancreatic necrosis; the heterogenous enhancement was secondary to interstitial edema

…

Evolving necrotizing pancreatitis with acute necrotic collections developing into walled off necrosis. 75-yo-M with severe mid-epigastric pain for 72 h and markedly elevated lipase. CECT a shows diffuse poor enhancement and regional stranding. b 6 days later deteriorated, requiring vasopressor support. Heterogenous enhancement of < 50% of the pancreas consistent with necrotizing pancreatitis. c 21 days later, acute necrotic collections with internal locules of fat necrosis. d 35 days later, acute necrotic collections evolve into walled off necrosis with areas of rim enhancement and increased internal necrotic debris/fat

…

Necrotizing pancreatitis with acute necrotic collection and secondary duodenal stenosis. a Initial CT in a 65-yo-F with severe upper mid abdominal pain radiating into her back which has been constant for about 12 h. b 9 days later after the patient started liquids and solid food intake, the patient developed worsening nausea, vomiting, and abdominal pain. The stomach and proximal duodenum are marked distended secondary to duodenal stenosis. c 20 days later, increasing size of acute necrotic collection with developing areas of rim enhancement. The stomach and duodenum are decompressed by nasogastric tube. d 26 days later, cystogastrostomy stent was placed, and acute necrotic collection was successfully drained and significantly decreased in size

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Collections associated with acute pancreatitis

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Acute recurrent pancreatitis resulting in acute peripancreatic collection with spontaneous hemorrhage and splenic vein thrombosis. 35-yo-M with abdominal/back pain with history of prior pancreatitis. a Arterial phase CT shows acute peripancreatic fluid collection in portocaval space containing punctate amorphous enhancement (yellow arrow), which becomes more ill-defined in venous phase (b). More inferior image in venous phase c shows fluid collection in portocaval space contains radiodense content, compatible with hematoma. IVC (blue arrow) and portal vein/SMV confluence are compressed by fluid collection. Splenic vein is thrombosed (red arrow)

…

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Vol.:(0123456789)

1 3

Abdominal Radiology (2020) 45:1243–1252

https://doi.org/10.1007/s00261-019-02236-4

SPECIAL SECTION: PANCREATITIS

CT imaging, classication, andcomplications ofacute pancreatitis

ChristopherFung1 · OrysyaSvystun1· DanielFadaeiFouladi2· SatomiKawamoto2

Published online: 26 September 2019

Abstract

Acute pancreatitis is an increasingly common condition and can result in signiﬁcant morbidity and mortality. Contrast

enhanced computed tomography (CECT) is the primary initial imaging modality in the characterization of acute pancreatitis.

In this article, we provide sample CECT technical acquisition parameters for pancreatic imaging. We also review the clas-

siﬁcation systems for acute pancreatitis and give examples of common and uncommon complications of acute pancreatitis.

Keywords Pancreatitis· Complication· CECT· Guideline· Classiﬁcation

Introduction toacute pancreatitis

Acute pancreatitis is an increasingly common condition

with an incidence of 20–80 per 100,000, ranging widely

by country. For example, while in the USA, the incidence

of acute pancreatitis is estimated at 30–40 per 100,000, in

Japan, the incidence was 49.4 per 100,000 in 2011 [1, 2].

Clinical presentation varies from transient abdominal dis-

comfort to systemic inﬂammatory response syndrome and

death may occur in up to 5% of cases [3, 4]. Patients with

acute pancreatitis result in over 275,000 hospital admissions

annually in the USA at a cost of over $2.6 billion (USD) in

a study from 2009 [5].

Historically, approximately 80% of adult cases were con-

sidered secondary to alcohol use or obstructing gallstones,

with other etiologies including drug reaction, pancreatic

neoplasm, and hypertriglyceridemia comprising the majority

of the remaining 20% of cases [3]. Newer data suggests that

rates of idiopathic causes of acute pancreatitis are increasing

and are now accounting for up to 20% of moderately severe

to severe acute pancreatitis in the USA [2].

Acute pancreatitis is generally stratiﬁed into mild, moder-

ately severe, and severe acute pancreatitis, further discussed

below. Mild acute pancreatitis is self-limiting, with very

low mortality and morbidity, and can often be diagnosed

clinically/biochemically without imaging. Moderately severe

acute pancreatitis, however, presents with transient (< 48h)

organ failure and/or local or systemic complications. Though

moderately severe pancreatitis results in high morbidity

compared to the mild version, its mortality is considered

low at up to 2% [2]. Organ failure (frequently established

using the modiﬁed Marshall scoring system) lasting greater

than 48h is classiﬁed as severe acute pancreatitis (Table1).

Mortality in the setting of severe acute pancreatitis is up to

50% [1, 3, 4, 6, 7].

Atlanta classication foracute pancreatitis

The Atlanta classiﬁcation for acute pancreatitis was ini-

tially developed in 1992 and provided common terms for

acute pancreatitis and related complications [1]. Advances

in imaging and pathophysiology understanding necessitated

a subsequent revision, the Revised Atlanta Classiﬁcation

(RAC) in 2012 [6]. Per the RAC, diagnosis of acute pan-

creatitis requires two of the following three features:

* Christopher Fung

chris.fung@ualberta.net

Orysya Svystun

svystun@ualberta.ca

Daniel Fadaei Fouladi

dfoulad1@jhmi.edu

Satomi Kawamoto

skawamo1@jhmi.edu

1 Department ofRadiology andDiagnostic Imaging,

University ofAlberta Hospital, 8440 – 112 Street NW,

Edmonton, AB, CanadaT6G2B7

2 Russell H. Morgan Department ofRadiology

andRadiological Science, Johns Hopkins University

School ofMedicine, 601N. Caroline Street, JHOC 3235A,

Baltimore, MD21287, USA

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Tracking Wall Characteristics of Necrotic Pancreatic Fluid Collections in Acute Pancreatitis on Serial Contrast-Enhanced Computed Tomography

Article

Full-text available

May 2024

Background Encapsulated pancreatic fluid collection (PFC) is a requisite for endoscopic drainage procedures. The 4-week threshold for defining walled-off necrosis does not capture the dynamic process of encapsulation. We aim to investigate the changes in the wall characteristics of PFC in acute necrotizing pancreatitis (ANP) by comparing baseline contrast-enhanced computed tomography (CECT) with follow-up CT scans. Methods This retrospective study comprised consecutive patients with ANP who underwent a baseline CECT within first 2 weeks and follow-up CECT in the third to fifth weeks of illness. Presence, extent, and encapsulation thickness (defined as enhancing wall around the collection) on baseline CECT were compared with follow-up CT (done in the third–fifth weeks of illness). Results Thirty patients (19 males and 11 females; mean age 41.5 ± 13.5 years) were included in the study. The mean time to first CECT was 10 ± 3.6 days. There were 58 collections. The most common site was the lesser sac (n = 29), followed by the left pararenal space (n = 15). At baseline CT, 52 (89.7%) collections had varying degree of encapsulation (15.3%, complete encapsulation). Complete encapsulation was seen in 52 and 82.6% collections in third and fourth week, respectively. All collections in fifth week and beyond were encapsulated. The wall was thicker on follow-up CECT scans (p < 0.01). The mean wall thickness was not significantly associated with the degree of encapsulation (p = 0.417). There was no significant association between the site and degree of encapsulation (p = 0.546). Conclusion Encapsulation is dynamic and collections may get “walled off” before 4 weeks. Walled-off collections should be defined based on imaging rather than a fixed 4-week revised Atlanta classification threshold.

Acute Pancreatitis- A narrative review

Article

Full-text available

Apr 2024
J Pakistan Med Assoc

Acute pancreatitis is a common cause of acute abdominal pain and can range from mild oedema to severe necrosis of the pancreas. It has a significant impact on morbidity, mortality and financial burden. The global prevalence of pancreatitis is substantial, with the highest rates observed in central and eastern Europe. Diagnosing acute pancreatitis involves considering clinical symptoms, elevated serum amylase and/or lipase levels, and characteristic imaging findings. The causes of acute pancreatitis include obstructive disorders, such as gallstones and biliary sludge, alcohol consumption, smoking, drug-induced pancreatitis, metabolic disorders, trauma, medical procedures, infections, vascular diseases and autoimmune pancreatitis. Appropriate management of acute pancreatitis involves determining the severity of the condition, providing supportive care, addressing the underlying cause, and preventing complications. Advances in classifying the severity of acute pancreatitis and implementing goal-directed therapy have contributed to a decrease in mortality rates. ---Continue

Possibilities of Transfistula Ultrasound in Predicting Intraoperative Bleeding in Patients with Infected Pancreatic Necrosis

Article

Mar 2024

Introduction . Assessing the risk of intraoperative bleeding is of great importance in the treatment of patients with infected pancreatic necrosis. The aim of the study — determine the role of transfistula ultrasound in assessing the risk of intraoperative bleeding in patients with infected pancreatic necrosis. Materials and methods . From 2015 to 2019, 193 people with infected pancreatic necrosis were treated at Regional Clinical Hospital No. 2 (Krasnodar). At stage 1, drains of various diameters were installed in all patients; at stage 2, necrotic tissue was removed using transfistula videoscopic necrosequestrectomy in 48 patients (24.9 %). Before performing instrumental necrosequestrectomy, a developed diagnostic method was used — transfistula ultrasound scanning — to determine the relationship between the location of foci of necrosis in the pancreas and blood vessels in 22 patients (11.4 %; group 1); the method was not used in 26 people (13.5 %; group 2). Results . The number of accesses created into the omental bursa was as follows: 141 patients (73.1 %) had 3 accesses, 52 people (26.9 %) had 2 accesses; into the retroperitoneal space: 102 patients (52.8 %) had 2 accesses, 51 people (26.4 %) had 1 access. Transfistula videoscopic necrosequestrectomy was performed 35 and 37 times in groups 1 and 2, respectively (p > 0.05). Transfistula ultrasound scanning to assess the risk of intraoperative bleeding was used 33 times in patients in group 1. In group 1, intraoperative bleeding was observed in 5 patients (23.8 %), in group 2 — in 7 patients (26.9 %) (p > 0.05). The volume of blood loss was (436.0±83.6) and (887.0±41.8) ml in groups 1 and 2, respectively (p < 0.05). There were no cases of death due to intraoperative bleeding in either group. Discussion . Transfistula ultrasound scanning makes it possible to stratify patients: into a high-risk group (with intimate adjacency of necrosis to vessels), medium (at a distance of up to 15 mm) and low-risk (with a distant location). In this regard, interventions in high-risk patients were carried out in the X-ray operating room to allow for endovascular hemostasis, which made it possible to reduce the volume of blood loss, as well as to create a supply of transfusion media in advance to replenish the volume of blood volume. Conclusion . The developed method of direct transfistula ultrasound scanning makes it possible to assess the risk of intraoperative bleeding in patients with infected pancreatic necrosis to achieve timely hemostasis and compensate for acute blood loss.

Implantação de aparelho de tomografia computadorizada no Hospital Regional de Planaltina – Distrito Federal consoante solicitações entre 2021 e 2022

Article

Feb 2024

Nos últimos anos, incontáveis exames complementares foram introduzidos na prática médicapara auxílio diagnóstico. Entre eles, houve destaque para a Tomografia Computadorizada (TC).Esse exame oferece diversas vantagens em seu uso e, como consequência disso, possibilita aidentificação de várias indicações, como acidente vascular encefálico, abdome agudo etraumas. Por essa razão, a falta de aparelho de TC no serviço médico pode gerar diversosprejuízos em relação ao diagnóstico e, consequentemente, à conduta adequada de certascondições, como acontece no caso do Hospital Regional de Planaltina (HRPl), no DistritoFederal, por não disponibilizar tal equipamento. O objetivo da pesquisa foi analisarcaracterísticas clínicas e epidemiológicas dos pacientes com solicitação médica de TC, pormeio do Laudo para Solicitação da Autorização de Procedimento Ambulatorial (APAC), noHRPl, no período de 2021 e 2022. Para isso, a metodologia utilizada foi a coleta de dadossecundários, transversais e retrospectivos fornecidos pelo hospital, com informaçõesanônimas de pacientes que tiveram TC solicitada pelo profissional médico durante o períodocitado. Assim, as variáveis analisadas, de forma quantitativa, foram sexo, faixa etária,procedimento solicitado, realização do procedimento, região anatômica estudada, indicaçãode realizar tomografia computadorizada, locais com tomógrafos disponíveis e utilizados porpacientes oriundos do HRPl. No período estudado, houve um total de 9.319 APACs,preenchidas para uma série de procedimentos, sendo que 2.627 foram preenchidas para arealização de TC. Em relação aos resultados encontrados, sintetizou-se que a principalindicação para o exame foi traumatismo cranioencefálico e, por isso. o principal sítioanatômico solicitado para análise foi o crânio. Verificou-se que a maioria das TCs que o HRPlsolicita é realizada no Hospital Regional de Sobradinho (HRS), totalizando 1.649, o que decorreda relativa proximidade entre os dois hospitais (20,6 km) e da disponibilidade de umtomógrafo HRS. Ademais, uma série de outras indicações e sítios anatômicos foramevidenciados na pesquisa. Diante da demanda pela TC, para auxílio no diagnóstico médico,consolidada por protocolos do sistema público e privado, fato evidenciado na pesquisa e naliteratura médica bem como proposto pelo Ministério da Saúde, por meio da recomendaçãode disponibilidade de um tomógrafo a cada 100 mil habitantes, é de fundamental importânciaa implementação desse equipamento no HRPl.

Early encapsulation of peripancreatic fluid/necrosis collections on imaging (CECT) in acute pancreatitis: influential factors and clinical significance for prognosis

Article

Full-text available

Jan 2024
BMC GASTROENTEROL

Background To identify the factors influencing the early encapsulation of peripancreatic fluid/necrosis collections via contrast-enhanced computed tomography (CECT) and to determine the clinical significance of early encapsulation for determining the prognosis of acute pancreatitis (AP) patients. Methods AP patients who underwent CECT between 4 and 10 days after disease onset were enrolled in this study. Early encapsulation was defined as a continuous enhancing wall around peripancreatic fluid/necrosis collections on CECT. Univariate and multivariate logistic regression analyses were performed to assess the associations between the variables and early encapsulation. Clinical outcomes were compared between the non-encapsulation and early encapsulation groups with 1:1 propensity score matching. Results A total of 289 AP patients were enrolled. The intra-observer and inter-observer agreement were considered good (kappa statistics of 0.729 and 0.614, respectively) for identifying early encapsulation on CECT. The ratio of encapsulation increased with time, with a ratio of 12.5% on day 5 to 48.7% on day 9. Multivariate logistic regression analysis revealed that the longer time from onset to CECT examination (OR 1.55, 95% CI 1.23–1.97), high alanine aminotransferase level (OR 0.98, 95% CI 0.97–0.99), and high APACHE II score (OR 0.89, 95% CI 0.81–0.98) were found to be independent factors associated with delayed encapsulation. The incidence of persistent organ failure was significantly lower in the early encapsulation group after matching (22.4% vs 6.1%, p = 0.043). However, there was no difference in the incidence of infected pancreatic necrosis, surgical intervention, or in-hospital mortality. Conclusions AP patients without early encapsulation of peripancreatic fluid/necrosis collections have a greater risk of persistent organ failure. In addition to longer time, the high APACHE II score and elevated alanine aminotransferase level are factors associated with delayed encapsulation.

The value of CT-based radiomics in predicting the prognosis of acute pancreatitis

Article

Full-text available

Nov 2023

Purpose Early judgment of the progress of acute pancreatitis (AP) and timely intervention are crucial to the prognosis of patients. The purpose of this study was to investigate the application value of CT-based radiomics of pancreatic parenchyma in predicting the prognosis of early AP. Materials and methods This retrospective study enrolled 137 patients diagnosed with AP (95 cases in the progressive group and 42 cases in the non-progressive group) who underwent CT scans. Patients were randomly divided into a training set (n = 95) and a validation set (n = 42) in a ratio of 7: 3. The region of interest (ROI) was outlined along the inner edge of the pancreatic parenchyma manually, and the Modified CT Severity Index (MCTSI) was assessed. After resampling and normalizing the CT image, a total of 2,264 radiomics features were extracted from the ROI. The radiomics features were downscaled and filtered using minimum redundancy maximum correlation (mRMR) and the least absolute shrinkage and selection operator algorithm (LASSO) regression, in turn, and the more optimal subset of radiomics features was selected. In addition, the radiomics score (rad-score) was calculated for each patient by the LASSO method. Clinical data were also analyzed to predict the prognosis of AP. Three prediction models, including clinical model, radiomics model, and combined clinical–radiomics model, are constructed. The effectiveness of each model was evaluated using receiver operating characteristic (ROC) curve analysis. The DeLong test was employed to compare the differences between the ROC curves. The decision curve analysis (DCA) is used to assess the net benefit of the model. Results The mRMR algorithm and LASSO regression were used to select 13 radiomics features with high values. The rad-score of each texture feature was calculated to fuse MCTSI to establish the radiomics model, and both the clinical model and clinical–radiomics model were established. The clinical–radiomics model showed the best performance, the AUC and 95% confidence interval, accuracy, sensitivity, and specificity of the clinical–radiomics model in the training set were 0.984 (0.964–1.000), 0.947, 0.955, and 0.931, respectively. In the validation set, they were 0.942 (0.870–1.000), 0.929, 0.966, and 0.846, respectively. The Delong test showed that the predictive efficacy of the clinical–radiomics model was higher than that of the clinical model (Z = 2.767, p = 0.005) and the radiomics model (Z = 2.033, p = 0.042) in the validation set. Decision curve analysis demonstrated higher net clinical benefit for the clinical–radiomics model. Conclusion The pancreatic parenchymal CT clinical–radiomics model has high diagnostic efficacy in predicting the progression of early AP patients, which is significantly better than the clinical or radiomics model. The combined model can help identify and determine the progression trend of patients with AP and improve the prognosis and survival of patients as early as possible.

Combination diagnostic approach of multilayer spiral CT enhanced scan and ultrasound in diffuse cell enlargement of the pancreas and inflammatory cell alterations in the peripancreatic fat connective tissue

Preprint

Full-text available

Oct 2023

Objective: Combination diagnostic approach of multilayer spiral CT enhanced scan and ultrasound in diffuse cell enlargement of the pancreas and inflammatory cell alterations in the peripancreatic fat connective tissue. Methods: 97 patients with suspected severe pancreatitis who were examined in our hospital and inpatient department between July 2019 and July 2021 were selected as the study subjects. All patients underwent multilayer spiral CT enhancement and ultrasound scans in a stable condition. The pictorial characteristics of multi-slice spiral CT enhancement and ultrasound scan in two groups of patients with acute severe pancreatitis were observed and recorded, the diagnostic value of multi-slice spiral CT enhanced scan and combined ultrasound diagnosis of acute severe pancreatitis and pathological examination results, and the diagnostic value of multi-slice spiral CT enhanced scan and joint ultrasound for the diagnosis of acute severe pancreatitis. Results: Multi-layer spiral CT (MSCT) enhanced scan showed local or diffuse cell enlargement of the pancreas and inflammatory cell changes in the peripaniatic fat connective tissue. Inflammatory changes in the peripaniatic adipate connective tissue, intra-parenchymal or peripancreatic effusion of the pancreas, including pancreatic and fat necrosis, pancreatic abscesses. Different degrees of localized or diffuse weak or no reinforced low-density necrosis areas are visible in the parenchyma of the pancreas. The pancreas is significantly enlarged, especially in the tail of the pancreas, and a small amount of exudation is seen around the pancreas; ultrasound image features: the echo of the pancreas parenchyma is uniform or unevenly weakened, manifested by edema or hemorrhagic necrosis. Clinical examination of the lesion confirmed that 61 patients were affected with Severe acute pancreatitis(SAP), and 33 cases were negative patients. Taking the pathological examination results as the gold standard, 65 patients were diagnosed with multi-slice spiral CT enhanced scan and 60 cases were diagnosed with joint diagnosis; the sensitivity of joint detection (93.44%) was significantly higher than that of multilayer spiral CT enhanced scan (88.52%); the specificity of joint detection (90.91%) was higher than that of multilayer spiral CT enhanced scan (78.79%); and the accuracy of joint detection (92.55%) was higher than that of multilayer spiral CT enhanced scan (85.11%). The diagnostic value of contrast-enhanced ultrasound (CEUS) combined with multi-slice helical CT (MSCT) for tongue cancer and its lymph node metastasis (LNM) has also been assessed. Conclusion: Multi-layer spiral CT enhanced scanning combined with ultrasonography can help diagnose in patients with diffuse cell enlargement of the pancreas and inflammatory cell alterations in the peripancreatic fat connective tissue., improve accuracy, sensitivity and specificity, and then improve the clinical diagnostic value.

Acute pancreatitis and computed tomography: Interest of portal venous phase alone in the initial phase

Article

Jun 2024
ACTA RADIOL

Background There are no guidelines in the literature for the use of a computed tomography (CT) protocol in the initial phase of acute pancreatitis (AP). Purpose To evaluate the contribution of single portal venous phase CT compared to triple-phase CT protocol, performed in the initial phase of AP for severity assessment. Material and Methods In this retrospective study, a total of 175 patients with acute pancreatitis who underwent initial triple-phase CT protocol (non-contrast, arterial phase, and portal venous phase) between D3 and D7 after the onset of symptoms were included. Analysis of AP severity and complications was independently assessed by two readers using three validated CT severity scores (CTSI, mCTSI, EPIC). All scores were applied to the triple-phase CT protocol and compared to the single portal venous phase. Inter-observer analyses were also performed. Results No significant difference whatever the severity score was observed after analysis of the single portal venous phase compared with the triple-phase CT protocol (interstitial edematous pancreatitis: CTSI: 2 vs. 2, mCTSI: 2 vs. 2, EPIC: 1 vs. 1; necrotizing pancreatitis: CTSI: 6 vs. 6, mCTSI: 8 vs. 8, EPIC: 5 vs. 5). Inter-observer agreement was excellent (ICC = 0.96–0.99), whatever the severity score. Conclusion A triple-phase CT protocol performed at the initial phase of AP was no better than a single portal venous for assessing the severity of complications and could lead to a 63% reduction in irradiation.

MZB1 regulates cellular proliferation, mitochondrial dysfunction, and inflammation and targets the PI3K-Akt signaling pathway in acute pancreatitis

Article

Mar 2024
CELL SIGNAL

Application of Medical Imaging in the Diagnosis of Acute Pancreatitis

Article

Full-text available

Jan 2023

子蓉姚

Intra peritoneal abdominal fat area measured from computed tomography is an independent factor of severe acute pancreatitis

Article

Full-text available

Apr 2019

Purpose: The purpose of this study was to search for a possible relationship between acute pancreatitis (AP) severity and visceral fat (VF) surface on contrast-enhanced computed tomography (CECT). Material and method: A total of 112 patients with AP who underwent CECT within 2 to 3 days after the beginning of AP were included. There were 68 mean and 44 women, with a mean age of 56.3±21.6 (SD) years (range: 19-98 years). AP was regarded as mild for patients with an hospital stay up to 5 days and severe for those with an hospital stay greater than 5 days. VF surface was measured on CECT at the level of L4-L5 and of the umbilicus. Association between AP severity and VF surface, computed tomography severity index (CTSI), modified CTSI (mCTSI) and other variables were searched for using uni- and multivariate analysis. Results: At univariate analysis, the VF surface at the level of L4 was greater in patients with severe AP (129.3±68.6 [SD] cm2; range: 21.8-355.8 cm2) than in patients with mild AP (100.1±68.4 [SD] cm2; range:13.2-333 cm2) (P=0.006). Similarly, the VF surface at the umbilicus was greater in patients with severe AP (161.1±76.1 [SD] cm2; range: 31.3-376.7cm2) than in those with mild AP (128.4±74.3cm2; range: 12.8-323.1cm2) (P=0.024). CTSI and mCTSI were also associated to AP severity. At multivariate analysis, only VF surface either measured at the umbilical or at the L4-L5 level was associated with AP severity (P=0.017 and 0.006, respectively). Conclusion: VF surface at the level of L4-L5 on CECT is an independent factor of AP severity. VF surface at the level of L4-L5 on CECT is an independent factor of AP severity. These results are in line with recent data on the role of abdominal fat in the genesis of inflammatory response, which is associated with severe forms of AP.

Computed tomography scan imaging in diagnosing acute uncomplicated pancreatitis: Usefulness vs cost

Article

Full-text available

Mar 2019
WORLD J GASTROENTERO

BACKGROUND Literature has suggested that imaging is over-utilized in the diagnosis of pancreatitis. If the diagnosis of acute pancreatitis (AP) is established with abdominal pain and increased serum amylase or lipase activity without systemic signs of severe disease, computed tomography (CT) imaging may not be necessary. We hypothesize that among patients with uncomplicated acute pancreatitis (AUP), there is a significant number of unwarranted CT imaging studies. This imposes increased expenditure and cost in our healthcare system and does not improve hospital stay or management of AUP. AIM To assess the overutilization and associated cost of CT imaging among patients meeting diagnostic criteria for AUP. METHODS In this Institutional Review Board-approved retrospective, single-center study, we identified all adult patients admitted with AP from January 1, 2012 through October 1, 2017. Patients were identified via International Classification of Diseases (ICD-9) code for AP (577.0) and ICD-10 codes for different etiological AP (K85.9 unspecified, K85.0 idiopathic, K85.1 biliary, K85.2 alcohol-induced, K85.3 drug-induced, and K85.8 other). Diagnosis was confirmed by chart review using established non-imaging diagnostic criteria (presence of typical abdominal pain and elevated lipase or amylase greater than 3 times upper limit of normal). Ranson criteria and BISAP scores on presentation were calculated and patients that met scores less than or equal to 2 for both were included to suggest AUP. The utilization and cost of imaging in these patients were recorded. RESULTS Between January 2012 and October 2017, 1305 patients presented to the emergency department with AP, and 405 patients (31%) met our inclusion criteria for AUP (201 males, 204 females; mean age 49 years, range 18-98). Of those, 210 patients (51.85%) underwent CT imaging. One patient (0.47%) had evidence of pancreatic necrosis, one patient had cyst formation (0.47%), and the remaining 208 patients (99.05%) had either normal CT scan imaging or findings consistent with mild AP without necrosis. The average cost of CT scan imaging was $4510 with a total cost of $947056. Median length of hospitalization stay was 3 d among both groups. Combining Ranson’s Criteria and BISAP score identified AUP in our patient population with an accuracy of 99.5%. CONCLUSION CT imaging is unnecessary when AUP is diagnosed clinically and biochemically. Reducing overuse of diagnostic CT scans will decrease healthcare expenditure and radiation exposure to patients.

Moderately severe and severe acute pancreatitis: A systematic review of the outcomes in the USA and European Union-5

Article

Full-text available

Feb 2019

Background and objectives The global incidence of hospitalisation due to acute pancreatitis (AP) has been rising in the recent decades. In the USA alone, there was a 13.2% increase between 2009 and 2012 compared with 2002–2005. There remains a lack of approved treatments to prevent disease progression, leaving many liable to developing complications that include multisystem organ failure (OF) and death. This therapeutic deficit raises questions about the scale of the current burden of illness (BOI) associated with severe forms of AP. The aim of the systematic literature review (SLR) was to assess clinical, humanistic, and economic outcomes associated with moderately severe AP (MSAP) and severe AP (SAP) in the USA and the European Union-5 (EU-5). Methods Systematic searches were conducted in MEDLINE and Embase to identify studies published in English (between 2007 and 2017) that reported on the BOI of MSAP and/or SAP. Manual searches of ‘grey’ literature sources were also conducted. Results The SLR identified 19 studies which indicated that 15%–20% of patients with AP progress to more severe forms of the disease, up to 10.5% of those with SAP require surgery for complications, and up to 40% die during hospitalisation. By contrast, there appears to be a lack of data on the extent to which SAP affects patients’ quality of life. Conclusion The available evidence clearly demonstrates that the current management for MSAP and SAP in the USA and EU-5 does not adequately meet patients’ needs. Early identification and intervention for AP is crucial, given the evidence of high rates of morbidity and an associated economic burden that is considerable. Since many patients with the condition present to hospitals at a point when multisystem OF or death is highly likely, there is a particularly urgent need for effective treatment options to prevent disease progression.

New Risk Factors for Infected Pancreatic Necrosis Secondary to Severe Acute Pancreatitis: The Role of Initial Contrast-Enhanced Computed Tomography

Article

Full-text available

Feb 2019
DIGEST DIS SCI

Background and Aims Pancreatic necrosis is a risk factor for poor prognosis of acute pancreatitis (AP). However, the associations between the findings on initial contrast-enhanced computed tomography (CT) of the pancreas and infected pancreatic necrosis (IPN) are unclear. Methods This was a retrospective cohort study. Patients with severe AP (SAP) from January 2014 to December 2016 at the First Affiliated Hospital of Nanchang University were enrolled and assigned to an IPN group and a non-IPN group. Univariate and multivariate logistic regression analyses were sequentially performed to assess the associations between the variables and IPN development. A receiver operating characteristic (ROC) curve was generated for the qualified independent risk factor. Results Forty-two patients with IPN were compared with 100 patients without IPN. Contrast-enhanced CT was performed 7 (range 3–10) days after AP onset. Multivariate stepwise logistic regression analyses showed that the number of acute peripancreatic fluid collections (APFCs) (OR 1.328, P = 0.006), presence of peripancreatic and pancreatic parenchymal necrosis (OR 4.001, P = 0.001), and gastrointestinal wall thickening (OR 3.353, P = 0.006) were independent risk factors for IPN secondary to SAP. The area under an ROC curve for the number of APFCs was 0.714, the sensitivity was 78.60%, and the specificity was 57.30% at a cutoff value of 4.5. Conclusions The number of APFCs, presence of peripancreatic and pancreatic parenchymal necrosis, and gastrointestinal wall thickening were independent risk factors associated with IPN. As initial contrast-enhanced CT (about 7 days from AP onset) plays an important role in predicting IPN, it is important for clinicians to consider initial imaging of the pancreas.

Clinico-radiological comparison and short-term prognosis of single acute pancreatitis and recurrent acute pancreatitis including pancreatic volumetry

Article

Full-text available

Oct 2018
PLOS ONE

PURPOSE:The necrosis-fibrosis hypothesis describes a continuum between single attacks of acute pancreatitis (SAP), recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) with endocrine and exocrine pancreatic insufficiency. For prevention purposes we evaluated clinico-radiological parameters and pancreatic volumetry to compare SAP and RAP and provide prognostic relevance on short-term mortality, need for intervention and the hospitalization duration. MATERIALS AND METHODS:We retrospectively investigated 225 consecutive patients (150 males, range 19-97years) with acute pancreatitis (74%SAP, 26%RAP) according to the revised Atlanta classification. All patients received an intravenous contrast-enhanced CT after a median time of 5 (IQR 5-7) days after onset of symptoms. Two experienced observers rated the severity of AP by 3 CT scores (CTSI, mCTSI, EPIC). Moreover, total pancreatic volumes and additional parenchymal necrosis volumes were assessed, when appropriate. Clinical parameters were etiology of AP, lipase on admission, CRP 48 hours after admission (CRP48), and the presence of organ dysfunction, assessed by the modified Marshall score. The modified Marshall score included systolic blood pressure, serum creatinine, and the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2 ratio) and was assessed on admission and 48 hours after admission to find patients with persistent organ failure. Outcome parameters were total hospitalization duration, short-term mortality and need for intervention. RESULTS:Lipase, CRP48, etiology of AP, EPIC, PaO2/FiO2 ratio, and the presence of a pleural effusion differed significantly in both groups (p

ACR Appropriateness Criteria® Acute Pancreatitis

Article

Nov 2019
J Am Coll Radiol

Acute pancreatitis (AP) is divided into two types: interstitial edematous and necrotizing. AP severity is classified clinically into mild, moderately severe, and severe, depending on the presence and persistence of organ failure and local or systemic complications. The revised Atlanta classification divides the clinical course of AP into an early (first week) and late phase (after first week) and the clinical phase determines the role of imaging. Imaging has a limited role in the early phase. In the early phase with typical presentations of AP, ultrasound is usually the only appropriate modality and is used for the detection of gallstones. CT and MRI are appropriate in the early phase in equivocal presentations. In the late phase (or at least 48-72 hours after presentation), CT and MRI play a primary role in the imaging of patients with AP for evaluation of etiology, complications, extent of disease, intervention, and follow-up; CT is particularly useful in patients with suspected acute hemorrhage. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Determinant-Based Classification of Acute Pancreatitis Severity. An international Multidisciplinary Consultation

Article

Dec 2012

To develop a new international classification of acute pancreatitis severity on the basis of a sound conceptualframework.comprehensive reviewof published evidence and worldwide consultation.

Dual-Energy CT in Evaluation of the Acute Abdomen

Article

Jan 2019

Evaluation of the nontraumatic acute abdomen with multidetector CT has long been accepted and validated as the reference standard in the acute setting. Dual-energy CT has emerged as a promising tool, with multiple clinical applications in abdominal imaging already demonstrated. With its ability to allow characterization of materials on the basis of their differential attenuation when imaged at two different energy levels, dual-energy CT can help identify the composition of internal body constituents. Therefore, it is possible to selectively identify iodine to assess the enhancement pattern of an organ, including the identification of hyperenhancement in cases of inflammatory processes, or ischemic changes secondary to vascular compromise. Quantification of iodine uptake with contrast material-enhanced dual-energy CT is also possible, and this quantification has been suggested to be useful in differentiating inflammatory from neoplastic conditions. Dual-energy CT can help determine the composition of gallstones and urolithiasis and can be used to accurately differentiate uric acid urinary calculi from non-uric acid urinary calculi. Moreover, dual-energy CT is capable of substantially reducing artifacts caused by metallic prostheses, to improve the imaging evaluation of abdominopelvic organs. The possibility of creating virtual nonenhanced images in the evaluation of acute aortic syndrome, gastrointestinal hemorrhage and ischemia, or pancreatic pathologic conditions substantially reduces the radiation dose delivered to the patient, by eliminating a true nonenhanced acquisition. Finally, by increasing the iodine conspicuity, contrast-enhanced dual-energy CT can render an area of free active extravasation or endoleak more visible, compared with conventional single-energy CT. This article reviews the basics of dual-energy CT and highlights its main clinical applications in evaluation of the nontraumatic acute abdomen.

Natural Course of Asymptomatic Walled Off Pancreatic Necrosis

Article

Oct 2018
DIGEST LIVER DIS

Introduction: There is paucity of data on natural course of asymptomatic walled off necrosis (WON). Objective: To study the natural course as well as outcome of conservative management in patients with asymptomatic WON. Methods: Retrospective analysis of prospectively maintained data base of patients with asymptomatic WON presenting to us 4-6 weeks after an episode of acute necrotising pancreatitis (ANP). Results: Forty three patients (37 M; mean age: 38.2 ± 10.4 years) with asymptomatic WON were studied. The size of WON ranged from 5 to 16 cm (mean 8.2 ± 2.2 cm). The site of WON was head, body and tail in 5 (11%), 34 (79%) and 4 (10%) patients respectively. Thirty of 43 patients (70%) patients did not have any complications during the expectant management period of 3 weeks-32 months with 13 (30%) patients having spontaneous resolution within 6.2 ± 3.4 months. Thirteen (30%) patients became symptomatic or developed complication within 3.2 ± 1.3 months. These were refractory pain (n = 7), infection (n = 4), spontaneous rupture into gastrointestinal tract (n = 5; stomach in 3, duodenum in 1 and colon in 1 patient respectively) and bleeding from splenic artery pseudoaneursym in 1 patient. Conclusions: Majority of patients with asymptomatic WON have an uneventful clinical course. However, one third patients will develop symptoms/complications requiring interventional treatment.

Maximizing the Use of Scoring Systems in the Prediction of Outcomes in Acute Pancreatitis

Article

Sep 2018

Background/aims: No single classification system has so far effectively predicted the severity for Acute Pancreatitis (AP). This study compares the effectiveness of classification systems: Original Atlanta (OAC), Revised Atlanta (RAC), Determinant based classification (DBC), PANC 3, Harmless AP Score (HAPS), Japanese Severity Score (JSS), Symptoms Nutrition Necrosis Antibiotics and Pain (SNNAP), and Beside Index of Severity for AP (BISAP) in predicting outcomes in AP. Methods: Scores for BISAP, Panc 3, HAPS, SNNAP, OAC, RAC, and DBC were calculated for 221 adult patients hospitalized for AP. Receiver Operating Characteristic curve analysis and Akaike Information Criteria were used to compare the effectiveness of predicting need for surgery, intensive care unit (ICU) admission, readmission within 30 days, and length of hospital stay. Results: Both the RAC and the DBC strongly predict the length of hospital stay (p < 0.0001 for both) and ICU admission (p < 0.0001 for both). Additionally, both BISAP and PANC 3 showed weak predictive capacity at identifying length of stay and ICU admission. Conclusions: We suggest that BISAP and PANC3 be obtained within the initial 24 h of hospitalization to offer an early prediction of length of stay and ICU admission. Subsequently, RAC and DBC can offer further information later in the course of the disease.

CT imaging, classification, and complications of acute pancreatitis

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