Imaging of Acute Pancreatitis

IMAGING OF ACUTE PANCREATITIS
Ade Handayani
120070100071
Reseptor
dr. Dessy Wimelda, SpRad
Owen J. O Connor, Sebastian McWilliams and Michael M. Maher.

American Journal of Roentgenology. 2011;197: W221-W225.
10.2214/AJR.10.4338
EDUCATIONAL OBJECTIVES
Acute pancreatitis : acute inflammatory process of the pancreas that may also
involve adjacent or remote tissues and organs.
Imaging : frequently recommended to confirm the clinical diagnosis,

ascertain the cause, and grade the extent and severity of acute pancreatitis.
Radiography, upper gastrointestinal series, and ultrasound  limited value

in the diagnosis of acute pancreatitis.
CT : plays an important role in patients with acute pancreatitis, the

identification of complications, and assessing the response to treatment.
MRI is used less commonly than CT.

2
INTRODUCTION
 Acute pancreatitis : an important cause of

acute abdominal pain.
 Imaging plays a central role :
o Management of selected cases
o Complementing laboratory investigations
o Confirm the clinical diagnosis
o Aids in the early detection of
complications .
3
Causes of Acute Pancreatitis
4
In practice, serum amylase or lipase levels greater than three times
normal  confirm acute pancreatitis
5
Pathophysiologic Basis
Acute pancreatitis may be classified based on :

 Clinical,
 Morphologic,
 Histologic criteria
 The others systems of classification exist, most based on the cause or
severity
6
Grading of Disease Severity
THE SEVERITY OF
ACUTE PANCREATITIS
MILD SEVERE
o 10% and 20% of cases
o Acute interstitial pancreatitis o Severe abdominal pain, vomiting, and
o Minimal or no organ and systemic dysfunction clinical signs of peritonism with tachycardia,
o Respond quickly to medical therapy, fever, and leukocytosis.
o The symptoms and laboratory values should o Systemic or organ failure with renal,
normalize promptly respiratory, and cardiovascular failure; DIC;
or gastrointestinal hemorrhage 7
EPIDEMIOLOGY
The incidence of acute pancreatitis is approximately 5–70 cases

per 100,000 per year
70% of
Cases
8
EPIDEMIOLOGY
Acute pancreatitis has a higher incidence in men
Gallstone acute pancreatitis is most frequent in

women (generally between 40 and 50 years old)
9
Second attack of acute pancreatitis was associated with a 38% incidence of
chronic pancreatitis.
second attack of acute pancreatitis
was associated with a 38% incidence
of chronic pancreatitis [17]. The incidence of
acute pancreatitis is increasing, and a 100%
increase in the number of hospitalizations
over the past two decades has been recorded
in the United States
 Incidence of acute pancreatitis is increasing,

 A 100% increase in the number of
hospitalizations over the past two decades has
been recorded in the United States
10
INDICATIONS FOR IMAGING
o The clinical signs of acute pancreatitis are nonspecific

o Elevated plasma serum amylase and lipase levels are not specific and may be elevated
by bowel obstruction, infarction, cholecystitis, and perforated ulcer.
Imaging
 The British Society of Gastroenterology guidelines recommend imaging between 3 and 10

days after presentation.
 Some groups recommend imaging within 24 hours to identify the cause of acute
pancreatitis
11
Indications for CT Imaging in Acute Pancreatitis
12
VARIATIONS IN CT TECHNIQUE
Single-phase Dual-phase Three-phase
Risks missing (control, pancreatic

Subsequent imaging hemorrhagic parenchymal, and
collections portal venous phase)
with CT in the
portal venous phase
The pancreatic
Thin-slice parenchymal phase is
(3 mm) the optimal phase for
assessment for necrosis
13
o Using positive oral contrast material  mask hemorrhage or calculi  many
institutions use negative oral contrast.
o IV administration of iodinated contrast material  increase the severity and
duration of acute pancreatitis  conflicting opinions
o At present the benefits of IV contrast administration appear to outweigh the
potential risks
MRI is particularly useful for the imaging of patients :

 Iodine allergies;
 for the characterization of collections in cases in which there is diagnostic
uncertainty;
 for evaluating the biliary tract
14
Radiography
Conventional radiography and upper gastrointestinal series no longer play an important
role in the diagnosis of acute pancreatitis.
Radiographic signs of acute pancreatitis :

• Sentinel loop sign (dilated air-filled
duodenum or jejunum),
• Colon cutoff sign (dilated large bowel to
the level of the splenic flexure),
• Loss of the left psoas shadow,
• Ascites,
• Gasless abdomen
• Pleural effusions*
• Atelektasis*
• An elevated hemidiaphragm* Colon cutoff sign
*  severe acute pancreatitis. Sentinel loop sign
15
USG
 Sonography of patients with acute
pancreatitis is often negatively
impacted.
 Abnormal ultrasound findings are seen
in 33–90% of patients with acute
pancreatitis.
 USG : not useful for the detection of
necrosis  to the detection of
cholelithiasis and choledocholithiasis
and identification of fluid collections
in the peritoneum, retroperitoneum,
and pleural spaces
16
CT Scan
Contrast-enhanced CT is the imaging MODALITY OF CHOICE for the diagnosis and
staging of acute pancreatitis
• Local edema is a common finding and may

extend along the mesentry, mesocolon, and
hepatoduodenal ligament and into
peritoneal spaces.
• Extension of edematous fluid into the
anterior perirenal space may create a mass
effect and a halo sign with sparing of the
perinephric fat.
17
CT Scan
 Peripancreatic fluid collections consist of exudate, peripancreatic fat tissue

necrosis, or hemorrhage.
 An organized peripancreatic fluid collection with a fibrous wall occurring
greater than 4 weeks after the onset of symptoms  “pseudocyst”.
18
 Nonenhancement of all or part of the
gland is termed “necrosis”
 CT is 100% specific for necrosis
 Necrosis develops between 24 and 48
hours after the onset
 Pancreatic abscess formation is usually

observed 4–6 weeks after the onset 
may enhance with IV contrast
 Necrosis and abscess are considered
among the most important imaging
features of acute pancreatitis
19
MRI
o The imaging of acute pancreatitis using MRI is
comparable with that of CT
o MRI may be performed using unenhanced and
contrast-enhanced T1-weighted and fat-
suppressed T2-weighted gradient-echo sequences.
o An enlarged edematous gland that is low signal
on T1-weighted and high signal on T2-weighed
MRI is observed.
o Acute pancreatitis is sometimes associated with
pancreatic ductal dilatation
20
CONCLUSION
Imaging plays an important role in the management of the

patient with acute pancreatitis.
CT in particular has revolutionized pancreatic imaging, and

what was once considered a hidden organ may now be
accurately and noninvasively imaged.
21
THANK YOU
22

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IMAGING OF ACUTE PANCREATITIS

Owen J. O Connor, Sebastian McWilliams and Michael M. Maher.

Imaging : frequently recommended to confirm the clinical diagnosis,

Radiography, upper gastrointestinal series, and ultrasound  limited value

CT : plays an important role in patients with acute pancreatitis, the

MRI is used less commonly than CT.

 Acute pancreatitis : an important cause of

Acute pancreatitis may be classified based on :

The incidence of acute pancreatitis is approximately 5–70 cases

Acute pancreatitis has a higher incidence in men

Gallstone acute pancreatitis is most frequent in

 Incidence of acute pancreatitis is increasing,

o The clinical signs of acute pancreatitis are nonspecific

 The British Society of Gastroenterology guidelines recommend imaging between 3 and 10

Single-phase Dual-phase Three-phase

Risks missing (control, pancreatic

MRI is particularly useful for the imaging of patients :

Radiographic signs of acute pancreatitis :

• Local edema is a common finding and may

 Peripancreatic fluid collections consist of exudate, peripancreatic fat tissue

 Pancreatic abscess formation is usually

Imaging plays an important role in the management of the

CT in particular has revolutionized pancreatic imaging, and

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