Radiographic Evidence of Pancreatitis

Nicole Chow Ahrenholz, MS4

June 2005

Tutorial Overview

• Etiologies of Acute and Chronic Pancreatitis• Clinical Features: History, PE, Labs• Radiographic Evidence

– Abdominal plain films

– Ultrasound

– CT

– ERCP

• Treatment

Etiologies of Acute Pancreatitis

• Gallstones (and other obstructive causes)

• Ethanol• Hyperlipidemia• Hypercalcemia• Drugs (many)

• Infections: mumps, Coxsackie, HIV, Mycoplasma, Toxo

• Trauma• Post-ERCP• Cystic Fibrosis

Etiologies of Chronic Pancreatitis

• Alcohol abuse

• Hereditary pancreatitis

• Ductal obstruction (eg, trauma, pseudocysts, stones, tumors, possibly pancreas divisum)

• Tropical pancreatitis

  

• Systemic disease: SLE, CF, possibly hyperparathyroidism

• Autoimmune pancreatitis

• Idiopathic pancreatitis• Mutations of the cystic

fibrosis gene

(lots of overlap with acute pancreatitis)

Clinical Features: Acute

History• Acute-onset of severe

abdominal pain• Typically epigastric pain,

radiating to back, occasionally RUQ or LUQ

• Nausea, vomiting

Clinical Features: Acute

Physical Exam• Mild: epigastric tenderness,

fever• Severe: shock, abdominal

distension, guarding• Grey-Turner’s sign:

ecchymotic flank discoloration, Cullen’s sign: periumbilical ecchymosis, due to retroperitoneal bleeding (rare)

• Epigastric mass: pseudocyst

http://www.jichi.ac.jp/usr/surg/nagai/AP1.gif

Clinical Features: Acute

Labs

• Elevated pancreatic enzymes: blockage of secretion leads to leakage through basolateral membrane into circulation

• Amylase: sensitivity 75-92%, specificity 20-60%

• Lipase: sensitivity 86-100%, specificity 50-99%

Munoz A and Katerndahl DA. Diagnosis and Management of Acute Pancreatitis. AAFP 2000 62(1).

http://gastroresource.com/GITextbook/en/chapter12/fig2.htm

Clinical Features: Chronic

History:• Abdominal pain• Pancreatic insufficiency

– Fat malabsorption: steatorrhea, Vitamins ADEK deficiency

– Glucose intolerance

• Symptoms chronic with acute exacerbationsLabs:• Pancreatic enzymes often normal

www.aafp.org/afp/ 20000701/164.html

Pancreas Anatomy

Abdominal X-ray

Acute Pancreatitis:

Findings are variable and have low sensitivity

• Normal or

• Localized ileus (“sentinel loop”) or

• “Colon cut-off sign” due to spasm of descending colon from inflammation

http://www.jichi.ac.jp/usr/surg/nagai/AP1.gif

Abdominal X-ray

Chronic Pancreatitis• Calcifications (seen

in 30% of patients)

http://utdol.com/application/image.asp?r=/application/image.asp&file=gast_pix/pancre4%26%2346%3Bgif&title=Pancreatic%20calcification&app=utdol

Abdominal Ultrasound

• Enlarged, hypoechoic pancreas (acute)

• Sensitivity 62-95% in diagnosing acute pancreatitis

• Looking for:– Calcifications– Ductal dilatation– Pseudocysts

Munoz A and Katerndahl DA. Diagnosis and Management of Acute Pancreatitis. AAFP 2000 62(1)

Abdominal Ultrasound

Pseudocyst of pancreatic tail by endoscopic ultrasound (renal vein in color angio)

http://images.google.com/imgres?imgurl=http://www.toshiba-europe.com/Medical/Materials/ImageGallery/EUS6RGB_small.jpg&imgrefurl=http://www.toshiba-D1412%26product_ID%3D1637&h=78&w=104&sz=3&tbnid=-9kW4dbwGiwJ:&tbnh=59&tbnw=79&hl=en&start=9&prev=/images%3Fq%3Dultrasound%2Bpancreatitis%26hl%3Den%26hs%3DeVY%26lr%3D%26client%3Dfirefox-a%26rls%3Dorg.mozilla:en-US:official%26sa%3DG

Abdominal Ultrasound: Acute

Pseudocyst

http://www.emedicine.com/ped/topic3014.htm

Abdominal CT

• Best study for acute pancreatitis, also helpful in chronic pancreatitis

• CT in acute pancreatitis: sensitivity 60%, specificity 98%

• Looking for:– Peripancreatic inflammation– Necrosis– Pseudocysts– Calcifications– Dilated common bile duct

Ahn SH. Mayo-Smith WW. Murphy BL. Reinert SE. Cronan JJ. Acute nontraumatic abdominal pain in adult patients: abdominal radiography compared with CT evaluation. Radiology. 225(1):159-64, 2002 Oct.

Balthazar CT Severity Index

Used as a prognostic tool in acute pancreatitis, predicting severity of disease, necrosis, and organ failure. Other prognostic tools include Ranson criteria and APACHE II and III systems.

Chatzicostas C. et al. Balthazar computed tomography severity index is superior to Ranson criteria and APACHE II and III scoring systems in predicting acute pancreatitis outcome. Journal of Clinical Gastroenterology. 36(3):253-60, 2003 Mar.

Normal Abdominal CT

http://images.google.com/imgres?imgurl=http://www.liv.ac.uk/HumanAnatomy/phd/mbchb/adolescent/xray/ctpancrl.jpg&imgrefurl=http://www.liv.ac.uk/HumanAnatomy/phd/mbchb/adolescent/pancreas.html&h=493&w=723&sz=37&tbnid=lotKZ7OaipgJ:&tbnh=94&tbnw=139&hl=en&start=1&prev=/images%3Fq%3Dpancreas%2Bct%26hl%3Den%26lr%3D%26sa%3DG

6 Body of pancreas7 Tail of pancreas8 IVC9 Common bile duct10 Stomach11 Air bubble12 Spleen

Answers:

Peripancreatic inflammation

Stevens T and Conwell DL. Acute Pancreatitis. http://www.clevelandclinicmeded.com/diseasemanagement/gastro/acutepan/acutepan.htm 2005.

Abdominal CT: Acute

What are the arrows pointing to?

NecrosisContrast-enhanced axial CT section showing peripancreatic and retroperitoneal edema. The arrows point to non-enhancing areas of necrosis.

Munoz A and Katerndahl DA. Diagnosis and Management of Acute Pancreatitis. AAFP 2000 62(1)

Abdominal CT: Acute

What is wrong with this pancreas?

A pseudocyst

http://utdol.com/application/image.asp?file=gast_pix/pancre3%26%2346%3Bgif&title=Pancreatic%20pseudocyst%20CT

Abdominal CT: Acute

What is wrong with this pancreas?

Abdominal CT: Chronic

Dilated main pancreatic duct

http://www.medscape.com/content/2003/00/44/28/442814/442814_fig.html

What is the arrow pointing to?

Calcifications

http://www.nlm.nih.gov/medlineplus/ency/imagepages/1157.htm

Identify

Abdominal CT: Chronic

ERCP: Acute

• Limited role in diagnosis of acute pancreatitis

• Indicated in severe disease due to biliary obstruction

• Diagnostic AND therapeutic (sphincterotomy can be done to relieve obstruction)

ERCP: Chronic Pancreatitis

“Beading” of main pancreatic duct

http://www.medscape.com/content/2003/00/44/28/442814/442814_fig.html

http://utdol.com/application/image.asp?file=gast_pix/chroni16%26%2346%3Bgif&title=Chronic%20pancreatitis%20ERCP

ERCP

Treatment

Usually conservative management• Monitor for shock, sepsis, ARDS• IV fluids• Pain control: meperidine (morphineSphincter of

Oddi spasm?)• NPO• NG for protracted vomiting• Antibiotics (controversial), mostly reserved for

necrotizing pancreatitis

SourcesAhn SH. Mayo-Smith WW. Murphy BL. Reinert SE. Cronan JJ. Acute nontraumatic abdominal

pain in adult patients: abdominal radiography compared with CT evaluation. Radiology. 225(1):159-64, 2002 Oct.

Chari ST and Vege SS. Clinical manifestations and diagnosis of acute pancreatitis. UpToDate 2005.

Chatzicostas C. Roussomoustakaki M. Vardas E. Romanos J. Kouroumalis EA. Balthazar computed tomography severity index is superior to Ranson criteria and APACHE II and III scoring systems in predicting acute pancreatitis outcome. Journal of Clinical Gastroenterology. 36(3):253-60, 2003 Mar.

Freeman SD. Clinical manifestations and diagnosis of chronic pancreatitis. UpToDate 2005.Freeman SD and Bishop MD. Etiology and pathogenesis of chronic pancreatitis. UpToDate

2005.Munoz A and Katerndahl DA. Diagnosis and Management of Acute Pancreatitis. American

Academy of Family Physicians 2000 62(1)Stevens T and Conwell DL. Acute Pancreatitis.

http://www.clevelandclinicmeded.com/diseasemanagement/gastro/acutepan/acutepan.htm 2005.

Thomas PB. Pancreatitis and Pancreatic Pseudocyst. EMedicine 2004.Radiograph citations listed on individual slides