Complications of Acute Complications of Acute
Pancreatitis: Radiologic Pancreatitis: Radiologic
EvaluationEvaluation
AllonAllon Beck, Harvard Medical School, Beck, Harvard Medical School,
Year IIIYear III
Gillian Lieberman, MDGillian Lieberman, MD
January 2005Allon Beck, HMS III
Gillian Lieberman, MD
ObjectivesObjectives
Anatomy of the pancreasAnatomy of the pancreas
Overview of pancreatitisOverview of pancreatitis
Role of imaging in pancreatitisRole of imaging in pancreatitis
Illustrative cases with complicationsIllustrative cases with complications
Allon Beck, HMS III
Gillian Lieberman, MD
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Pancreas anatomyPancreas anatomy
Liver
Gall Bladder
Duodenum
Allon Beck, HMS III
Gillian Lieberman, MD
Right and Left
gastroepiploic
arteries
Stomach
Pancreas
Spleen
Celiac trunk
Common
hepatic artery
Splenic artery
Superior
Mesenteric
Artery
Aorta
From Virtual Hospital: http://www.vh.org/adult/provider/anatomy/atlasofanatomy/
Left gastric
artery
3
Anatomy cont’d: posterior viewAnatomy cont’d: posterior view
Allon Beck, HMS III
Gillian Lieberman, MD
From Virtual Hospital: http://www.vh.org/adult/provider/anatomy/atlasofanatomy/
Spleen
Liver
Pancreas
Duodenum
IVC
Splenic artery
Splenic vein
Inferior
Mesenteric
Vein
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Acute PancreatitisAcute Pancreatitis
Approx. 185,000 cases/yr in USApprox. 185,000 cases/yr in US
75% caused by 75% caused by EtOHEtOH and gallstonesand gallstones
Other causes:Other causes:
Drugs Drugs ((ddIddI, , metronidazolemetronidazole, , furosemidefurosemide, , valproicvalproic acid…)acid…) (2(2--5%)5%)
HypertriglyceridemiaHypertriglyceridemia (>1000 mg/(>1000 mg/dLdL)) (1(1--4%)4%)
HypercalcemiaHypercalcemia
Infection Infection (Mumps, viral (Mumps, viral hephep, , coxsackieviruscoxsackievirus, , ascariasisascariasis))
Pancreas Pancreas divisumdivisum
(Scorpion venom)(Scorpion venom)
Allon Beck, HMS III
Gillian Lieberman, MD
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Patient 1: Patient SDPatient 1: Patient SD
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Gillian Lieberman, MD
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Patient SDPatient SD
58 58 y/oy/o F presents w/1 week of acute F presents w/1 week of acute
epigastricepigastric pain, worse w/fatty foodspain, worse w/fatty foods
PMHxPMHx: HTN, hypothyroidism, depression: HTN, hypothyroidism, depression
SHxSHx: 30+ years : 30+ years EtOHEtOH abuseabuse
PE: Temp: 99.8. No PE: Temp: 99.8. No organomegalyorganomegaly, ,
ascitesascites. O/W unremarkable. O/W unremarkable
Labs: WNL except: WBC: 14.8; Amy: 215; Labs: WNL except: WBC: 14.8; Amy: 215;
Lipase: >2000Lipase: >2000
U/S: Gallstones, no dilatation of CBD.U/S: Gallstones, no dilatation of CBD.
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DiagnosisDiagnosis
HxHx: : EtOHEtOH and/or and/or cholelithiasischolelithiasis, previous , previous
episodesepisodes
Abdominal/Abdominal/epigastricepigastric pain +/pain +/-- radiation to radiation to
backback
Elevated serum lipase (amylase), Elevated serum lipase (amylase),
leukocytosisleukocytosis, , hypocalcemiahypocalcemia, hyperglycemia, hyperglycemia
Allon Beck, HMS III
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Role of ImagingRole of Imaging
Abdominal Plain Film Abdominal Plain Film
Usually to Usually to r/or/o other causes of abdominal other causes of abdominal
pain pain –– esp. perforated esp. perforated viscusviscus
May show nonspecific focal May show nonspecific focal ileusileus due to due to
irritation: “sentinel loop.”irritation: “sentinel loop.”
Allon Beck, HMS III
Gillian Lieberman, MD
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Allon Beck, HMS III
Gillian Lieberman, MD
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From Pickhardt, Radiology: 2000
Coned-down Abdominal X-Ray
Shows dilated colon with
abrupt cutoff: Colon
cutoff sign, indicative of
inflammation
Role of Imaging IIRole of Imaging II
UltrasoundUltrasound
Can show Can show cholelithiasischolelithiasis, dilated bile ducts, dilated bile ducts
Absence of findings does not Absence of findings does not r/or/o gallstonegallstone--
induced pancreatitisinduced pancreatitis
Findings do not clinch diagnosisFindings do not clinch diagnosis
Pancreatitis associated with Pancreatitis associated with cholelithiasischolelithiasis
usually warrants usually warrants cholecystectomycholecystectomy
Limited by bowel gas, depth of pancreasLimited by bowel gas, depth of pancreas
Endoscopic US can show Endoscopic US can show pseudocystpseudocyst
Allon Beck, HMS III
Gillian Lieberman, MD
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Allon Beck, HMS III
Gillian Lieberman, MD
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Abdominal Ultrasound: Cholelithiasis
Images from BIDMC PACS
Findings: Multiple echogenic gallstones, no CBD dilatation. Pancreas poorly visualized
Endoscopic US: Pancreatic Endoscopic US: Pancreatic PseudocystPseudocyst
Allon Beck, HMS III
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From: Digestive Disease Center, Medical University of South Carolina
http://www.ddc.musc.edu/
Looking posteriorly
from the fundus of
the stomach
Shows homogenously
anechoic region with
through-transmission,
with poorly defined
walls, consistent with a
pseudocyst.
Role of Imaging III: CTRole of Imaging III: CT
Most commonly used modality to image Most commonly used modality to image
pancreaspancreas
Can accurately visualize pancreatitisCan accurately visualize pancreatitis--
induced changes:induced changes:
Minimal edemaMinimal edema
PseudocystsPseudocysts
HemorrhageHemorrhage
NecrosisNecrosis
Erosion into adjacent structuresErosion into adjacent structures
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Role of Imaging III: CT cont’dRole of Imaging III: CT cont’d
Diagnostic changes can sometimes be Diagnostic changes can sometimes be
visualized when serological tests are visualized when serological tests are
negativenegative
Major use: When diagnosis is uncertain or Major use: When diagnosis is uncertain or
when complications are known or when complications are known or
suspectedsuspected
Allon Beck, HMS III
Gillian Lieberman, MD
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Patient SD’s CT:Patient SD’s CT:
Allon Beck, HMS III
Gillian Lieberman, MD
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Allon Beck, HMS III
Gillian Lieberman, MD
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BIDMC PACS
Patient SD’s CT: Cont’dPatient SD’s CT: Cont’d
Findings: Findings:
Distended GB (white arrows)Distended GB (white arrows)
Extensive Extensive peripancreaticperipancreatic stranding and free stranding and free
fluid (yellow arrows)fluid (yellow arrows)
Pancreas enhances homogeneously: no Pancreas enhances homogeneously: no
evidence of necrosis, hemorrhage, or evidence of necrosis, hemorrhage, or
pseudocystpseudocyst
CT Diagnosis: Mild pancreatitisCT Diagnosis: Mild pancreatitis
Allon Beck, HMS III
Gillian Lieberman, MD
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A more severe case…A more severe case…
Allon Beck, HMS III
Gillian Lieberman, MD
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Patient NAPatient NA
55 55 y/oy/o F presents with 2 days of 7/10 F presents with 2 days of 7/10
epigastricepigastric and RUQ pain, nausea, vomitingand RUQ pain, nausea, vomiting
SHxSHx: Occasional : Occasional EtOHEtOH
Labs included elevated Labs included elevated bilirubinbilirubin, elevated , elevated
amylase and elevated lipase, WBC count amylase and elevated lipase, WBC count
of 19.of 19.
CT:CT:
Allon Beck, HMS III
Gillian Lieberman, MD
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Patient Patient NA’sNA’s CTCT
Allon Beck, HMS III
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BIDMC PACS
FindingsFindings
IllIll--defined nondefined non--enhancing lowenhancing low--attenuation attenuation
area in body of pancreas w/o defined wall area in body of pancreas w/o defined wall
(blue circles)(blue circles)
Marked Marked peripancreaticperipancreatic stranding (yellow stranding (yellow
arrows)arrows)
Dilated pancreatic duct (red arrow)Dilated pancreatic duct (red arrow)
CT Diagnosis: Necrotizing pancreatitisCT Diagnosis: Necrotizing pancreatitis
Allon Beck, HMS III
Gillian Lieberman, MD
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6 weeks later…6 weeks later…
Allon Beck, HMS III
Gillian Lieberman, MD
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BIDMC PACS
Large
pseudocyst
Role of Imaging IV: MRIRole of Imaging IV: MRI
Better softBetter soft--tissue contrast than CTtissue contrast than CT
Gadolinium contrast safer than iodine, Gadolinium contrast safer than iodine,
safe in renal failuresafe in renal failure
Some evidence iodine contrast can Some evidence iodine contrast can
exacerbate pancreatitisexacerbate pancreatitis
Better differentiation of subtle lesionsBetter differentiation of subtle lesions
Better evaluation of residual tissue when Better evaluation of residual tissue when
extensive necrosis has occurredextensive necrosis has occurred
Allon Beck, HMS III
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MRIMRI
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Images courtesy of Dr. Pedrosa
T2WI
Coronal Fat Sat T2
Coronal Fat Sat T2
Peripancreatic edema (bright on T2 – yellow
arrows)
Filling defect in bile duct (blue arrows)
CT vs. MRICT vs. MRI
Allon Beck, HMS III
Gillian Lieberman, MD
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Courtesy of Dr. Pedrosa
Minimal edema around
Gerota’s fascia (yellow
arrow)
CT vs. MRI cont’dCT vs. MRI cont’d
Allon Beck, HMS III
Gillian Lieberman, MD
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Courtesy of Dr. Pedrosa
Pancreatic duct dilatation (yellow arrow)
Heterogeneous tail enhancement (green
arrow)
Late and heterogeneous tail enhancement
(blue arrows)
T2WI
T2WI
Arterial phase
Allon Beck, HMS III
Gillian Lieberman, MD
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CT vs. MRI cont’d CT vs. MRI cont’d –– 6 weeks later6 weeks later
Courtesy of Dr. Pedrosa
T2WI
Peripancreatic edema (yellow arrows)
Less tail enhancement (green circle)
Heterogeneous area between body
and tail (blue arrow)
Diagnosis: Necrotic pancreatitis,
not seen on CT.
CT vs. MRI cont’dCT vs. MRI cont’d
Allon Beck, HMS III
Gillian Lieberman, MD
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Courtesy of Dr. Pedrosa
CT: Large fluid collection displacing stomach anteriorly
(blue arrows)
Small area of parenchymal enhancement (red arrow)
MR: Gallstones clearly visible (green arrow)
Diffusely necrotic pancreatic parenchyma visible
(yellow arrows) – not visible on CT
MRCP: Patent pancreatic duct (orange arrow) – ERCP
not necessary! – not visible on CT
T2WICT
MRCP
MRI cont’d MRI cont’d –– evaluation of residual evaluation of residual
pancreatic parenchymapancreatic parenchyma
Allon Beck, HMS III
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Courtesy of Dr. Pedrosa
T2WI T2WI with contrast
Left image: some pancreatic parenchyma (green arrows), no change with
contrast – likely necrotic. Is any functional tissue left?...
Allon Beck, HMS III
Gillian Lieberman, MD
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MRI cont’d MRI cont’d –– subtraction of subtraction of
contrast and noncontrast and non--contrast imagescontrast images
Courtesy of Dr. Pedrosa
Most of pancreatic parenchyma is
lost in subtraction (green arrows) –
it has no blood supply and is
necrotic.
One small area remains (red arrow)
that enhanced with contrast but
not without – it has blood supply
and is likely functional.
ConclusionsConclusions
Imaging is useful if diagnosis is unclearImaging is useful if diagnosis is unclear
Ultrasound is used to evaluate for Ultrasound is used to evaluate for cholelithiasischolelithiasis, ,
begin begin w/uw/u for for cholecystectomycholecystectomy if indicatedif indicated
CT with and without contrast if complications are CT with and without contrast if complications are
suspected (severe or prolonged course), or to suspected (severe or prolonged course), or to
f/uf/u known complicationsknown complications
MR used if patient has iodine allergy or renal MR used if patient has iodine allergy or renal
failure, or for subtle findings not ascertainable failure, or for subtle findings not ascertainable
on CTon CT
Allon Beck, HMS III
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ReferencesReferences
Virtual Hospital:
http://www.vh.org/adult/provider/anatomy/atlasofanatomy/
Steer ML, Waxman I, and Freedman S. Medical Progress: Chronic
Pancreatitis. N Engl J Med 1995; 332:1482-1490
Lee JKT, Lee JKT, SagelSagel SS, Stanly RJ (1989). SS, Stanly RJ (1989). Computed body tomography with Computed body tomography with
MRI correlationMRI correlation. (Ch. 14: Pancreas) New York, Raven Press.. (Ch. 14: Pancreas) New York, Raven Press.
BruggeBrugge WR, Van Dam J. Medical Progress: Pancreatic and WR, Van Dam J. Medical Progress: Pancreatic and BiliaryBiliary
Endoscopy. Endoscopy. N N EnglEngl J Med J Med 1999; 341:18081999; 341:1808--18161816
BraunwaldBraunwald E. et al (2001). E. et al (2001). Harrison’s Principles of Internal Medicine, 15Harrison’s Principles of Internal Medicine, 15thth
ed. ed. (Ch. 304: Acute and Chronic Pancreatitis.) McGraw(Ch. 304: Acute and Chronic Pancreatitis.) McGraw--Hill.Hill.
PickhardtPickhardt PJ. Signs In Imaging: The Colon Cutoff Sign. PJ. Signs In Imaging: The Colon Cutoff Sign. Radiology.Radiology. 2000; 2000;
215: 387215: 387--389.389.
Digestive Disease Atlas, Medical University of South Carolina: Digestive Disease Atlas, Medical University of South Carolina:
http://www.ddc.musc.edu/ddc_pro/pro_development/atlases/EUS/benihttp://www.ddc.musc.edu/ddc_pro/pro_development/atlases/EUS/benign.htmgn.htm
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AcknowledgementsAcknowledgements
Dr. Ivan Dr. Ivan PedrosaPedrosa
Dr. Bettina Dr. Bettina SiewertSiewert
Dr. Gillian LiebermanDr. Gillian Lieberman
Pamela Pamela LepkowskiLepkowski
Larry BarbarasLarry Barbaras
Allon Beck, HMS III
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Complications of Acute Pancreatitis: Radiologic Evaluation
Objectives
Pancreas anatomy
Anatomy cont’d: posterior view
Acute Pancreatitis
Patient 1: Patient SD
Patient SD
Diagnosis
Role of Imaging
Slide Number 10
Role of Imaging II
Abdominal Ultrasound: Cholelithiasis
Endoscopic US: Pancreatic Pseudocyst
Role of Imaging III: CT
Role of Imaging III: CT cont’d
Patient SD’s CT:
Slide Number 17
Patient SD’s CT: Cont’d
A more severe case…
Patient NA
Patient NA’s CT
Findings
6 weeks later…
Role of Imaging IV: MRI
MRI
CT vs. MRI
CT vs. MRI cont’d
CT vs. MRI cont’d – 6 weeks later
CT vs. MRI cont’d
MRI cont’d – evaluation of residual pancreatic parenchyma
MRI cont’d – subtraction of contrast and non-contrast images
Conclusions
References
Acknowledgements
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