An early CT may be misleading
concerning the severity of the
pancreatitis, since it can underestimate
the presence and amount of necrosis.
Early CT is only recommended when the
diagnosis is uncertain, or in case of
suspected early complications such as
perforation or ischemia.
The widespread clinical practice of relying solely on
hyperamylasemia to establish the diagnosis of acute alcoholic
pancreatitis is unjustified and should be abandoned.
Serum lipase was measured in 65 of these normoamylasemic cases and was
found to be elevated in 68%.thus increasing diagnostic sensitivity from 81% when
amylase alone is used to 94% for both enzymes.
there is normal enhancement of the entire pancreatic gland with
only mild surrounding fatty infiltration.
There are no fluid collections or necrosis
(Balthazar grade C, CTSI: 2).
on day 18 there is expansion of
the peripancreatic collections.
There are two or more
collections, but no pancreatic
(Balthazar grade E, CTSI: 4)
In exudative pancreatitis, or better
called EXPN, there is normal
enhancement of the entire
pancreas associated with extensive
These are often heterogeneous in
appearance and may be
EXPN consists of necrosis of
peripancreatic fat, extravasated
pancreatic fluid and inflammatory
and hemorrhagic components.
When peripancreatic collections
persist or increase, it is usually due
to the presence of fat necrosis (i.e.
Since fat does not enhance on CT,
we cannot diagnose fat necrosis.
There are 2 or more fluid collections
and more than 50% of the gland does
(Balthazar grade E, CTSI :10).
Body and tail of the
pancreas do not enhance
after i.v. contrast (blue
There is however normal
enhancement of the
pancreatic head (yellow
More than 50% of the
pancreas is necrotic and
there are at least two
collections (CTSI : 10)
Central gland necrosis
Central gland necrosis is a
subtype of necrotizing
It represents necrosis between
the pancreatic head and tail
and is nearly always
associated with disruption of
the pancreatic duct.
This leads to persistent
collections as the viable
pancreatic tail continues to
secrete pancreatic juices.
These collections react poorly to
endoscopic or percutaneous
Central gland necrosis
Two weeks later the
collection in the omental
bursa and pancreatic
body has increased
The pancreatic tail still
enhances and so does
the pancreatic head
Based on imaging
alone it is often not
possible to determine
collections contain fluid
or necrotic tissue and
whether they are
infected or not.
of naming them as
'necrosis', it is better to
describe them as
There is a collection in the area of the pancreatic head in the right anterior pararenal space.
On a follow up scan the collection is larger.
One day later the patient developed septicaemia and percutaneous drainage was performed.
After drainage the collection has barely diminished in size and consequently there was suspicion of necrotic
The patient therefore underwent surgery and the collection was found to consist of necrotic debris,
The necrotic debris was too thick for successful percutaneous drainage.
infected necrosis is:
Infection of necrotic pancreatic
And/or necrotic extrapancreatic fatty
Usually occurs in the 2nd-3rd week.
Most severe local complication of
Most common cause of death in
patients with acute pancreatitis
Air bubbles are seen in 20% of
cases with infected necrosis.
Infected necrosis (2)
• here is a normal
enhancement of the
with fluid- and fat
• Two weeks later there
are air bubbles in the
consistent with infected
Collection of pancreatic juice
enclosed by a wall of fibrous
Absence of necrotic tissue is
imperative for its diagnosis
Often communication with the
Requires 4 or more weeks to
On CT we cannot diagnose a
collection with certainty as a
pseudocyst, since it is usually
not possible to determine what
the content of a collection is
collection contained fluid
and necrotic tissue which
was removed from the
area of the pancreas
CT of an ICU patient on day
40 with central gland
necrosis with a spiking
The CT shows a similar
collection to that of the
previous patient, exept for
its pancreatic location.
The collection is
homogeneous and welldemarcated with a thin wall
abutting the stomach.
well-demarcated with an
Since this patient had
fever and multiple
organ failure, this
collection was suspected
to be infected necrosis
and not a pseudocyst.
At surgery the collection
contained a lot of
necrotic debris, which
was not recognizable on
Take home messages
Severity of acute pancreatitis and pancreatic necrosis can only
be reliably assessed by imaging after 72 hours.
Absence of pancreatic parenchymal necrosis does not
preclude a serious course of the illness.
CT can not reliably differentiate between collections that
consist of fluid and those that contain solid debris.
In these cases MRI can be of additional value.
Name collections always according to 2012 Atlanta definitions.
Central gland necrosis is a subtype of necrotizing pancreatitis
with important implications.