Pancreatitis scoring and terminology


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this lecture focuses on two points:scoring of pancreatitis ,and the new Atlanta 2012 terminology of acute pancreatitis

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Pancreatitis scoring and terminology

  1. 1. Pancreatitis... scoring and new atlanta terms Dr/Ahmed Bahnassy Consultant radiologist
  2. 2. causes and outcomes
  3. 3. Imaging golden rule 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.
  4. 4. too early CT misleading exam
  5. 5. Alcoholic pancreatitis special issue 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.
  6. 6. scoring of severity c i io icht d ayhe nspw
  7. 7. Interstitial pancreatitis 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).
  8. 8. Exudative Pancreatitis on day 18 there is expansion of the peripancreatic collections. There are two or more collections, but no pancreatic necrosis. (Balthazar grade E, CTSI: 4) In exudative pancreatitis, or better called EXPN, there is normal enhancement of the entire pancreas associated with extensive peripancreatic collections. These are often heterogeneous in appearance and may be progressive. 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. EXPN). Since fat does not enhance on CT, we cannot diagnose fat necrosis.
  9. 9. Necrotizing Pancreatitis There are 2 or more fluid collections and more than 50% of the gland does not enhance (Balthazar grade E, CTSI :10).
  10. 10. Necrotizing Pancreatitis Body and tail of the pancreas do not enhance after i.v. contrast (blue arrows). There is however normal enhancement of the pancreatic head (yellow arrow). More than 50% of the pancreas is necrotic and there are at least two collections (CTSI : 10)
  11. 11. Central gland necrosis Central gland necrosis is a subtype of necrotizing pancreatitis. 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 drainage. serious Dx
  12. 12. Central gland necrosis Two weeks later the collection in the omental bursa and pancreatic body has increased significantly. The pancreatic tail still enhances and so does the pancreatic head (arrows).
  13. 13. Peripancreatic Collections resolution
  14. 14. Based on imaging alone it is often not possible to determine whether these collections contain fluid or necrotic tissue and whether they are infected or not. Consequently, instead of naming them as 'pseudocysts', 'abscesses' or 'necrosis', it is better to describe them as 'peripancreatic collections'. 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 tissue. 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.
  15. 15. Infected necrosis infected necrosis is: Infection of necrotic pancreatic parenchyma And/or necrotic extrapancreatic fatty tissue Usually occurs in the 2nd-3rd week. Most severe local complication of acute pancreatitis Most common cause of death in patients with acute pancreatitis Air bubbles are seen in 20% of cases with infected necrosis. ==
  16. 16. Infected necrosis (2) • here is a normal enhancement of the pancreas with surrounding septated heterogeneous peripancreatic collections with fluid- and fat densities . • Two weeks later there are air bubbles in the peripancreatic collection, consistent with infected necrosis. 2 weeks later
  17. 17. Pseudocyst • • • • • Collection of pancreatic juice enclosed by a wall of fibrous tissue Absence of necrotic tissue is imperative for its diagnosis Often communication with the pancreatic duct Requires 4 or more weeks to develop 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
  18. 18. During endoscopic debridement this 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 fever. 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.
  19. 19. another example 25 d...Homogeneous pancreatic and peripancreatic collection, well-demarcated with an enhancing wall. 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 CT.
  20. 20. role of MRI collection debris
  21. 21. lessons learned
  22. 22. New atlanta definitions
  23. 23. Interstitial edematous pancreatitis Interstitial edematous pancreatitis Acute peripancreatic fluid collection pancreatic pseudocyst
  24. 24. Acute necrotizing pancreatitis. Acute necrotizing pancreatitis acute necrotic collection walled off cystic necrosis
  25. 25. Interstitial edematous pancreatitis acute peripancreatic fluid collection acute necrotizing pancreatitis acute necrotic collection d 0 to d 28
  26. 26. after 28 IEP acute necrotizing pan. pancreatic pseudocyst walled off necrosis
  27. 27. abscess pseudocyst wopn wopn wopn
  28. 28. 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.