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Balthazar 1985


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  • 1. Emil J. Baithazar, M.D..4, John H.C Ranson, BM., B.Ch. Acute Pancreatitis: Prognostic Value David P. Naidich, M.D. Alec J. Megibow, M.D. of CT1I’ Robert Caccavale, M.D. Matthew M. Cooper, M.D. In 83 patients with acute pancreatitis, the T HE degree, duration, and type of treatment of acute pancreatitis initial computed tomographic (CT) ex- are based on the early evaluation of the initial attack’s severity. A aminations were classified by degree of Until recently, this evaluation relied mainly on the presence on disease severity (grades A-E) and were absence of varied clinical parameters such as tachycardia, fever, correlated with the clinical follow-up, dyspnea, oligunia, protracted ileus, and tense abdomen. Several objective prognostic signs, and complica- methods of a more objective evaluation have been reported (1-7) . tions and death. The length of hospital- that potentially improve prognostic ability and prediction of com- ization correlated well with the severity plications. Among them, the statistical analysis of early objective of the initial CT findings. Abscesses oc- measurements of multiple risk factors, described by Ranson (2, 3), .4 curred in 21.6% of the entire group, com- has received wide attention and has been considered a reliable pared with 60.0% of grade E patients. prognostic indicator of the diseases’s severity. These objective prog- Pleural effusions were also more common nostic signs (grave signs or risk factors) have significantly im- in grade E patients. Grades A and B pa- proved the initial assessment based on clinical criteria alone and are , tients did not have abscesses, and none used as guidelines in the decision-making process of selecting died, regardless of the number of prog- proper medical or surgical treatment in our institution.F nostic signs. Abscesses were seen in 80.0% Since morbidity and mortality depend in great measure on theI ‘ of patients with six to eight prognostic local pancreatic and penipancreatic complications (i.e., abscess, signs, compared with 12.5% of those with pseudocyst, hemorrhage), computed tomographic (CT) examina- zero to two. The use of prognostic signs tion could play an important role in the initial assessment of the with initial CT findings results in im- severity of acute pancneatitis. For this reason, in the past 4 years we proved prognostic accuracy. Early CT ex- have embarked on a comprehensive study designed to assess the 4 amination of patients with acute pancrea- prognostic value of the initial CT examination in patients with titis is a useful prognostic indicator of acute pancreatitis. Our objectives are (a) to describe, classify, and morbidity and mortality. analyze the early CT findings in acute pancreatitis; and (b) to assess their predictive value based on correlation of early CT findings ‘ Index terms: Pancreas, computed tomography, with clinical and objective prognostic signs. Pancreatitis, 77.1211 #{149} 77.291 Radiology 1985; 156:767-772 MATERIALS AND METHODS Our study is based on a detailed analysis of CT, clinical, and laboratory findings of 83 patients with acute pancreatitis admitted to our institution in the past 4 years. There were 63 men and 20 women, aged 17-79 years, with a mean age of 45 years. The clinical diagnosis was based on typical symptoms such as nausea, vomiting, abdominal pain, and elevation of serum amylase levels above 200 Somogyi units. The etiology of pancreatitis was chronic alcohol abuse in 51 patients, cholelithiasis in 11, gallstones and alcohol in five, hyperlipidemia in two, and miscellaneous or unknown in 14. There were no cases of traumatic pancreatitis included in this series. We used the previously reported objective prognostic signs (2, 3, 6, 7), listed in Table 1, to assess the severity of the attack and its possible compli- cations. All patients were initially treated by nasogastric suction, intrave- nous fluid, and supportive therapy. We drained infected fluid collections (abscesses) in 18 patients (21.7%), some upon initial evaluation and others as complications developed. The clinical course, complications, treatment, and response to treatment were recorded for all individuals, until death or discharge from the hospital. CT examinations were performed on a GE 8800 scanner (Milwaukee) using standard technical parameters. Diluted 2% barium sulfate (E-Z-CAT, From the Departments of Radiology (E.J.B., D.P.N., E-Z-EM, Westbury, N.Y.) was used as oral contrast material, and a rapid A.J.M.) and Surgery (J.H.C.R., R.C., M.M.C.), New intravenous drip infusion of 30% diatrizoate meglumine (Reno-M-DIP York University Medical Center, Bellevue Hospital [Squibb]) was started immediately before scanning unless contraindicated. Medical Center, New York City. Received January 10, 1985; accepted and revision requested March 18, 1985; Bolus injections were not used in this study. revision received April 3. 1985. A total of 152 CT scans were obtained, either as a single examination or as c RSNA, 1985 consecutive, follow-up examinations approximately every 2 weeks. The 767
  • 2. Figures 1, 2, and 3 4 “I 4, 4 2. A 1. CT scan of normal pancreas in patient with clinical pan- creatitis (grade A). 2. Diffuse enlargement of the pancreas without peripan- creatic inflammatory changes (grade B). 3. Enlarged pancreas associated with haziness and in- creased density of peripancreatic fat (grade C). Note presence of diffuse fatty infiltration of liver. Iinitial examinations were performedwithin the first 3 hospital days in 40 pa-tients and between day 4 and 10 in 43 pa-tients. In general, severely ill patients me-ceived priority for CT examination,making this sample unrepresentative of 4all patients with acute pancreatitis ad-mitted to our institution. CT scans were interpreted without priorknowledge of clinical findings or objec-tive prognostic signs. The following con-ditions were specifically looked for andrecorded: presence of fatty liver, gallblad- 8.den pathology, peritoneal effusion, andpleural effusions. In addition, we classified the type ofpancreatic inflammation seen on CT scansinto five categories. This classification wasbased on an overall assessment of size,contour, and density of the gland and per-ipancreatic abnormalities. Specific mea-surements were not used in this assess-ment. We used the following grades,which are similar to those reported in theliterature (8): grade A, normal pancreas I(Fig. 1); grade B, focal or diffuse enlarge-ment of the pancreas (Fig. 2) (includingcontour irregularities, nonhomogeneousattenuation of the gland, dilatation of the .#,pancreatic duct, and foci of small fluid col- (Fig. 5) or presence of gas in or adjacent to quired surgical drainage abscesses. oflections within the gland, as long as there the pancreas (Fig. 6). One patient underwent surgery to me-was no evidence of peripancreatic dis- move a persistent pseudocyst. Five Aease); grade C, intrinsic pancreatic abnor- patients with abscesses died, and onemalities associated with haziness and RESULTS other patient died of hepatic andstreaky densities representing inflamma-tory changes in the peripancreatic fat (Fig. Of the 83 patients surveyed, 63 me- renal failure without evidence of pan-3); grade D, single, ill-defined fluid collec- covered with medical treatment alone creatic abscess. The relationship oftion (phlegmon) (Fig. 4); grade E, two or and were discharged, while 18 pa- the objective prognostic signs to themultiple, poorly defined fluid collections tients (21.7%) became septic and me- clinical course is shown in Table 2.768 Radiology #{149} September 1985
  • 3. Figure 4 a. b. CT scan of enlarged body and tail of the pancreas (a) with associated fluid collection in left anterior pararenal space (b) (arrows) (grade D).r Figure 5 a. b. CT scan showing large fluid collections in the lesser sac and anterior pararenal space in patient with grade E pancreatitis. Note compression . with partial obstruction of the duodenum and slight thickening of gallbladder wall (arrows). cholelithiasis on sonognams or during surgical exploration. We observed gallbladdens with thickened walls in five patients, none of whom had gall- stone pancreatitis (Fig. 5). Six patients (7.2%) had free fluid in the pemitoneal cavity, five with grade D or E pancrea- titis. We detected pleural effusions in 27 patients (32.5%). Effusions were present in 41% of the 12 patients with grade D and 65% of the 23 patients with grade E pancreatitis. Bilateral ef- fusions were seen in 22% of patients with grade E pancreatitis. Secondary CT Findings 21 patients (25.3%) (Fig. 3) from all In our morphologic evaluation, we Secondary CT findings that may five grades of pancreatitis. Gallstones noted a diffuse involvement of the correlate with the severity of acute were seen on CT scans in 12 patients pancreas in 68 of 83 cases and a seg- pancreatitis were recorded. We ob- (14.5%), but were missed in a number mental distribution in the remaining served fatty infiltration of the liver in of other patients who proved to have 15 cases (18.1%). In nine patients Volume 156 Number 3 Radiology 769 #{149}
  • 4. Figure 6 .. 44 4a. CT scan showing increased density of the peripancreatic retroperitoneal fat associated with extraluminal air (arrow) in patient with pemipancreatic abscess.b. Bilateral, ill-defined, retroperitoneal fluid collections with multiple gas bubbles in patient with abscess (grade E). 4(10.8%), the inflammatory process in-volved exclusively or predominantly I-the head of the pancreas (Fig. 7); infive, the body and tail; and in one,only the tail of the pancreas. Swelling Iof only the head of the pancreas waspresent in three of the 1 1 patientswith gallstone pancreatitis (27.3%)but in only six cases of all other types .4of pancreatitis (8.3%). Two patientswith histories of previous pancreatitishad pancreatic ductal calcificationsdemonstrated on CT scans. The patients were divided accord-ing to the five grades, and the mela-tionships between different gradesand the clinical course and prognosticsigns were analyzed. There were 12patients (14.5%) in grade A, 19 (22.9%)in grade B, 17 (20.5%) in grade C, 12(14.5%) in grade D, and 23 (27.7%) ingrade E. CT and Clinical Course r The relationship between early CTfindings and clinical course is sum-manized in Table 3. The average num- ‘4ben of fasting days (nothing bymouth) and days in the hospital come- abscesses. In three cases, gas bubbles initially and were classified as gradelated roughly with the severity of the were detected on CT scans in patients C pancreatitis. One of these patients Iinitial CT findings. Exceptions to the with only one to three prognostic ended up with a pseudocyst and twogeneral trend, however, occurred, signs within the first 24 hours of hos- with abscesses. In 15 patients, the in-with some patients in grade B requir- pitalization. fected fluid collections were draineding 4 weeks of hospitalization and .I Fluid collections were initially seen between the 5th and 50th day hospi-some in grade D requiring less than 2 in 35 patients in grades D and E (or talized after an average stay of 25weeks of treatment. No patient with 45.7% of these combined grades). Fol- days.grade A pancreatitis was seriously ill, low-up CT scans showed that in 19 Aand all five patients who died because patients (54.3%), fluid collections me- CT and Prognostic Signsof local complications (abscesses) mi- solved without further complications,tially had grade D or E pancmeatitis. while in 16 patients (45.7%), they did The relationship between early CT Retropemitoneal, extraluminal air not and eventually became infected. findings and prognostic signs iswas seen in four patients (Fig. 5) who Fluid collections developed in only shown in Table 4. The relationshipall proved at surgery to have infected three patients who did not have them between the number of prognostic770 Radiology #{149} September 1985
  • 5. Figure 7 signs and grades of pancreatitis varies Secondary CT Findings tion can be established between the . widely in patients with zero to five severity of pancreatitis, as determined Our search of the literature did not prognostic signs. All patients with at the initial CT examination, and the disclose a previous assessment of the more than five prognostic signs were clinical course. We noted a steady secondary CT findings evaluated in in grade E; however, a few patients trend toward an increased average this study. Fatty infiltration of the liv-pa with four and five signs were in number of fasting days and days hos- en was seen in 21% of our patients grades A and B. pitalized in patients with more severe (Fig. 3) and occurred about equally in When the number of patients with grades of pancreatitis (Table 3). Five patients with mild, moderate, or se-r abscesses or those that died were ana- of six deaths and 88.8% of all abscesses vene pancreatitis. Gallbladders with lyzed as a function of combined CT occurred in patients initially classi- thickened walls were seen in five findings and prognostic signs (Table fied as having grades D and E pan- cases (Fig. 5), and the significance is 5), the complication rate and progno- creatitis. No patients originally classi- unknown since the condition was sis could be better assessed. The num- fied as having grade A or B pan- present in patients without clinical ., ben of patients with abscesses in creatitis had subsequent abscesses. All evidence of cholecystitis. It may me- grades C and D is significantly larger patients with a normal pancreas on present nonspecific edema associated if the number of prognostic signs is CT scan (grade A) had a mild clinical with alcoholic liver disease or non- higher. In addition, the percentage of course without complications and specific inflammation related to pan- deaths correlated well with the num- were discharged in less than 2 weeks. creatitis. Pleural effusions were larger bem of prognostic signs. Although the clinical course was and more commonly seen in patients consistent with the grade of pancrea- with severe pancreatitis. In this series, titis, some grade A patients may not they were present in 65% of grade E have had pancreatitis at all. There- DISCUSSION patients and in only 10% in grades A fore, the exact percentage of patients The radiologic features and role of and B. Bilateral pleural effusions were with acute pancreatitis and a normal . -. CT scanning in initial diagnosis of seen almost exclusively in grade E pa- CT scan is difficult to assess. This per- tients. There was no correlation be- acute pancreatitis and its complica- centage depends mainly on the sever- tween the severity of pancreatitis and tions are well established in the lit- ity of acute pancreatitis and the time its cause in this series. Five of the 11 - erature (8-18). The CT appearance of of the examination and should be ex- cases of gallstone pancreatitis were clinical forms of mild (edematous, in- pected to vary from series to series. classified as grade E, while the other terstitial) or severe (necrotizing, hem- six were grade A, B, or C. omnhagic) pancreatitis has been de- While acute pancreatitis is general- CT and Development of p scnibed (8, 19, 20). To our knowledge, ly considered a diffuse disease, in this Abscesses however, a comprehensive evalua- series a segmental form of pancreati- tion of the prognostic value of the mi- A strong relationship exists be- tis was observed in 18.1% of the cases. .3 tial CT examination based on clinical tween the initial presence of pemipan- (Fig. 7). Specifically, the head of the follow-up, surgical findings, and con- creatic fluid collections (grades D and pancreas was enlarged in a larger pro- S relation with prognostic signs has not E) and the development of abscesses. portion of patients with gallstone been performed. This study attempts Abscesses occurred in 18 patients in pancreatitis (27.3%), compared with to fill this gap and establishes the val- this series (21 .7%), but they developed the proportion of the total series ue of CT scanning, not only in the in only two patients without initial (8.3%). initial diagnosis of pancreatitis, but as fluid collections. a prognostic indicator of the disease’s CT and Clinical Course The presence of poorly encapsulat- severity and its expected complica- The survey of the statistical data ed pemipancneatic fluid collections in tions. presented shows that a clear comrela- patients with acute pancreatitis Volume 156 Number 3 Radiology . 771
  • 6. should not be regarded casually. Flu- Prognostic Signs, CT, and 5. Berry AT, Taylor TV, Davies CC. Diag- nostic tests and prognostic indicators inid collections resolved spontaneously Clinical Course acute pancreatitis. J R Coil Surg Edinbin 54.3% of patients who had them but 1982; 27:345-52. The relationship between prognos-lingered on and eventually became 6. Ranson JHC, Spencer FC. The role of tic signs and severity of pancreatitis is peritoneal lavage in severe acute pancrea- .4infected in the remaining 45.7%. Fol- documented in Table 2. Infected ab- titis. Ann Surg 1978; 187:565-575.low-up CT examinations should be scesses occurred with an increased in- 7. Ranson JHC, Rifkind KM. Turner JW.performed in these patients to assess Prognostic signs and nonoperative perito- cidence in patients with several prog-the presence, size, and location of neal lavage in acute pancreatitis. Surg nostic signs. Abscesses were seen inthese collections until they resolve. Gynecol Obstet 1976; 143:209-219. 80.0% of patients with six to eight 8. Hill MC, Barkin J, Isikoff MB, et al. Acute Previously, extravasated pancreatic signs, compared with 12.5% of pa- pancreatitis: clinical vs. CT findings. AJRsecretions and the development of 1982; 139:263-269. tients with zero to two signs. We 4large pemipancreatic fluid collections 9. Silverstein W, Isikoff MB, Hill MC, Barkin found that using prognostic signs andwere considered an escape mecha- J. Diagnostic imaging of acute pancreati- CT findings led to a better estimation tis: prospective study using CT and sono-nism, leading to a beneficial decom- of the risk of death in this series. In graphy. AJR 1981; 137:497-502.pression of the pancreatic duct system “4 grades A and B patients, none of the 10. Mendez G Jr., Isikoff MB, Hill MC. CT of(12). In our study, however, based on pancreatitis: interim assessment. AIR 1980; patients died, regardless of the num-short-term CT and clinical follow-up 135:463-469. ben of prognostic signs, which varied 11. Williford ME, Foster WLJr., Halvorsen RA,evaluation, we failed to detect any ad- 4 between zero and five. On the other Thompson WM. Pancreatic pseudocystvantages of large fluid collections for hand, the mortality of patients initial- comparative evaluation of sonography andthis group of patients. While we did computed tomography. AJR 1983; 140:53- ly classified as grades C, D, on E come-not conduct long-term evaluations, 57. lated with the increasing number of 12. Siegelman 55, Copeland BE, Saba GP, et Awe found that extravasated fluid was prognostic signs (Table 5). al. CT of fluid collections associated withassociated with a protracted and se- We conclude that initial CT exami- pancreatitis. AJR 1980; 134:1121-1132.vene clinical course. In patients with- 13. Jeffrey RB, Fedemle MP, Cello JP, Crass nation in cases of acute pancreatitis isout such fluid, the course of pancrea- RA. Early computed tomographic scan- very helpful in establishing on con-titis was mild or significantly shorten ning in acute severe pancreatitis. Surg firming the clinical diagnosis, as well Gynecol Obstet 1982; 154:170-174.and less complicated. as in depicting associated abnonmali- 14. Pningot J, Dardenne AN, Lousse JP, et al. The diagnosis of abscess in most of ties. CT can also be used as an early Contribution of computed tomography inour cases was based on the presence the diagnosis of severe acute pancreatitis. indicator of the disease’s severity andof a persistent fluid collection plus In: Hollender LF, ed. Controversies in its expected morbidity and mortality. acute pancreatitis. Berlin: Springer, 1981;sepsis unresponsive to antibiotic them- We found a good correlation between 64-71.apy. Because of debris and necrotic the grades of mild, moderate, or se- 15. Dembner AG, Jaffee CC, Simeone J, Walshtissue, the density of fluid collections J. A new computed tomographic sign of vene pancreatitis as established by CTwas variable (5-30 HU) and not help- pancreatitis. AJR 1979; 133:477-479. appearance and the clinical course, 16. Jeffrey RB, Federle MP, Laing FC. Corn-ful in this diagnosis. The roles of per- development of abscesses, and death. puted tomography of mesentemic involve-cutaneous aspiration and drainage of The use of objective prognostic signs ment in fulminant pancreatitis. Radiologypancreatic abscesses have been me- 1983; 147:185-188. with initial CT findings improves theported in the literature (21, 22), but 17. Federle MP, Jeffrey RB, Crass RA, Dalsern original prognostic estimation and vv. Computed tomography of pancreaticthese procedures were not used in identifies patients in whom life- abscesses. AJR 1981; 136:879-882.this series. threatening complications may devel- 18. Segal I, Epstein B, Lawson HL, et al. The Retmopemitoneal air was seen in four op. CT examinations should be pen- syndrome of pancreatic pseudocysts andpatients, all of whom had proved ab- fluid collections. Gastrointest Radiol 1984; formed in all patients with moderatescesses at surgery. As reported in the 9:115-122. or severe clinical forms of pancreatitis 19. Darnmann HG, Grabbe E, Eichfuss HP, Fla-literature (23, 24), fluid collections to evaluate the presence and severity shoff D. Computed tomography andcontaining air may develop secon- clinical severity of acute pancreatitis. In: of the initial attack and to assess itsdamy to entemic fistulas and may not Hollender LF, ed. Controversies in acute clinical evolution. Ualways indicate an abscess. However, pancreatitis. Berlin: Springer, 1981; 72-77.this CT finding, particularly when 20. Kivisaari L, Somer K, Standertskjold-Nor- Send correspondence and reprint requests to: denstam CC, Schroeder T, Kivilaakso E,seen during the initial attack, strong- Emil Balthazar, M.D., NYU Medical Center, Bel- Lempinen M. A new method for diagno-ly suggests a gas-forming infection levue Hospital, Department of Radiology, 27th sis of acute hemorrhagic-necrotizing pan-and is extremely valuable in quickly Street and 1st Avenue, New York, New York creatitis using contrast-enhanced CT. Gas-identifying this potentially life- 10016. trointest Radiol 1984; 9:27-30. 21. Hill MC, Dach JL, Barkin J, et al. Role ofthreatening complication. In three percutaneous aspiration in diagnosis ofpatients, metropemitoneal aim visual- References pancreatic abscess. AJR 1983; 141:1035-ized on CT scan in the first 24 hours 1038.led to a correct diagnosis that was not 1. Jacobs ML, Daggett WM, Civetta JM, et 22. Karlson KB, Martin EC, Fanuchen El. Per-suspected clinically. Surgery was per- al. Acute pancreatitis: analysis of factors cutaneous drainage of pancreatic pseudo- influencing survival. Ann Surg 1977; cysts and abscesses. Radiology 1982;formed without delay, and all three 142:619-624. 185:43-51.patients survived. 2. Ranson JHC, Pastemnak BS. Statistical 23. Alexander ES, Clark RA, Federle MP. Pan- methods for qualifying the severity of creatic gas: indication of pancreatic fistula. clinical acute pancreatitis. J Surg Res 1977; AJR 1982; 139:1089-1093. 22:79-91. 24. Torres WE, Clements JL Jr., Sones PJ, 3. Ranson JHC. Etiological and prognostic Knopf DR. Gas in the pancreatic bed factors in human acute pancreatitis: a me- withoutabscess. AJR 1981; 137:1131-1133. view. Am J Gastroenterol 1982; 9:633-638. 4. McMahon MJ, Pickford IR, Playforth MJ. Early prediction of severity of acute pancreatitis using peritoneal lavage. Acta ChirScand 1980; 146:171-175.772 . Radiology September 1985