2. Acute pancreatitis is an acute inflammatory condition,
with a range of severity as well as various local and
systemic complication
ACUTE PANCREATITS
4. 1.Abdominal pain consistent
with acute pancreatitis:
Acute onset of persistent,
severe, epigastric pain often
radiating to the back.
2.Serum lipase or amylase
activity at least three times
greater than the upper limit of
normal.
3.Characteristic findings of
acute pancreatitis on contrast-
enhanced CT (CECT) and less
commonly MRI or US.
5.
6. 3-Types :
-There are two subtypes of acute pancreatitis :
a) Interstitial Edematous Pancreatitis :
-Vast majority (90-95%)
-Most often referred to simply as "acute
pancreatitis" or "uncomplicated pancreatitis“
b) Necrotizing Pancreatitis :
-Necrosis develops within the pancreas and/or
peripancreatic tissue
7.
8.
9. INTERSTITIAL EDEMATOUS PANCREATITS
• IEP is more common and represents non
necrotizing inflammation of the pancreas.
• IEP usually manifests with focal or diffuse
pancreatic enlargement and is typically
surrounded by peri pancreatic inflammation
or a small amount of fluid
10.
11.
12.
13. On US, an inflamed pancreas appears bulky and hypoechoic relative to liver
(reversal of normal pattern) because of edema with presence of peri pancreatic
fluid
15. A stripe of fluid in front of pancreatic
tissue marked by white arrows
Bulky and edematous pancreas
16.
17. Acute edematous pancreatitis, demonstrating diffuse pancreatic enlargement,
densification of the peripancreatic fat planes (long arrows) and acute fluid
collections in the left anterior pararenal space and in the left paracolic gutter
(short arrows), without areas of parenchymal necrosis
CT: The entire pancreas will enhance at
contrast-enhanced CT imaging, with no
unenhanced (necrotic) areas, although
enhancement of the gland may be less avid
than that of the normal pancreas owing to
interstitial edema
18. Interstitial pancreatits, CT+C shows satisfactory enhancement of
pancreatic tissue, but there is some loss of marginal definition, in
keeping with edema, and there is moderate swelling of Gerota's
fascia (between arrowheads)
19. ACUTE NECROTIZING PANCREATITS
Acute necrotizing pancreatitis is a severe form of acute
pancreatitis characterized by necrosis in and around the
pancreas and is associated with high rates of morbidity
and mortality.
20. There are three subtypes of necrotizing pancreatitis;
the subtypes are based on the anatomic area of
necrotic involvement:
(a)pancreatic only,
(b) peripancreatic only, and
(c) combined pancreatic and peripancreatic
22. Combined necrosis is the most common morphologic
subtype, occurring in approximately 75%–80% of
cases of necrotizing pancreatitis
IMAGING: The combined subtype demonstrates
non enhancing pancreatic parenchyma and non
enhancing heterogeneous peripancreatic
collections, and accumulating in the lesser sac
and anterior para renal space.
23. Combined necrosis in a 46-year-old man, (a) Axial CT+C shows an ill-defined
hypoattenuating region in the body and tail of the pancreas (*), along with ill-
defined heterogeneous peripancreatic fluid, stranding, and increased fat
attenuation (arrows), (b) Axial CT+C acquired 6 weeks later reveals
evolution of the pancreatic and heterogeneous peripancreatic collection into
well-defined WON (arrows), residual pancreatic parenchyma is seen in the
tail (*)
24.
25. Peripancreatic necrosis alone, in which the
pancreas enhances normally but the
peripancreatic tissues show necrosis, with
collections containing variable amounts of
fluid and non liquefied components.
26. Peripancreatic necrosis in a 22-year-old man, (a) Axial CT+C shows stranding,
increased attenuation, and a heterogeneous appearance of the
peripancreatic fat around the body and tail of the pancreas (white arrows), a
feeding tube is seen in the stomach (black arrow), (b) Axial CT+C acquired
20 days later reveals evolution of the heterogeneous peripancreatic
collection into well-defined WON (Walled-off necrosis) (arrows)
31. Acute Peripancreatic Fluid Collection (APFC)
• Collections of enzyme-rich pancreatic fluid occur in
40% of patients
• No fibrous capsule
• Location – Lesser sac, Ant and Post para renal
space, Transverse mesocolon , small bowel
mesentry.
• Prognosis: 50% resolve spontaneously; the rest
evolve into pseudocysts
32. IEP in a 25-year-old woman with alcohol abuse and epigastric pain for
72 hours, axial CT image shows the pancreas (arrowhead) to be
slightly edematous and heterogeneously enhancing, APFCs
(arrows) are seen surrounding the pancreas
33. Pseudocyst
• A collection of fluid enclosed by a complete wall of
fibrous tissue.
• It is seen in IEP and absence of necrotic component is
imperative for diagnosis.
• Take 4 or more weeks to develop
• Most common location is Lesser Sac
34.
35.
36. Acute Necrotic Collection
• Necrosis of pancreas
• Inhomogenous collection in the Peripancreatic tissue
• No wall
Walled off Necrosis
After 4 weeks most necrotic collections are fully
encapsulated and are called Walled off Necrosis.
41. Infection
• Infection occurs as a complication in 20% of patients with necrotizing
pancreatitis
• most commonly occurs 2–4 weeks after presentation
• Patients with infected necrosis typically present with fever, tachycardia, and
an elevated white blood cell count.
• At imaging, the presence of gas within a collection suggests infection,
although the absence of gas does not signify the absence of infection .
• Gas can also be found in uninfected collections as a result of gastrointestinal
fistulas
46. Pseudoaneurysm
It develops when an arterial
vessel wall is weakened by
pancreatic proteolytic
enzymes and is a typically
late and potentially life-
threatening complication of
pancreatitis.
47. • At CT, MR imaging, or angiography, a
pseudoaneurysm appears as a focal
outpouching of a vessel
• At US, turbulent arterial flow may be
seen within an anechoic structure
• The artery that is most frequently
involved by pseudoaneurysm
formation in the setting of
necrotizing pancreatitis is the
splenic artery, followed by the
gastroduodenal,
pancreaticoduodenal, hepatic, and
left gastric arteries.
48. Venous Thrombosis
• Venous thrombosis results from a
multifactorial process involving local
pro thrombotic inflammatory factors,
reduced venous flow, and mass effect
on a venous structure from adjacent
necrotic tissue and collections.
• Acute venous thrombosis appears as
focal or complete non enhancement of
an expanded venous structure.
• In chronic cases, scarring results in a
diminutive, less well-visualized vein
and multiple collateral vessels
• The splenic vein is the most common
site for thrombosis (up to 23% of cases
of acute pancreatitis); the superior
mesenteric and portal veins are less
commonly affected.
•
Axial contrast-enhanced fat-saturated T1-
weighted MR image demonstrates a
chronically thrombosed splenic vein (arrows)
and combined necrosis in the body and tail
of the pancreas
49.
50. Hemmorhage
• can occur from erosion of vasculature
by necrosis or from rupture of a
pseudoaneurysm or varices.
• Hemorrhage can occur within the
pancreatic parenchyma, fluid
collections, or the gastrointestinal
tract.
• The splenic artery, portal vein, splenic
vein, and other smaller peripancreatic
vessels are the most common sources
of bleeding
• Hemorrhage manifests at CT as a
region of high attenuation, typically in
an area of necrosis
Hemorrhage in a 44-year-old man with
combined necrosis. Axial contrast-
enhanced CT image obtained for the
evaluation of worsening abdominal pain
shows hyperattenuating material (arrows)
within the region of combined necrosis, a
finding that is suggestive of hemorrhage
53. 1-Etiology :
-The most common cause of chronic
pancreatitis in adults is excessive alcohol
consumption in developed countries and
malnutrition in developing countries
54. 2-Clinical Picture :
-Patients may present with exacerbations
(episodes of acute pancreatitis)
manifesting as epigastric pain, which may
recur over a number of years
55. 3-Radiographic Findings :
a) Plain Radiography :
-Calcification
b) US :
-The pancreas might appear atrophic, calcified or
fibrotic
-Findings that may be present on ultrasound
include :
*Hyperechogenicity (often diffuse) often indicates
fibrotic changes
*Pseudocysts
*Pseudoaneurysms
*Presence of ascites
56.
57.
58.
59. c) CT :
CT features of chronic pancreatitis include :
1-Dilatation of the main pancreatic duct
2 Pancreatic calcification
3 Changes in pancreatic size (i.e. atrophy),
shape, and contour
4 Pancreatic pseudocysts
63. Chronic pancreatitis with an intrapancreatic pseudocyst in a 42-year-old man
with a history of alcoholic pancreatitis, (a) CT+C shows a dilated pancreatic
duct (arrows) with mild pancreatic atrophy, an appearance compatible with
chronic pancreatitis, (b) CT scan shows a round mass with diffuse low
attenuation in the pancreatic head (curved arrow), the mass represents a
pseudocyst, note the dilated pancreatic duct (straight arrow), (c) CT+C
shows pancreatic calcifications (arrow), a finding compatible with chronic
pancreatitis
