Acute pancreatitis: the role of imaging in diagnosis and management

Consensus guidelines on the diagnosis and treatment of pancreatic pseudocyst and walled-off necrosis from a Chinese multiple disciplinary team expert panel

Objective

To prepare a set of practice guidelines to standardize the entire process, from diagnosis to treatment and follow-up, for pancreatic pseudocysts and walled-off necrosis.

Methods

Thirty-six experts in the fields of digestive endoscopy, pancreatic surgery, interventional radiology, and others presented their opinions via discussions in online conferences by referring to the patient, intervention, comparison, and outcomes principles and then reviewed the evidence and statements using the Delphi method to reach a consensus. The consensus of >80% was finally achieved for the items.

Results

The experts discussed and reached a consensus on 29 statements including 10 categories: (1) definition and classification, (2) imaging and endoscopic diagnosis, (3) therapeutic implications, (4) surgical therapy, (5) percutaneous catheter drainage, (6) endoscopic retrograde cholangiopancreatography, (7) EUS-guided drainage, (8) stent selection for EUS-guided drainage, (9) complication related to stents for cyst drainage, and (10) drug treatment and follow-up.

Conclusion

This consensus based on the clinical experience of experts in various fields and international evidence-based medicine further standardizes the multidisciplinary diagnosis and treatment processes for pancreatic pseudocysts and walled-off necrosis.

Optimal CT windowing on low-monoenergetic images using a simplex algorithm-based approach for abdominal inflammatory processes

BACKGROUND

OBJECTIVES: To determine optimal window settings for conspicuity of abdominal inflammatory processes on 50 keV low-monoenergetic images derived from dual-energy spectral CT (DECT).

METHODS

A retrospective study of 30 patients with clinically proven pancreatitis (15/30) or pyelonephritis (15/30) with inflammatory lesions visible on DECT scans were selected to serve as reference populations. 50 keV low-monoenergetic images in the portal venous phase were iteratively evaluated by 6 abdominal radiologists in twenty-one different windows (7-350HU center; 120-580HU width), selected using a simplex optimization algorithm. Each reader graded the conspicuity of the parenchymal hypodense lesions and image background quality. Three-dimensional contour maps expressing the relationship between overall reader grade and window center and width were constructed and used to find the ideal window for inflammatory pancreatic and renal processes and the image background quality. Finally, 15 appendicitis cases were reviewed on optimal pancreas and kidney windows and the manufacturer recommended conventional abdominal window settings for conventional imaging.

RESULTS

Convergence to optimal windowing was achieved based upon a total of 3,780 reads (21 window settings × 6 readers × 15 cases for pancreas and kidney). Highest conspicuity grade (>4.5 ± 0.0) for pancreas inflammatory lesions was seen at 116HU/430HU, whereas hypodense pyelonephritis had highest conspicuity at 290HU/570HU. This rendered an ideal "compromise" window (>4 ± 0.2) of 150HU/450HU which differed substantially from conventional manufacturer recommended settings of 50HU/380HU (2.1 ± 1.0, p = 0.00001). Appendix mucosal enhancement was best visualized at manufacturer settings.

CONCLUSIONS

Optimal visualization of inflammatory processes in abdominal organs on 50 keV low-monoenergetic images may require tailored refinement of window settings.

Acute Pancreatitis following L-Asparaginase in Acute Lymphoblastic Leukemia A.Elouali1,2 S.M'harzi1,2, A.Ghannam1,2, A.Babakhouya1,2, M.Rkain1,2, N.Benajiba1,2

Acute lymphoblastic leukemia (ALL) is the most frequent malignancy in children,representing 25–30% of all childhood malignancies. Although treatment outcome has improved owing to advances in chemotherapy, there is still a group of patients who experience severe adverse events. L-Asparaginase is an effective antineoplastic agent used in chemotherapy of ALL. Despite its indisputable indication, it can cause various adverse effects, including acute pancreatitis (AP). Recently, an increase in the number of pediatric AP cases following L-Asparaginase in Acute Lymphoblastic Leukemia been reported. We presented a case of acute pancreatitis in children with ALL induced by administration of L-ASPA preparations.

Acute Pancreatitis Imaging in MDCT: State of the Art of Usual and Unusual Local Complications. 2012 Atlanta Classification Revisited

Acute pancreatitis is an inflammatory disease in which most common etiologies are biliary lithiasis and alcoholism. Acute pancreatitis can be classified into 2 groups according to its morphologic features: interstitial edematous pancreatitis and necrotizing acute pancreatitis. The prognosis of this group of diseases and its complications varies significantly and contrast-enhanced computed tomography is the imaging study of choice for the diagnosis and detection of complications. . In this review, we aim to summarize the changes introduced in the revised Atlanta classification and describe other usual and unusual local complications of acute pancreatitis that are not analyzed in that classification. We will also describe early detection signs and provide an accurate interpretation of complications on contrast-enhanced computed tomography that will lead to prompt management decisions which can reduce the morbidity and mortality of these patients.

Pancreatic fluid collections: Clinical manifestations, diagnostic evaluation and management

Pancreatic fluid collections (PFC), including pancreatic pseudocysts and walled-off pancreatic necrosis, are a known complication of severe acute pancreatitis. A majority of the PFCs remain asymptomatic and resolve spontaneously. However, some PFCs persist and can become symptomatic. Persistent PFCs can also cause further complications such as the gastric outlet, intestinal, or biliary obstruction and infection. Surgical interventions are indicated for the drainage of symptomatic sterile and infected PFCs. Management of PFCs has evolved from a primarily surgical or percutaneous approach to a less invasive endoscopic approach. Endoscopic interventions are associated with improved outcomes with lesser chances of complications, faster recovery time, and lower healthcare utilization. Endoscopic ultrasound-guided drainage of PFCs using lumen-apposing metal stents has become the preferred approach for the management of symptomatic and complicated PFCs.

Can Disturbed Liver Perfusion Revealed in p-CT on the First Day of Acute Pancreatitis Provide Information about the Expected Severity of the Disease?

Background

The aim of the study was to evaluate the prognostic properties of perfusion parameters of liver parenchyma based on computed tomography (CT) of patients with acute pancreatitis (AP) made on the first day of onset of symptoms, to assess their usefulness in identifying patients with increased risk of the development of severe AP.

Methods

79 patients with clinical symptoms and biochemical criteria indicative of AP underwent perfusion computed tomography (p-CT) within 24 hours after onset of the symptoms. Perfusion parameters in 41 people who developed a severe form of AP were compared with parameters in 38 patients in whom the course of AP was mild.

Results

Statistical differences in the liver perfusion parameters between the group of patients with mild and severe AP were shown. The permeability-surface area product was significantly lower, and the hepatic arterial fraction was significantly higher in the group of patients with progression of AP.

Conclusions

Based on the results, it seems that p-CT performed on the first day from the onset of AP is a method that, by revealing disturbances in hepatic perfusion, can help in identifying patients with increased risk of the development of severe AP.

The utility of early cross-sectional imaging to evaluate suspected acute mild pancreatitis

Background

There are roughly 300,000 hospitalizations for acute pancreatitis annually in the United States. Many of the affected patients at our institution undergo computed tomography (CT) or magnetic resonance imaging (MRI) unnecessarily early during their admissions. We hypothesize that cross-sectional imaging within 48 h of admission in patients meeting the criteria for acute, mild pancreatitis is over-utilized and does not change management.

Methods

We performed a retrospective analysis of patients with a discharge diagnosis of acute pancreatitis from our tertiary care institution from January 1, 2010 to December 31, 2015. Inclusion criteria were a lipase more than three times the upper limit of normal and clinical suspicion of pancreatitis. Exclusion criteria were an etiology of pancreatitis following endoscopic retrograde cholangiopancreatography, recurrent or chronic pancreatitis, severe pancreatitis, and ultrasound findings being the reason for imaging.

Results

Of the 166 patients who met the criteria for analysis, 105 (63.3%) underwent cross-sectional imaging within 48 h of presentation (CT: 104, MRI: 1). Of the examined CTs, 27 (26.0%) showed no abnormality and 55 (52.9%) revealed uncomplicated pancreatitis. The remaining 22 (21.2%) demonstrated at least one of the following: local complications, biliary ductal dilatation or other findings. On thorough chart review, only two patients received a beneficial change in management as a result of the early imaging.

Conclusions

This analysis supports current guidelines that early cross-sectional abdominal imaging (CT or MRI) in patients with suspected acute mild pancreatitis does not alter medical management. Early imaging may lead to unnecessary resource use and patient irradiation.

Difference in Diffusion-Weighted Magnetic Resonance Imaging and Diffusion Tensor Imaging Parameters Between Endometrioid Endometrial Adenocarcinoma and Uterine Serous Adenocarcinoma: A Retrospective Study

OBJECTIVE

This study aimed to elucidate the difference in diffusion-weighted magnetic resonance imaging (DWI) and diffusion tensor imaging (DTI) parameters between endometrioid endometrial adenocarcinoma (EEA) and uterine serous adenocarcinoma (SA).

METHODS

Data of patients with pathologically confirmed EEA or SA who underwent DWI and DTI scanning between May 2013 and July 2016 were retrospectively analyzed. Apparent diffusion coefficient (ADC) value from DWI and ADC from DTI (ADC) map and fractional anisotropy (FA) values from DTI were analyzed and compared statistically. The correlation between ADC and ADC was analyzed by Pearson correlation analysis. Apparent diffusion coefficient, ADC, and FA between the 2 groups were compared using independent t test. The effect of ADC, ADC, and FA in distinguishing EEA and SA was evaluated by receiver operator characteristic curve.

RESULT

Thirty-three patients were enrolled into the study, including 13 cases of SA and 20 cases of EEA. Pearson correlation analysis suggested that the value of ADC was highly related with ADC in both the SA group (r = 0.812, P = 0.001) and the EEA group (r = 0.858, P < 0.001). The value of ADC and ADC in the SA group was significantly lower than that in the EEA group; FA was significantly higher than that in the EEA group. Receiver operator characteristic curve analysis showed that ADC and ADC have high sensitivity and specificity; FA has low sensitivity and high specificity.

CONCLUSIONS

We suggest that both DWI and DTI could be used in distinguishing EEA from SA. Apparent diffusion coefficient and ADC possess potential diagnostic value with high sensitivity and specificity.

Acute pancreatitis: A 7 year retrospective cohort study of the epidemiology, aetiology and outcome from a tertiary hospital in Jamaica

BACKGROUND

Acute pancreatitis (AP) is a significant cause of acute abdominal pain, morbidity and hospitalisation. There was previously a dearth of studies exploring the incidence, risk factors and outcome of AP in the Caribbean region.

MATERIALS AND METHODS

All patients with a diagnosis of AP admitted to the University Hospital of the West Indies (UHWI) between 2006 and 2012 were reviewed. The epidemiological profile, risk factors, clinical presentation and outcomes of patients with AP were retrospectively studied.

RESULTS

There were 70 females and 21 males with a median age of 44 years (range 2-86). The median age of males was significantly higher than that of females (p = 0.041). The incidence of AP was 74 per 100,000 admissions per year. Vomiting and abdominal tenderness were noted in the majority of patients. The most common aetiology was biliary disease (71.4%), idiopathic (12%), post-ERCP (6.6%) and alcohol (5.5%). Alcoholic pancreatitis was only seen in males whereas idiopathic and post-ERCP pancreatitis only occurred in females. The mean duration of hospitalisation was 9.51 ± 8.28 days. Disease severity was mild in 61.1%, moderately severe in 26.7%, and severe in 12.2% of patients. Factors associated with more severe disease included overweight/obesity, idiopathic aetiology and post-ERCP status. The case fatality rate was 2%.

CONCLUSION

The incidence of AP was 74/100,000 hospital admissions annually. There was an unusual female preponderance, with biliary pancreatitis being the most common type occurring at an equal frequency among males and females. Only 12.2% of the total cases seen were severe. The case fatality rate was 2%. Local health policy should target timely interventions for biliary pancreatitis and should also address the local factors affecting disease severity.

Effects of Melatonin and Its Analogues on Pancreatic Inflammation, Enzyme Secretion, and Tumorigenesis

Melatonin is an indoleamine produced from the amino acid l-tryptophan, whereas metabolites of melatonin are known as kynuramines. One of the best-known kynuramines is N¹-acetyl-N¹-formyl-5-methoxykynuramine (AFMK). Melatonin has attracted scientific attention as a potent antioxidant and protector of tissue against oxidative stress. l-Tryptophan and kynuramines share common beneficial features with melatonin. Melatonin was originally discovered as a pineal product, has been detected in the gastrointestinal tract, and its receptors have been identified in the pancreas. The role of melatonin in the pancreatic gland is not explained, however several arguments support the opinion that melatonin is probably implicated in the physiology and pathophysiology of the pancreas. (1) Melatonin stimulates pancreatic enzyme secretion through the activation of entero-pancreatic reflex and cholecystokinin (CCK) release. l-Tryptophan and AFMK are less effective than melatonin in the stimulation of pancreatic exocrine function; (2) Melatonin is a successful pancreatic protector, which prevents the pancreas from developing of acute pancreatitis and reduces pancreatic damage. This effect is related to its direct and indirect antioxidant action, to the strengthening of immune defense, and to the modulation of apoptosis. Like melatonin, its precursor and AFMK are able to mimic its protective effect, and it is commonly accepted that all these substances create an antioxidant cascade to intensify the pancreatic protection and acinar cells viability; (3) In pancreatic cancer cells, melatonin and AFMK activated a signal transduction pathway for apoptosis and stimulated heat shock proteins. The role of melatonin and AFMK in pancreatic tumorigenesis remains to be elucidated.

Visualization, Quantification and Characterization of Caerulein-Induced Acute Pancreatitis in Rats by 3.0T Clinical MRI, Biochemistry and Histomorphology

Purpose: To investigate whether Caerulein-induced acute pancreatitis (AP) in rats could be noninvasively studied by clinical magnetic resonance imaging (MRI) techniques and validated by enzymatic biochemistry and histomorphology. Materials and Methods: The study was approved by the institutional animal ethical committee. The AP was induced in 26 rats by intraperitoneal injections of Caerulein, as compared to 6 normal rats. T2-weighted 3D MRI, T2 relaxation measurement and contrast enhanced T1-weighted MRI were performed at 3 Tesla. Pancreatic volume and contrast ratio of pancreas against surrounding tissues were measured by MRI. Animals were scarified at 3, 8, 24 and 48-hr respectively for analyses of serum lipase and amylase levels, and biliopancreatic perfusion-assisted histomorphology. Results: The AP could be observed on MRI 3-hr onwards after Caerulein-administration. T2 relaxation within the pancreas was prolonged due to high water content or edema. Increase of vascular permeability was indicated by T1 contrast enhancement. Both edema and vascular permeability gradually recovered afterwards (p<0.05/0.01), paralleled by declining serum enzyme levels (p<0.05). Microscopy revealed cell vacuolization and edema for early stage, and increased inflammatory cell infiltration and acinar cell loss after 24 and 48-hr. Conclusion: Multiparametric MRI techniques at 3.0T could facilitate noninvasive diagnosis and characterization of Caerulein induced AP in rats, as validated by a novel ex vivo method.

Acute pancreatitis: international classification and nomenclature

The incidence of acute pancreatitis (AP) is increasing and it is associated with a major healthcare concern. New insights in the pathophysiology, better imaging techniques, and novel treatment options for complicated AP prompted the update of the 1992 Atlanta Classification. Updated nomenclature for pancreatic collections based on imaging criteria is proposed. Adoption of the newly Revised Classification of Acute Pancreatitis 2012 by radiologists should help standardise reports and facilitate accurate conveyance of relevant findings to referring physicians involved in the care of patients with AP. This review will clarify the nomenclature of pancreatic collections in the setting of AP.

Acute Pancreatitis: Revised Atlanta Classification and the Role of Cross-Sectional Imaging

OBJECTIVE

The 2012 revision of the Atlanta Classification emphasizes accurate characterization of collections that complicate acute pancreatitis: acute peripancreatic fluid collections, pseudocysts, acute necrotic collections, and walled-off necroses. As a result, the role of imaging in the management of acute pancreatitis has substantially increased.

CONCLUSION

This article reviews the imaging findings associated with acute pancreatitis and its complications on cross-sectional imaging and discusses the role of imaging in light of this revision.

Walled-off pancreatic necrosis and other current concepts in the radiological assessment of acute pancreatitis

Acute pancreatitis is an inflammatory condition caused by intracellular activation and extravasation of inappropriate proteolytic enzymes determining destruction of pancreatic parenchyma and peripancreatic tissues. This is a fairly common clinical condition with two main presentations, namely, endematous pancreatitis - a less severe presentation -, and necrotizing pancreatitis - the most severe presentation that affects a significant part of patients. The radiological evaluation, particularly by computed tomography, plays a fundamental role in the definition of the management of severe cases, especially regarding the characterization of local complications with implications in the prognosis and in the definition of the therapeutic approach. New concepts include the subdivision of necrotizing pancreatitis into the following presentations: pancreatic parenchymal necrosis with concomitant peripancreatic tissue necrosis, and necrosis restricted to peripancreatic tissues. Moreover, there was a systematization of the terms acute peripancreatic fluid collection, pseudocyst, post-necrotic pancreatic/peripancreatic fluid collections and walled-off pancreatic necrosis. The knowledge about such terms is extremely relevant to standardize the terminology utilized by specialists involved in the diagnosis and treatment of these patients.

Effect of percutaneous catheter drainage on pancreatic injury in rats with severe acute pancreatitis induced by sodium taurocholate

OBJECTIVE

This study investigated the effect of percutaneous catheter drainage (PCD) on pancreatic injury in severe acute pancreatitis (SAP) rats.

METHODS

Sixty Wistar rats were equally randomized into three groups: a sham operated control group, an SAP control group, and a PCD group. The levels of inflammatory cytokines, the activity of group II phospholipase A2 (PLA2) in blood and ascitic fluid, and the pancreas level of group II PLA2 and trypsin activity were measured 24 h after the operation. The apoptosis of the pancreatic cells, the expression of cycloxygenase-2 (COX-2), inducible nitric oxide synthase (iNOS), active caspase-3, Bcl-2 and Bax in the pancreas was detected. Pancreatic pathological changes were observed.

RESULTS

The levels of proinflammatory cytokines, the activity of group II PLA2 and trypsin activity in pancreas in the SAP group were higher than those in the PCD group. The histopathological results revealed that the pancreatic injury was alleviated in the PCD group. The expression of COX-2 and iNOS in the pancreatic tissue in the SAP control rats was higher than that in the PCD rats. The expression of Bcl-2 was decreased and the expression of active caspase-3 and Bax was increased in the pancreas of PCD rats. The apoptosis index of the pancreatic cells in the PCD rats was higher than that in the SAP control rats.

CONCLUSION

PCD can relieve SAP-induced pancreatic injury by inhibiting inflammatory reactions, and promoting apoptosis of pancreatic cells.

Relationship between modified CT severity index and clinical features of L-asparaginase-associated pancreatitis in pediatric acute lymphoblastic leukemia

PURPOSE

To describe clinical and CT features of L-asparaginase-associated pancreatitis (L-AP) and to correlate CT grades with clinical parameters.

METHODS

A total of 16 children (M:F = 9:7; mean age, 8.1 years) who developed L-AP after L-asparaginase (L-asp) treatment and underwent abdominal CT scan were included. We retrospectively reviewed clinical data (age, sex, signs, and symptoms related to pancreatic toxicity and its complications, the number of L-asp doses receiving before L-AP); laboratory test results (serum amylase, lipase, C-reactive protein (CRP), calcium, blood urea nitrogen (BUN), lactate dehydrogenase (LDH), aspartate aminotransferase (AST), glucose, and serum albumin); and clinical course (the number of days of hospitalization, number of NPO days, use of nasogastric tube, intravenous (IV) narcotics, total parenteral nutrition (TPN) or any surgical intervention). We also reviewed CT images and modified CT severity index (MCSI) for grading the severity of AP and classified to three groups (mild, moderate, and severe) or two groups (low and high score) according to MCSI.

RESULTS

L-AP typically occurred early in the course of therapy. Use of IV narcotics (P = .014) and peak amylase (P = .009) showed a significant difference between mild and severe L-AP groups according to MCSI. Between the low and high score groups, Use of IV narcotics (P = .046), BUN (P = .039), and peak amylase level (P = .013) was significantly different. However, the L-asp dose, hospital day, and other clinical date associated with prognosis did not show any significant difference.

CONCLUSION

In L-AP with pediatric ALL patients, MCSI may correlate with usage of IV narcotics, BUN, and peak amylase levels.

Imaging of acute pancreatitis and its complications. Part 2: complications of acute pancreatitis

The Atlanta classification of acute pancreatitis was introduced in 1992 and divides patients into mild and severe groups based on clinical and biochemical criteria. Recently, the terminology and classification scheme proposed at the initial Atlanta Symposium have been reviewed and a new consensus statement has been proposed by the Acute Pancreatitis Classification Working Group. Major changes include subdividing acute fluid collections into "acute peripancreatic fluid collection" and "acute post-necrotic pancreatic/peripancreatic fluid collection (acute necrotic collection)" based on the presence of necrotic debris. Delayed fluid collections have been similarly subdivided into "pseudocyst" and "walled of pancreatic necrosis". Appropriate use of the new terms describing the fluid collections is important for management decision-making in patients with acute pancreatitis. The purpose of this review article is to present an overview of complications of the acute pancreatitis with emphasis on their prognostic significance and impact on clinical management and to clarify confusing terminology for pancreatic fluid collections.

Imaging of acute pancreatitis and its complications. Part 1: acute pancreatitis

Acute pancreatitis is an acute inflammatory disease of the pancreas that may also involve surrounding tissues or remote organs. The Atlanta classification of acute pancreatitis was introduced in 1992 and divides patients into mild and severe groups based on clinical and biochemical criteria. Recently, the terminology and classification scheme proposed at the initial Atlanta Symposium have been reviewed and a new consensus statement has been proposed by the Acute Pancreatitis Classification Working Group. Generally, imaging is recommended to confirm the clinical diagnosis, investigate the etiology, and grade the extend and severity of the acute pancreatitis. Ultrasound is the first-line imaging modality in most centers for the confirmation of the diagnosis of acute pancreatitis and the ruling out of other causes of acute abdomen, but it has limitations in the acute clinical setting. Computed tomography not only establishes the diagnosis of acute pancreatitis, but also enables to stage severity of the disease. Magnetic resonance imaging has earned an ever more important role in the diagnosis of acute pancreatitis. It is especially useful for imaging of patients with iodine allergies, characterizing collections and assessment of an abnormal or disconnected pancreatic duct. The purpose of this review article is to present an overview of the acute pancreatitis, clarify confusing terminology, underline the role of ultrasound, computed tomography and magnetic resonance imaging according to the proper clinical context and compare the advantages and limitations of each modality.

Analysis of the Power of Common Diagnostic Tools in the Management of Acute Pancreatitis

Acute pancreatitis (AP) is a serious medical condition usually associated with severe upper abdominal pain. The purpose of our study is to assess the therapeutic consequences of contrast-enhanced computed tomography (CE-CT) and the predictive value of CRP for severe pancreatitis. We included patients with a threefold increase of plasma lipase who had received a CE-CT or had a CRP of =150 mg/dl. A total of 74 out of 283 patients got a contrast-enhanced CT scan; in 11 cases the CT was followed by endoscopic or surgical interventions as therapeutic consequences compared with 19 out of 50 control cases. 69 out of 283 patients (24,3%) had CRP >150 mg/dl within 48 hours after admission. 32 of them had SAP. The CRP cutoff of 150 mg/L had a sensitivity of 80% and a specificity of 65%. The positive predictive value for SAP in patients beyond the cutoff is 46.4%. The negative predictive value for SAP in patients below the cutoff was 89.5%. Our results support the opinion that an early CE-CT is usually not indicated. CRP helps to assess the course of AP; levels below 150 mg/dl between the first 48 h indicate a mild course in most of the cases.

Approaches to the difficult drainage and biopsy

Percutaneous abscess drainage and percutaneous biopsy are effective and widely used techniques in the diagnosis and treatment of patients with abdominal or pelvic abscesses and lesions. Some abscesses and lesions can initially appear unsuitable for percutaneous access for a variety of reasons. This article reviews the circumstances in which collections or lesions may appear undrainable or inaccessible to percutaneous biopsy, and it describes techniques for overcoming these circumstances.

Laboratory diagnosis of acute pancreatitis: in search of the Holy Grail

Acute pancreatitis is an acute inflammatory condition of the pancreas, which might extend to local and distant extrapancreatic tissues. The global incidence varies between 17.5 and 73.4 cases per 100,000 and the pathogenesis recognizes alcohol exposure and biliary tract disease as the leading causes, ahead of post-endoscopic retrograde cholangiopancreatography, drugs and abdominal trauma. The diagnosis of acute pancreatitis is substantially based on a combination of clinical signs and symptoms, imaging techniques and laboratory investigations. Contrast-enhanced computed tomography is the reference standard for the diagnosis, as well as for establishing disease severity. The assessment of pancreatic enzymes, early released from necrotic tissue, is the cornerstone of laboratory diagnosis in this clinical setting. Although there is no single test that shows optimal diagnostic accuracy, most current guidelines and recommendations indicate that lipase should be preferred over total and pancreatic amylase. Although a definitive diagnostic threshold cannot be identified, cut-offs comprised between ≥ 2 and ≥ 4 times the upper limit of the reference interval are preferable. The combination of amylase and lipase has been discouraged as although it marginally improves the diagnostic efficiency of either marker alone, it increases the cost of investigation. Some interesting biomarkers have been also suggested (e.g., serum and urinary trypsinogen-1, -2 and -3, phospholipase A2, pancreatic elastase, procalcitonin, trypsinogen activated protein, activation peptide of carboxypeptidase B, trypsin-2-alpha1 antitrypsin complex and circulating DNA), but none of them has found widespread application for a variety of reasons, including the inferior diagnostic accuracy when compared with the traditional enzymes, the use of cumbersome techniques, or their recent discovery. The promising results of recent proteomics studies showed that this innovative technique might allow the identification of changes characterizing pancreatic tissue injury, thus highlighting new potential biomarkers of acute pancreatitis.

Endoscopic approach to pancreatic pseudocyst, abscess and necrosis: review on recent progress

AIM

The aim of this study is to introduce recent progress in the treatment of pancreatic pseudocyst, abscess and necrosis using the endoscopic approach.

METHODS

Studies on PubMed and MEDLINE from the last 30 years on progress in the management of the complications from severe pancreatitis were researched and reviewed. Herein, the indication for intervention, definition of fluid collection associated with acute pancreatitis and treatment modalities of these complications are summarized.

RESULTS

Three types of management are employed for complications of severe pancreatitis: the endoscopic, surgical and percutaneous approaches.

CONCLUSIONS

Over the years, as technical expertise has increased and instruments for endoscopy have improved, patients who had endoscopic surgery to address the complications of severe pancreatitis have had higher survival rates, lower mortality rates and lower complication rates than those having open debridement. However, traditional open abdominal surgery should be advocated when minimally invasive management fails or necrosis is extensive and extends diffusely to areas such as the paracolic gutter and the groin (i.e. locations not accessible by endoscopy).

Acute pancreatitis secondary to gestational hypertriglyceridaemia

Gestational hypertriglyceridaemia is a rare cause of acute pancreatitis. Its pathophysiology is incompletely understood. Severity scoring and effective management remain challenging. We report a case of acute pancreatitis secondary to gestational hypertriglyceridaemia. We describe the use of computed tomography to provide an alternative determination of severity, as well as plasmapheresis as a means of treating the condition.

Imaging of acute pancreatitis: update of the revised Atlanta classification

Acute pancreatitis is an acute inflammatory process of the pancreatic gland with increasing incidence worldwide. Usually the clinical presentation and course are mild, with an uneventful recovery. In 10% to 20% of patients, however, local and systemic complications develop, resulting in significant morbidity and mortality. In 1992, the Atlanta symposium provided definitions for acute pancreatitis and its severity. Insights into the pathophysiology of the disease, improved diagnostic imaging, and implementation of minimally invasive techniques have led to classification updates. This article reviews the cross-sectional imaging features of acute pancreatitis and presents proposed definitions of the revised Atlanta classification.

The revised Atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment

An international working group has modified the Atlanta classification for acute pancreatitis to update the terminology and provide simple functional clinical and morphologic classifications. The modifications (a) address the clinical course and severity of disease, (b) divide acute pancreatitis into interstitial edematous pancreatitis and necrotizing pancreatitis, (c) distinguish an early phase (1st week) and a late phase (after the 1st week), and (d) emphasize systemic inflammatory response syndrome and multisystem organ failure. In the 1st week, only clinical parameters are important for treatment planning. After the 1st week, morphologic criteria defined on the basis of computed tomographic findings are combined with clinical parameters to help determine care. This revised classification introduces new terminology for pancreatic fluid collections. Depending on presence or absence of necrosis, acute collections in the first 4 weeks are called acute necrotic collections or acute peripancreatic fluid collections. Once an enhancing capsule develops, persistent acute peripancreatic fluid collections are referred to as pseudocysts; and acute necrotic collections, as walled-off necroses. All can be sterile or infected. Terms such as pancreatic abscess and intrapancreatic pseudocyst have been abandoned. The goal is for radiologists, gastroenterologists, surgeons, and pathologists to use the revised classifications to standardize imaging terminology to facilitate treatment planning and enable precise comparison of results among different departments and institutions.

Comparative evaluation of blood markers and extrapancreatic inflammatim on CT score in the early prediction of the severity of acute panereatitis

AIM: To compare the value of blood markers and extrapancreatic inflammation on CT score (EPIC) in early prediction of the severity of acute pancreatitis (AP).

METHODS: The clinical, laboratory and CT data obtained on admission (within 24 h of hospitalization) for 96 patients with AP who were hospitalized from September 2010 to September 2011 were analyzed. Severe AP (SAP) was defined as the presence of one or more of the following signs: mortality, persistent organ failure and/or admission ICU, and/or operation. Blood markers and EPIC were compared between SAP group and mild AP (MAP) using the t test. The correlation between blood markers, EPIC and severity of AP was analyzed. The value of blood markers and EPIC in predicting the severity of AP was assessed using receiver operation curve analysis. The sensitivity, positive predictive value and accuracy were also studied.

RESULTS: There were 20 patients with SAP and 76 patients with MAP. The levels of blood markers and EPIC in the SAP group were significantly higher than those in the MAP group [white blood cell (WBC): (15.16 ± 5.06) × 10⁹/L vs (11.05 ± 1.76) × 10⁹/L, neutrophil-lymphocyte ratio (NLR): 18.95 ± 12.13 vs 6.63 ± 3.44, high-sensitivity C-reactive protein (hs-CRP): 58.35 mg/L ± 20.47 mg/L vs 28.59 mg/L ± 12.92 mg/L, D-dimer (DD): 1596.95 μg/L ± 1409.05 μg/L vs 412.52 μg/L ± 316.66 μg/L, EPIC: 3.30 ± 0.86 vs 1.50 ± 0.96, all P = 0.000]. The Spearman correlation coefficients (rs) between severity of AP and WBC, NLR, hs-CRP, DD and EPIC were 0.419, 0.571, 0.568, 0.434 and 0.613, respectively (all P = 0.000). The area under the curve (AUC) of WBC, NLR, hs-CRP, DD and EPIC in predicting the severity of AP were 0.798 (0.670-0.925), 0.906 (0.830-0.981), 0.904 (0.838-0.970), 0.808 (0.638-0.938) and 0.917 (0.851-0.983), respectively. The predictive sensitivities were 70.00%, 85.00%, 85.00%, 75.00% and 85.00%; the positive predictive values were 58.33%, 73.91%, 51.52%, 48.39% and 72.00%; and the accuracies were 83.33%, 90.63%, 80.21%, 78.13% and 90.63%, respectively.

CONCLUSION: WBC and DD have a moderate value in predicting the severity of AP, while NLR, hs-CRP, and EPIC have a much higher value.

Pancreatic choledochal fistula complicating acute pancreatitis

Background:

Biliary tract involvement in acute necrotizing pancreatitis is rare.

Case Report:

We report a case of a 53-year-old man who had a pancreatic choledochal fistula complicating acute necrotizing pancreatitis. The fistula was suspected at computed tomography and confirmed at surgery. The patient underwent necrosectomy, cholecystectomy and proximal biliary diversion. He is well at 1-year follow-up.

Conclusions:

Simultaneous presence of air in the biliary tree and pancreatic collection is highly suggestive of a pancreaticobiliary fistula. Pancreatic necrosectomy and proximal biliary diversion resulted in closure of the fistula.

Severe acute pancreatitis: advances and insights in assessment of severity and management

The patients with acute pancreatitis are at risk to develop different complications from ongoing pancreatic inflammation. Often, there is no correlation between the degree of structural damage to pancreas and clinical manifestation of the disease. The effectiveness of any treatment is related to the ability to predict severity accurately, but there is no ideal predictive system or biochemical marker. Severity assessment is indispensable to the selection of proper initial treatment in the management of acute pancreatitis. The use of multiparametric criteria and the evaluation of severity index permit us to select high-risk patients. Furthermore, contrast-enhanced computed tomographic scanning and contrast-enhanced MRI play an important role in severity assessment. The adoption of multiparametric criteria proposed together with morphological evaluation consents the formulation of a discreetly reliable prognosis on the evolution of the disease a few days from onset.