Acute Pancreatitis: The Role of Diagnostic Imaging

The role of Doppler sonography in predicting severity of acute pancreatitis

PURPOSE

To investigate the role of Doppler sonography (DUS) examination of major abdominal arteries in predicting severity of acute pancreatitis (AP).

METHODS

Twenty-nine patients diagnosed with AP and 14 controls were blindly and prospectively evaluated with Doppler sonography. Disease severity was defined clinically according to acute physiology and chronic health evaluation (APACHE II) score and was classified as severe for APACHE II score > or =8. DUS examination included the measurement of peak systolic velocity (PSV), end diastolic velocity (EDV), pulsatility index (PI), and resistance index (RI) of the celiac artery (CA) and superior mesenteric artery (SMA). Statistical analysis included Mann-Whitney U test, Student t test, and receiver operating characteristic curve analysis.

RESULTS

Twelve patients had severe AP and 17 had mild AP. PSV, EDV, and PI of the CA and RI of the SMA were higher in the severe AP group than in the mild AP and control groups (p < 0.001 and p < 0.0001, respectively). The sensitivity and specificity were 100% and 94%, respectively, for a 87 cm/second CA PSV cutoff value, 75% and 100%, respectively, for a 22 cm/second CA EDV cutoff value, 92% and 82%, respectively, for a 1.29 CA PI cutoff value, and 100% and 100%, respectively, for a 0.86 SMA RI cutoff value.

CONCLUSION

DUS can be useful in predicting the severity of AP in the early period of admission phase of the disease.

Acute Abdominal Pain: Diagnostic Impact of Immediate CT Scanning

BACKGROUND

Acute abdominal pain is a common diagnostic problem. This study aimed to evaluate the routinely use of contrast enhanced computed tomographic (CT) scanning early in the diagnostic process.

METHODS

A retrospective review of 2,222 patients with acute abdominal pain who underwent contrast enhanced CT scanning within 24 h after admission. The diagnoses obtained were compared with the final diagnoses after 1 month.

RESULTS

After CT scanning the following diagnoses were suggested as the primary cause of the abdominal pain: nonspecific abdominal pain 984 (44.3%), appendicitis 354 (15.9%), bowel obstruction 190 (8.6%), diverticulitis 182 (8.2%), gastrointestinal perforation 52 (2.3%), gallstone disease 64 (2.9%), pancreatitis 72 (3.2%), inflammatory bowel disease 13 (0.6%), intra-abdominal malignancy 34 (1.5%), vascular disease (including 1 completely cured patient with paradoxical embolization in the superior mesenteric artery) 33 (1.5%), urological 131 (5.9%), gynecological 54 (2.4%), miscellaneous 31 (1.4%). In 28 cases a conclusive CT examination could not be carried out. The suggested diagnoses were correct in 2,151 cases (96.8%). In 16 cases (0.7%) an incorrect diagnosis was reported, leading to 7 unnecessary laparotomies. False negative reports were obtained in 27 cases (1.2%). After CT examination 500 patients could be discharged immediately.

CONCLUSIONS

Contrast-enhanced CT scanning results in superior diagnostic precision in patients with acute abdominal pain. The present work supports the strategy to include this examination early in the routine diagnostic process.

Disconnected pancreatic duct syndrome: imaging findings and therapeutic implications in 26 surgically corrected patients

PURPOSE

The lack of ductal continuity between a viable pancreatic tissue and the gastrointestinal tract results in the disconnected pancreatic duct syndrome (DPDS). The purpose of our study is to describe accurately the imaging features of CT scanning and endoscopic retrograde pancreatography (ERCP) that define the DPDS.

METHODS

We conducted a retrospective analysis of the computed tomography (CT) and ERCP examinations in 26 consecutive patients with surgically proven disconnected pancreatic ducts treated over a 5-year period at our institution. Two abdominal radiologists concurrently defined the imaging features (presence and size of fluid collection along the course of the pancreatic duct, upstream enhancing pancreatic parenchyma, and ERCP abnormalities) via consensus for both exams. Patient demographics, etiology of pancreatitis, surgical treatment, initial CT interpretation, and the delay between symptom onset to correct diagnosis were recorded.

RESULTS

A discrete, intrapancreatic fluid collection (average size = 27 cm2 (range, 4-74 cm2) along the course of the main pancreatic duct with upstream viable pancreatic parenchyma was identified by CT in 26 cases. ERCP showed ductal obstruction at the level of the intrapancreatic fluid collection in all patients with extravasation of contrast in 14 (54%). All patients were treated by operation: 15 (58%) by internal drainage into a Roux-en-Y limb of jejunum and 11 (42%) by distal pancreatic resection. No prior CT interpretation correctly identified DPDS. The average delay between symptom onset and definitive diagnosis was 9.3 months (range, 3-36 months).

CONCLUSIONS

A discrete intrapancreatic fluid collection along the expected course of the main pancreatic duct with viable upstream pancreatic parenchyma suggests the diagnosis of DPDS. ERCP findings of ductal obstruction at the level of this fluid collection with or without contrast extravasation confirm this diagnosis. Treatment is surgical and requires either internal drainage or distal pancreatic resection for complete resolution.