multi modality imaging acute...
TRANSCRIPT
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Multi‐modality Imaging in Acute Pancreatitis
Marsha Lynch, HMS IIIGillian Lieberman, MD
BIDMC Core Clerkship in RadiologyMarch 2009
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Our Patient R: Introduction
52M with 10d history of nausea, vomiting and abdominal pain.
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Patient R: Initial Presentation
PRESENTATION
• WBC 19.1
• ARF: Cr 3.2 (baseline 1.2)
• BG: 235
• Lipase: 2211(0‐60)
• Amylase: 804 (0‐100)
• ALT:10 AST:9 AP:79
• Ca: 7.9 (8.4‐10.2)
• TGs: 511 (0‐149)
PMH
• HTN
• Hyperlipidemia
• Congenital deafness
• Gout
• Obesity
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Patient R demonstrates a typical presentation of acute
pancreatitis
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Acute Pancreatitis: Pathophysiology
INFLAMMATION OF THE PANCREAS• Inappropriate activation of pancreatic enzymes• Intraparenchymal
and extraparenchymal
extravasation
of enzymes cause autodigestion
of pancreatic parenchyma and damage to peripancreatic
tissues and
vascular network• Inflammatory response to this injury out of proportion
to that of other organs to a similar insult• Inflammatory response causes further damage
– Fluid sequestration, fat necrosis, vasculitis
leading to
occlusions and thrombosis, hemorrhageWhitcomb, D C, Acute Pancreatitis. N Engl J Med 2006Balthazar, E J, Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation. Radiology 2002
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Acute Pancreatitis: Etiologies
Etiologies of Acute Pancreatitis
Mechanical Gallstones (>45%) , sludge, pancreatic mass, ampullary
stenosis
or
mass ,duodenal stricture or obstruction
Toxic Alcohol (>35%), methanol, steroids/ drugs, scorpion venom
Metabolic Hyperlipidemia, hypertriglyceridemia, hypercalcemia
Trauma Blunt or penetrating, ERCP, s/p
abdominal surgery
Infection Viral (mumps), parasitic, bacterial
Vascular Ischemia, embolism, vasculitis
Congenital Pancreas divisum
Genetic CFTR mutation
Miscellaneous Autoimmune, renal transplant, alpha‐1‐anti‐trypsin deficiency
Adapted from “etiology of acute pancreatitis”; Up-To-Date
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Acute Pancreatitis: Epidemiology
• >200,000 US hospital admission yearly
• 20% have a severe course
– Associated with systemic
and local complications
and increased mortality
(10‐30%)
• Severe CourseSYSTEMIC COMPLICATIONS
• Shock• DIC• Pulm. Insufficiency/ARDS
LOCAL COMPLICATIONS• Necrosis• Abscess• Pseudocyst• Pseudoaneurysm• Splenic
vein thrombosis
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Acute Pancreatitis: Severity Assessment
Severity of acute pancreatitis is commonly assessed using :
1.
Ranson’s Criteria– 5 clinical signs at presentation and 6 at 48hrs
– ≥
3 associated with severe course (systemic complications and/or
pancreatic necrosis)
2.
APACHE II– 12 routine physiologic measurement, age and previous health status
– ≥
8 associated with severe course
3.
CT Severity Index (CTSI)– Based on extent of inflammation and presence of complications on
CT scan.
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Let’s briefly review the anatomy of the pancreas
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Pancreas Anatomy
Retroperitoneal organ stretching from the curvature of the duodenum to the spleen. Rich arterial supply from vessels off the celiac artery superiorly and the SMA inferiorly. Glandular tissue with both endocrine and exocrine function.
http://www.fairview.org/healthlibrary/content/pancreas.gif
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Pancreas Anatomy: Axial CT View
Image from: PACS, BIDMC
pancreas pancreas
Companion Patient 1: Delayed Phase Axial CT
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Acute Pancreatitis
CLINICAL DIAGNOSIS• Abdominal pain• Nausea/Vomiting• Elevated Pancreatic Enzymes
MANAGEMENT• Bowel Rest/NPO• IVF• Analgesics
http://www.fairview.org/healthlibrary/content/pancreas.gif
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The diagnosis of pancreatitis is largely a clinical one based on physical signs and symptoms as well as serum levels of
pancreatic enzymes.
What then is the role of Radiology in its management?
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Role of Radiology in Acute Pancreatitis
• Rule out other intra‐abdominal conditions as cause of abdominal pain or other symptoms
– Bowel obstruction, infarction or perforation; acute cholecystitis; appendicitis
• Confirm diagnosis and Identify causes (e.g. gallstones)
• Evaluate and stage local pancreatic morphology
• Identify and manage complications
• Menu of Tests: US, Plain Film, CT, MR
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Back to Our Patient R
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Patient R: Ranson’s
CriteriaRanson’s Score ≥ 3 (Threshold)
• At Presentation– Age > 55– BG > 200– WBC > 16,000– LDH > 350– ALT > 250
• Within 48 Hours– Hct
> 10% decrease– Serum Ca < 8– Base Def > 4– BUN > 5 increase– Fluid Sequestration > 6L– PaO2
< 60
PATIENT X PRESENTATION– WBC 19.1
– BG 235
– Age 52
– ALT 10
– LDH 15
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We are less concerned about our patient progressing down an more severe path based
on him having only 2/5 Ranson’s criteria at presentation.
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However, we can use radiology to assess whether his acute pancreatitis is due to one
of the commonest etiologies: gallstones.
We therefore proceed to abdominal Ultrasound…
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Use of Abdominal Ultrasound in Acute Pancreatitis
Indicated early in acute pancreatitisPros– Inexpensive– Excellent for identifying gallbladder pathology, sludge and gallstones
(Most common cause of pancreatitis!)
– Evaluate bile‐duct dilation– May visualize masses and
follow up of pseudocystCons– Not optimal for pancreas; retroperitoneal location easily obscured by
bowel gas distension
– Less sensitive for stones in distal CBD– Limited in early assessment of pancreatitis
Balthazar, E J, Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation. Radiology 2002
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Patient R Abdominal US: Liver,GB
Image from: PACS, BIDMC
Gallbladder: anechoic cystic region with increased through- transmission
Liver parenchyma: no gross intra-hepatic ductal dilitation
Abdominal Ultrasound: RUQ
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Patient R Abdominal US: GB
Image from: PACS, BIDMC
Absence of hyperechoic foci
Non-distended GB withnormal wall thickness
No signs of acute cholecyctitis: lack of gallbladder wall thickening, pericholecystic fluid or cholelithiasis
Abdominal Ultrasound: RUQ
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Happily, our suspicion of gallbladder pathology as the cause of our patient R’s
acute pancreatitis is now greatly lowered.
So we continue supportive management with bowel rest, IVF
and analgesics.
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On Hospital Day 5…
…our Patient R develops bowel distension and abdominal pain.
We proceed immediately to Abdominal Plain Film
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Use of Abdominal Plain Film in Acute Pancreatitis
Pros– Screen
for/exclude separate or accompanying abdominal process• Signs of peritonitis or bowel ischemia
– Free air• Bowel Obstruction• Ascites
– Inexpensive, readily available and fastCons– Poor visualization of the pancreas and retroperitoneum
• May see calcifications due to chronic process
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Patient R: Abdominal Plain Film
HD 5
Image from: PACS, BIDMC
residual contrast in asc. and desc. colon
----- isolated segments of dilated sm. bowel, up to 3cm luminal diameter
Transverse colon shows no marked distention but with no contrast
Abdominal Plain Film: Supine
spasm of the desc. colon just distal to splenic flexure
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Patient R Abdominal
Plain Film HD 5
Image from: PACS, BIDMCAbdominal Plain Film: L Lat Decubitus
Air fluid levels
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The presence of distension in the along with air‐fluid levels concern us for small bowel
obstruction. We decide to closely follow our patient.
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On Hospital Day 6…
Our patient has worsening abdominal pain and distension. We
quickly perform a repeat abdominal plain film.
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Patient X Abdominal
Plain Film HD 6
3.3 cm
8.5 cm
Distended stomach
Increased focal distension of small bowel
Abdominal Plain Film: Supine Image from: PACS, BIDMC
Marked distension of transverse colon, still with no contrast in lumen.
arrest of contrast (2 days)
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We are certainly more concerned about obstruction now. Before we continue, let’s review some possible causes of obstruction in
this patient.
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Possible Causes of Bowel Obstruction in Our Patient R
• Functional – Focal ileus/Sentinel loops (Transverse colon and
segments of small bowel) due to adjacent pancreatic inflammatory process
• Mechanical– Pancreatic mass
• Developing fluid collections or pseudocyst• GB unseen on U/S
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We are more concerned about yet unseen causes of any mechanical obstruction.
We now proceed to Abdominal CT to further evaluate the cause of the increasing
abdominal distension and to have a better look at the inflamed pancreas.
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Use of Abdominal CT in Acute Pancreatitis
Pros– Readily available and Fast– Aid in diagnosis and staging of pancreatitis– Depict,
quantify pancreatic
parenchymal
injury• Ability to assess the presence or absence of:
– Edema (focal or diffuse)
– Peripancreatic
fluid and inflammation
– Fluid collections
– Pseudocysts
– Necrosis
– Evaluate common bile duct for stones or other obstructions
Cons– Our Patient R is in ARF and this may be exacerbated by IV contrast
administration
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Patient R Delayed‐Phase axial CT: Supra‐pancreatic fluid collection
Image from: PACS, BIDMC
4x7cm fluid collection just superior to the pancreas
Delayed Phase CT: Axial
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Normal vs. Acute Pancreatitis
Images from: PACS, BIDMC
Acute pancreatitis: swollen, edematous gland with indistinct edges blurred into those of surrounding structures
Axial Delayed Phase CT: Companion Pt. 1 Axial Delayed Phase CT: Patient R
Normal pancreas: Fluffy, macronodular gland texture distinct from surrounding organs
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Patient R: Abdominal CT ‐ peripancreatic
fat stranding and
patent splenic
veinperipancreatic fat strandingpatent splenic vein
Axial Delayed Phase CT: Patient RAxial Delayed Phase CT: Patient R
Images from: PACS, BIDMC
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Patient R Abdominal CT: Focal Transverse Ileus
and Arrest of
Contrastarrest of contrastadynamic transverse colon
Axial Delayed Phase CT: Patient RAxial Delayed Phase CT: Patient R
Images from: PACS, BIDMC
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Patient R Abdominal CT: Suspicious hyperattenuating
lesion
There is a round hyperdensity measuring 1.4cm with similar attenuation as the adjacent aorta. We can also visualize the IVC posterior and the GDA adjacent and just superior to the lesion.
This could represent: 1.Pseudoaneurysm of GDA2.Gallstone3.Reactive lymph node.
Image from: PACS, BIDMCDelayed Phase CT: Axial
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What Now??? We need to further explore this lesion as our
last study was limited by the lack of both a non‐contrast and arterial phase.
Luckily, we have another tool in our arsenal.
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Use of MR in Acute Pancreatitis
Increasingly used in diagnosis and management of acute pancreatitis
Pros– Non‐invasive and no use of IV contrast– Ability to better characterize fluid collections (acute collection vs.
abscess, necrosis, hemorrhage, pseudocyst)
– Ability to delineate pancreatic and bile ducts (detect
choledocholithiasis
missed on U/S ) and other complications
comparable to ERCP
– Greater sensitivity vs. CT in detecting mild pancreatitis
Cons– Expensive and in many less severe cases not necessary for diagnosis
and management
– Less readily available in non‐tertiary medical centers
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Patient R: Abdominal MR
Image from: PACS, BIDMCT2 MRI: flow-void sequence
Our lesion has high signal distinct from the absence of signal (flow-void sequence) in the other three vessels of interest: GDA, IVC and aorta.
In particular, the lesion is distinct from the GDA, significantly reducing our suspicion for pseudoaneurysm.
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Patient R: High signal lesion on MR
In this sequence, gallstones would demonstrate no signal and our lesion is consistent with a reactive lymph node.
Image from: PACS, BIDMCT2 MRI: flow-void sequence
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Patient R: Comparison of CT versus MRI findings
The suspicious lesion on CT was further evaluated on MR and found to be benign consistent with a reactive lymph nose Images from: PACS, BIDMC
T2 MR: flow-void sequenceDelayed Phase CT: Axial
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A word about Pleural Effusions…
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Pleural Effusions: a common complication of Acute Pancreatitis
Approx. 1/3 patients with acute pancreatitis will have will have abnormal CXRs. The typical findings include elevated hemidiaphragm, pleural effusions, atelectasis and in more severe cases ARDS
Patient R: Delayed Phase CT Low lung volumes,Bibasilar atelectasis and pleural effusions
Images from: PACS, BIDMC
Patient R: Frontal CXR
Patient R: Lateral CXR
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Patient R: Remaining Course
• HD 6– Emesis and large BM that largely relieved abdominal pain
• Started on TPN– Diet slowly advanced until tolerated regular diet
• Continued on supportive measures as labs normalized and symptoms resolved
• Discharged to Home on HD 16
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Patient R Remaining Course cont’d
PRESENTATION
• WBC 19.1
• ARF: Cr 3.2 (baseline 1.0)
• BG: 235
• Lipase: 2211(0‐60)
• Amylase: 804 (0‐100)
• ALT:10 (0‐40)
• AST:9 (0‐40)
• AP:79 (39‐117)
• Ca: 7.9 (8.4‐10.2)
• TGs: 511 (0‐149)
DISCHARGE
• WBC 7.4
• Cr 0.9
• BG: 95
• Lipase: 59*(0‐60)
• Amylase: 50* (0‐100)
• ALT:18
• AST:29
• AP:79*
• Ca: 8.7 (8.4‐10.2)
• TGs: 112 (0‐149)
* Last labs drawn before date of discharge
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Summary
• Acute Pancreatitis is a common illness with many potential highly morbid complications.
• Many cases are diagnosed clinically and managed supportively with bowel rest,
aggressive fluid administrations and analgesics.
• Radiology plays important role in confirming diagnoses, evaluating severity and identifying
and managing complications of acute pancreatitis.
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References
• Whitcomb, D C, Acute Pancreatitis. N Engl
J Med 2006;354:2142‐50.
• Balthazar, E J, Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation. Radiology
2002; 223:603–
613• Textbook of Gastrointestinal Radiology /
[edited by] Richard M. Gore, Marc S. Levine. London : W. B. Saunders Co., c2000.
• Up-To-Date, ‘Clinical manifestations and diagnosis of acute pancreatitis’, ‘etiologies of acute pancreatitis’
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Acknowledgements
• Ernest Yeh, MD
• Maria Levantakis, Course Co‐ordinator
• Gillian Lieberman, MD