radiographic evidence of pancreatitis
TRANSCRIPT
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Radiographic Evidence of Pancreatitis
Nicole Chow Ahrenholz, MS4
June 2005
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Tutorial Overview
• Etiologies of Acute and Chronic Pancreatitis• Clinical Features: History, PE, Labs• Radiographic Evidence
– Abdominal plain films
– Ultrasound
– CT
– ERCP
• Treatment
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Etiologies of Acute Pancreatitis
• Gallstones (and other obstructive causes)
• Ethanol• Hyperlipidemia• Hypercalcemia• Drugs (many)
• Infections: mumps, Coxsackie, HIV, Mycoplasma, Toxo
• Trauma• Post-ERCP• Cystic Fibrosis
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Etiologies of Chronic Pancreatitis
• Alcohol abuse
• Hereditary pancreatitis
• Ductal obstruction (eg, trauma, pseudocysts, stones, tumors, possibly pancreas divisum)
• Tropical pancreatitis
• Systemic disease: SLE, CF, possibly hyperparathyroidism
• Autoimmune pancreatitis
• Idiopathic pancreatitis• Mutations of the cystic
fibrosis gene
(lots of overlap with acute pancreatitis)
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Clinical Features: Acute
History• Acute-onset of severe
abdominal pain• Typically epigastric pain,
radiating to back, occasionally RUQ or LUQ
• Nausea, vomiting
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Clinical Features: Acute
Physical Exam• Mild: epigastric tenderness,
fever• Severe: shock, abdominal
distension, guarding• Grey-Turner’s sign:
ecchymotic flank discoloration, Cullen’s sign: periumbilical ecchymosis, due to retroperitoneal bleeding (rare)
• Epigastric mass: pseudocyst
http://www.jichi.ac.jp/usr/surg/nagai/AP1.gif
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Clinical Features: Acute
Labs
• Elevated pancreatic enzymes: blockage of secretion leads to leakage through basolateral membrane into circulation
• Amylase: sensitivity 75-92%, specificity 20-60%
• Lipase: sensitivity 86-100%, specificity 50-99%
Munoz A and Katerndahl DA. Diagnosis and Management of Acute Pancreatitis. AAFP 2000 62(1).
http://gastroresource.com/GITextbook/en/chapter12/fig2.htm
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Clinical Features: Chronic
History:• Abdominal pain• Pancreatic insufficiency
– Fat malabsorption: steatorrhea, Vitamins ADEK deficiency
– Glucose intolerance
• Symptoms chronic with acute exacerbationsLabs:• Pancreatic enzymes often normal
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www.aafp.org/afp/ 20000701/164.html
Pancreas Anatomy
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Abdominal X-ray
Acute Pancreatitis:
Findings are variable and have low sensitivity
• Normal or
• Localized ileus (“sentinel loop”) or
• “Colon cut-off sign” due to spasm of descending colon from inflammation
http://www.jichi.ac.jp/usr/surg/nagai/AP1.gif
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Abdominal X-ray
Chronic Pancreatitis• Calcifications (seen
in 30% of patients)
http://utdol.com/application/image.asp?r=/application/image.asp&file=gast_pix/pancre4%26%2346%3Bgif&title=Pancreatic%20calcification&app=utdol
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Abdominal Ultrasound
• Enlarged, hypoechoic pancreas (acute)
• Sensitivity 62-95% in diagnosing acute pancreatitis
• Looking for:– Calcifications– Ductal dilatation– Pseudocysts
Munoz A and Katerndahl DA. Diagnosis and Management of Acute Pancreatitis. AAFP 2000 62(1)
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Abdominal Ultrasound
Pseudocyst of pancreatic tail by endoscopic ultrasound (renal vein in color angio)
http://images.google.com/imgres?imgurl=http://www.toshiba-europe.com/Medical/Materials/ImageGallery/EUS6RGB_small.jpg&imgrefurl=http://www.toshiba-D1412%26product_ID%3D1637&h=78&w=104&sz=3&tbnid=-9kW4dbwGiwJ:&tbnh=59&tbnw=79&hl=en&start=9&prev=/images%3Fq%3Dultrasound%2Bpancreatitis%26hl%3Den%26hs%3DeVY%26lr%3D%26client%3Dfirefox-a%26rls%3Dorg.mozilla:en-US:official%26sa%3DG
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Abdominal Ultrasound: Acute
Pseudocyst
http://www.emedicine.com/ped/topic3014.htm
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Abdominal CT
• Best study for acute pancreatitis, also helpful in chronic pancreatitis
• CT in acute pancreatitis: sensitivity 60%, specificity 98%
• Looking for:– Peripancreatic inflammation– Necrosis– Pseudocysts– Calcifications– Dilated common bile duct
Ahn SH. Mayo-Smith WW. Murphy BL. Reinert SE. Cronan JJ. Acute nontraumatic abdominal pain in adult patients: abdominal radiography compared with CT evaluation. Radiology. 225(1):159-64, 2002 Oct.
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Balthazar CT Severity Index
Used as a prognostic tool in acute pancreatitis, predicting severity of disease, necrosis, and organ failure. Other prognostic tools include Ranson criteria and APACHE II and III systems.
Chatzicostas C. et al. Balthazar computed tomography severity index is superior to Ranson criteria and APACHE II and III scoring systems in predicting acute pancreatitis outcome. Journal of Clinical Gastroenterology. 36(3):253-60, 2003 Mar.
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Normal Abdominal CT
http://images.google.com/imgres?imgurl=http://www.liv.ac.uk/HumanAnatomy/phd/mbchb/adolescent/xray/ctpancrl.jpg&imgrefurl=http://www.liv.ac.uk/HumanAnatomy/phd/mbchb/adolescent/pancreas.html&h=493&w=723&sz=37&tbnid=lotKZ7OaipgJ:&tbnh=94&tbnw=139&hl=en&start=1&prev=/images%3Fq%3Dpancreas%2Bct%26hl%3Den%26lr%3D%26sa%3DG
6 Body of pancreas7 Tail of pancreas8 IVC9 Common bile duct10 Stomach11 Air bubble12 Spleen
Answers:
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Peripancreatic inflammation
Stevens T and Conwell DL. Acute Pancreatitis. http://www.clevelandclinicmeded.com/diseasemanagement/gastro/acutepan/acutepan.htm 2005.
Abdominal CT: Acute
What are the arrows pointing to?
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NecrosisContrast-enhanced axial CT section showing peripancreatic and retroperitoneal edema. The arrows point to non-enhancing areas of necrosis.
Munoz A and Katerndahl DA. Diagnosis and Management of Acute Pancreatitis. AAFP 2000 62(1)
Abdominal CT: Acute
What is wrong with this pancreas?
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A pseudocyst
http://utdol.com/application/image.asp?file=gast_pix/pancre3%26%2346%3Bgif&title=Pancreatic%20pseudocyst%20CT
Abdominal CT: Acute
What is wrong with this pancreas?
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Abdominal CT: Chronic
Dilated main pancreatic duct
http://www.medscape.com/content/2003/00/44/28/442814/442814_fig.html
What is the arrow pointing to?
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Calcifications
http://www.nlm.nih.gov/medlineplus/ency/imagepages/1157.htm
Identify
Abdominal CT: Chronic
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ERCP: Acute
• Limited role in diagnosis of acute pancreatitis
• Indicated in severe disease due to biliary obstruction
• Diagnostic AND therapeutic (sphincterotomy can be done to relieve obstruction)
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ERCP: Chronic Pancreatitis
“Beading” of main pancreatic duct
http://www.medscape.com/content/2003/00/44/28/442814/442814_fig.html
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http://utdol.com/application/image.asp?file=gast_pix/chroni16%26%2346%3Bgif&title=Chronic%20pancreatitis%20ERCP
ERCP
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Treatment
Usually conservative management• Monitor for shock, sepsis, ARDS• IV fluids• Pain control: meperidine (morphineSphincter of
Oddi spasm?)• NPO• NG for protracted vomiting• Antibiotics (controversial), mostly reserved for
necrotizing pancreatitis
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SourcesAhn SH. Mayo-Smith WW. Murphy BL. Reinert SE. Cronan JJ. Acute nontraumatic abdominal
pain in adult patients: abdominal radiography compared with CT evaluation. Radiology. 225(1):159-64, 2002 Oct.
Chari ST and Vege SS. Clinical manifestations and diagnosis of acute pancreatitis. UpToDate 2005.
Chatzicostas C. Roussomoustakaki M. Vardas E. Romanos J. Kouroumalis EA. Balthazar computed tomography severity index is superior to Ranson criteria and APACHE II and III scoring systems in predicting acute pancreatitis outcome. Journal of Clinical Gastroenterology. 36(3):253-60, 2003 Mar.
Freeman SD. Clinical manifestations and diagnosis of chronic pancreatitis. UpToDate 2005.Freeman SD and Bishop MD. Etiology and pathogenesis of chronic pancreatitis. UpToDate
2005.Munoz A and Katerndahl DA. Diagnosis and Management of Acute Pancreatitis. American
Academy of Family Physicians 2000 62(1)Stevens T and Conwell DL. Acute Pancreatitis.
http://www.clevelandclinicmeded.com/diseasemanagement/gastro/acutepan/acutepan.htm 2005.
Thomas PB. Pancreatitis and Pancreatic Pseudocyst. EMedicine 2004.Radiograph citations listed on individual slides