this lecture focuses on two points:scoring of pancreatitis ,and the new Atlanta 2012 terminology of acute pancreatitis

1. Pancreatitis... scoring
and new atlanta terms
Dr/Ahmed Bahnassy
Consultant radiologist

2. causes and outcomes

3. Imaging
golden rule
An early CT may be misleading
concerning the severity of the
pancreatitis, since it can underestimate
the presence and amount of necrosis.
Early CT is only recommended when the
diagnosis is uncertain, or in case of
suspected early complications such as
perforation or ischemia.

4. too early CT misleading exam

5. Alcoholic pancreatitis
special issue
The widespread clinical practice of relying solely on
hyperamylasemia to establish the diagnosis of acute alcoholic
pancreatitis is unjustified and should be abandoned.
Serum lipase was measured in 65 of these normoamylasemic cases and was
found to be elevated in 68%.thus increasing diagnostic sensitivity from 81% when
amylase alone is used to 94% for both enzymes.

6. scoring of severity
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7. Interstitial pancreatitis
there is normal enhancement of the entire pancreatic gland with
only mild surrounding fatty infiltration.
There are no fluid collections or necrosis
(Balthazar grade C, CTSI: 2).

8. Exudative Pancreatitis
on day 18 there is expansion of
the peripancreatic collections.
There are two or more
collections, but no pancreatic
necrosis.
(Balthazar grade E, CTSI: 4)
In exudative pancreatitis, or better
called EXPN, there is normal
enhancement of the entire
pancreas associated with extensive
peripancreatic collections.
These are often heterogeneous in
appearance and may be
progressive.
EXPN consists of necrosis of
peripancreatic fat, extravasated
pancreatic fluid and inflammatory
and hemorrhagic components.
When peripancreatic collections
persist or increase, it is usually due
to the presence of fat necrosis (i.e.
EXPN).
Since fat does not enhance on CT,
we cannot diagnose fat necrosis.

9. Necrotizing Pancreatitis
There are 2 or more fluid collections
and more than 50% of the gland does
not enhance
(Balthazar grade E, CTSI :10).

10. Necrotizing Pancreatitis
Body and tail of the
pancreas do not enhance
after i.v. contrast (blue
arrows).
There is however normal
enhancement of the
pancreatic head (yellow
arrow).
More than 50% of the
pancreas is necrotic and
there are at least two
collections (CTSI : 10)

11. Central gland necrosis
Central gland necrosis is a
subtype of necrotizing
pancreatitis.
It represents necrosis between
the pancreatic head and tail
and is nearly always
associated with disruption of
the pancreatic duct.
This leads to persistent
collections as the viable
pancreatic tail continues to
secrete pancreatic juices.
These collections react poorly to
endoscopic or percutaneous
drainage.
serious Dx

12. Central gland necrosis
Two weeks later the
collection in the omental
bursa and pancreatic
body has increased
significantly.
The pancreatic tail still
enhances and so does
the pancreatic head
(arrows).

13. Peripancreatic Collections
resolution

14. Based on imaging
alone it is often not
possible to determine
whether these
collections contain fluid
or necrotic tissue and
whether they are
infected or not.
Consequently, instead
of naming them as
'pseudocysts',
'abscesses' or
'necrosis', it is better to
describe them as
'peripancreatic
collections'.
There is a collection in the area of the pancreatic head in the right anterior pararenal space.
On a follow up scan the collection is larger.
One day later the patient developed septicaemia and percutaneous drainage was performed.
After drainage the collection has barely diminished in size and consequently there was suspicion of necrotic
tissue.
The patient therefore underwent surgery and the collection was found to consist of necrotic debris,
The necrotic debris was too thick for successful percutaneous drainage.

15. Infected necrosis
infected necrosis is:
Infection of necrotic pancreatic
parenchyma
And/or necrotic extrapancreatic fatty
tissue
Usually occurs in the 2nd-3rd week.
Most severe local complication of
acute pancreatitis
Most common cause of death in
patients with acute pancreatitis
Air bubbles are seen in 20% of
cases with infected necrosis.
==

16. Infected necrosis (2)
• here is a normal
enhancement of the
pancreas with
surrounding septated
heterogeneous
peripancreatic collections
with fluid- and fat
densities .
• Two weeks later there
are air bubbles in the
peripancreatic collection,
consistent with infected
necrosis.
2 weeks
later

17. Pseudocyst
•
•
•
•
•
Collection of pancreatic juice
enclosed by a wall of fibrous
tissue
Absence of necrotic tissue is
imperative for its diagnosis
Often communication with the
pancreatic duct
Requires 4 or more weeks to
develop
On CT we cannot diagnose a
collection with certainty as a
pseudocyst, since it is usually
not possible to determine what
the content of a collection is

18. During endoscopic
debridement this
collection contained fluid
and necrotic tissue which
was removed from the
area of the pancreas
CT of an ICU patient on day
40 with central gland
necrosis with a spiking
fever.
The CT shows a similar
collection to that of the
previous patient, exept for
its pancreatic location.
The collection is
homogeneous and welldemarcated with a thin wall
abutting the stomach.

19. another example
25 d...Homogeneous
pancreatic and
peripancreatic collection,
well-demarcated with an
enhancing wall.
Since this patient had
fever and multiple
organ failure, this
collection was suspected
to be infected necrosis
and not a pseudocyst.
At surgery the collection
contained a lot of
necrotic debris, which
was not recognizable on
CT.

20. role of MRI
collection
debris

21. lessons learned

22. New atlanta definitions

23. Interstitial
edematous
pancreatitis
Interstitial
edematous
pancreatitis
Acute peripancreatic
fluid collection
pancreatic
pseudocyst

24. Acute necrotizing
pancreatitis.
Acute necrotizing
pancreatitis
acute necrotic
collection
walled off cystic
necrosis

25. Interstitial
edematous
pancreatitis
acute peripancreatic
fluid collection
acute necrotizing
pancreatitis
acute necrotic
collection
d 0 to d 28

26. after 28
IEP
acute necrotizing
pan.
pancreatic
pseudocyst
walled off necrosis

27. abscess
pseudocyst
wopn
wopn
wopn

30. Take home messages
•
•
•
•
•
•
Severity of acute pancreatitis and pancreatic necrosis can only
be reliably assessed by imaging after 72 hours.
Absence of pancreatic parenchymal necrosis does not
preclude a serious course of the illness.
CT can not reliably differentiate between collections that
consist of fluid and those that contain solid debris.
In these cases MRI can be of additional value.
Name collections always according to 2012 Atlanta definitions.
Central gland necrosis is a subtype of necrotizing pancreatitis
with important implications.