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Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation¹

¹ From the Department of Radiology, New Bellevue Hospital, 462 First Ave, 3rd Fl, Rm 3W37-3W42, New York, NY 10016. Received March 27, 2001; revision requested May 21; revision received July 16; accepted August 9. Address correspondence to the author (e-mail: emiljmd@aol.com).

View larger version (139K): [in a new window]   Figure 1a. Gallstones, acute pancreatitis, and gland necrosis in a 47-year-old man with four Ranson grave signs. (a) Early transverse nonenhanced CT scan obtained at the time of admission to the hospital shows a homogeneously enlarged pancreas (solid arrows). There are large heterogeneous peripancreatic fluid collections (open arrows). Gland necrosis cannot be ruled out. K = kidney, L = liver, P = pancreas, Sp = spleen, St = stomach. (b) Follow-up transverse contrast-enhanced CT scan obtained 13 days after a reveals two zones (straight arrows) of liquefied pancreatic necrosis in the neck and tail of the gland. There are residual nodular areas adjacent to the tail of the pancreas, consistent with fat necrosis (curved arrow). P = pancreas. (c) Follow-up transverse contrast-enhanced CT scan obtained 10 days after b reveals development of large pseudocysts (P) in the neck and tail of the pancreas.

View larger version (134K): [in a new window]   Figure 1b. Gallstones, acute pancreatitis, and gland necrosis in a 47-year-old man with four Ranson grave signs. (a) Early transverse nonenhanced CT scan obtained at the time of admission to the hospital shows a homogeneously enlarged pancreas (solid arrows). There are large heterogeneous peripancreatic fluid collections (open arrows). Gland necrosis cannot be ruled out. K = kidney, L = liver, P = pancreas, Sp = spleen, St = stomach. (b) Follow-up transverse contrast-enhanced CT scan obtained 13 days after a reveals two zones (straight arrows) of liquefied pancreatic necrosis in the neck and tail of the gland. There are residual nodular areas adjacent to the tail of the pancreas, consistent with fat necrosis (curved arrow). P = pancreas. (c) Follow-up transverse contrast-enhanced CT scan obtained 10 days after b reveals development of large pseudocysts (P) in the neck and tail of the pancreas.

View larger version (140K): [in a new window]   Figure 1c. Gallstones, acute pancreatitis, and gland necrosis in a 47-year-old man with four Ranson grave signs. (a) Early transverse nonenhanced CT scan obtained at the time of admission to the hospital shows a homogeneously enlarged pancreas (solid arrows). There are large heterogeneous peripancreatic fluid collections (open arrows). Gland necrosis cannot be ruled out. K = kidney, L = liver, P = pancreas, Sp = spleen, St = stomach. (b) Follow-up transverse contrast-enhanced CT scan obtained 13 days after a reveals two zones (straight arrows) of liquefied pancreatic necrosis in the neck and tail of the gland. There are residual nodular areas adjacent to the tail of the pancreas, consistent with fat necrosis (curved arrow). P = pancreas. (c) Follow-up transverse contrast-enhanced CT scan obtained 10 days after b reveals development of large pseudocysts (P) in the neck and tail of the pancreas.

View larger version (18K): [in a new window]   Figure 2. Bar graph shows clinical relevance of CT grading in acute pancreatitis (67). Black bars = complications, white bars = mortality.

View larger version (112K): [in a new window]   Figure 3. Pancreatitis induced by endoscopic retrograde cholangiopancreatography (ERCP) in a 37-year-old woman. Transverse CT scan obtained with intravenous and oral contrast material shows an enlarged and homogeneously enhancing pancreatic gland (p). Residual contrast material from recent ERCP is seen in the common duct (open arrow). Extravasated fluid (solid arrow) is present around the gland. The patient had an uneventful recovery. d = duodenal bulb, S = stomach.

View larger version (141K): [in a new window]   Figure 4a. Pancreatic necrosis in a 50-year-old woman after an episode of acute pancreatitis. (a, b) Transverse CT scans obtained with intravenous and oral contrast material reveal an encapsulated fluid collection associated with liquefied necrosis (large straight arrows in a) in the body of the pancreas. The head, part of the body, and the tail of the pancreas are still enhancing (small straight arrows in a, straight arrows in b). Residual fluid collections and areas of soft-tissue attenuation (curved arrow) consistent with fat necrosis are seen adjacent to the pancreas. f = fluid, N = liquefied gland necrosis, S = stomach.

View larger version (140K): [in a new window]   Figure 4b. Pancreatic necrosis in a 50-year-old woman after an episode of acute pancreatitis. (a, b) Transverse CT scans obtained with intravenous and oral contrast material reveal an encapsulated fluid collection associated with liquefied necrosis (large straight arrows in a) in the body of the pancreas. The head, part of the body, and the tail of the pancreas are still enhancing (small straight arrows in a, straight arrows in b). Residual fluid collections and areas of soft-tissue attenuation (curved arrow) consistent with fat necrosis are seen adjacent to the pancreas. f = fluid, N = liquefied gland necrosis, S = stomach.

View larger version (12K): [in a new window]   Figure 5. Bar graph shows clinical relevance of CT for detection of pancreatic necrosis in acute pancreatitis (74). Black bars = complications, white bars = mortality.

View larger version (128K): [in a new window]   Figure 6a. Alcoholism-related pancreatitis in a 32-year-old man with necrosis of the tail of the pancreas. P = pancreas. (a) Initial transverse CT scan obtained with intravenous and oral contrast material shows fluid collections (arrow) adjacent to the body and tail of the pancreas. There is lack of enhancement of the tail of the pancreas. (b) Follow-up transverse CT scan obtained 6 months later reveals scarring with atrophy of the tail of the pancreas (arrow). S = spleen.

View larger version (128K): [in a new window]   Figure 6b. Alcoholism-related pancreatitis in a 32-year-old man with necrosis of the tail of the pancreas. P = pancreas. (a) Initial transverse CT scan obtained with intravenous and oral contrast material shows fluid collections (arrow) adjacent to the body and tail of the pancreas. There is lack of enhancement of the tail of the pancreas. (b) Follow-up transverse CT scan obtained 6 months later reveals scarring with atrophy of the tail of the pancreas (arrow). S = spleen.

View larger version (129K): [in a new window]   Figure 7. Fatty infiltration of the pancreas in an asymptomatic 42-year-old patient. Transverse CT scan obtained with intravenous and oral contrast material reveals a low-attenuating (7-HU) pancreas (1), which maintains its normal acinar texture. 2 = spleen (95 HU).

View larger version (125K): [in a new window]   Figure 8a. Gallstone-induced pancreatitis in a 27-year-old woman. (a) Transverse CT scan obtained with intravenous and oral contrast material reveals a large, edematous, homogeneously attenuating (73-HU) pancreas (1) and peripancreatic inflammatory changes (white arrows). Although the attenuation values are low, there is no pancreatic necrosis. Calcified gallstones are seen in gallbladder (black arrow). 2 = liver (140 HU). (b) Follow-up transverse CT scan obtained 7 days later reveals total resolution, with a normal pancreas (P, arrows) with CT number of 104 HU.

View larger version (124K): [in a new window]   Figure 8b. Gallstone-induced pancreatitis in a 27-year-old woman. (a) Transverse CT scan obtained with intravenous and oral contrast material reveals a large, edematous, homogeneously attenuating (73-HU) pancreas (1) and peripancreatic inflammatory changes (white arrows). Although the attenuation values are low, there is no pancreatic necrosis. Calcified gallstones are seen in gallbladder (black arrow). 2 = liver (140 HU). (b) Follow-up transverse CT scan obtained 7 days later reveals total resolution, with a normal pancreas (P, arrows) with CT number of 104 HU.

View larger version (111K): [in a new window]   Figure 9a. Acute pancreatitis in an 18-year-old woman with three Ranson grave signs. (a) Initial early transverse CT scan obtained with intravenous and oral contrast material reveals an enlarged low-attenuating (50-70-HU) pancreas (P), consistent with pancreatic ischemia and necrosis. Degree of necrosis is difficult to ascertain. A large fluid collection (arrow) is seen around the pancreatic body and tail (t). (b) Follow-up transverse CT scan obtained 14 days later reveals a fluid collection associated with liquified necrosis of most of the body of the pancreas, with the development of a pseudocyst (c). Note that the tail of the pancreas (arrow) is enhancing normally at this time.

View larger version (108K): [in a new window]   Figure 9b. Acute pancreatitis in an 18-year-old woman with three Ranson grave signs. (a) Initial early transverse CT scan obtained with intravenous and oral contrast material reveals an enlarged low-attenuating (50-70-HU) pancreas (P), consistent with pancreatic ischemia and necrosis. Degree of necrosis is difficult to ascertain. A large fluid collection (arrow) is seen around the pancreatic body and tail (t). (b) Follow-up transverse CT scan obtained 14 days later reveals a fluid collection associated with liquified necrosis of most of the body of the pancreas, with the development of a pseudocyst (c). Note that the tail of the pancreas (arrow) is enhancing normally at this time.