Practice Rational Imaging

Non-invasive imaging in pancreatitis

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5223 (Published 28 August 2014) Cite this as: BMJ 2014;349:g5223
  1. Patrick Rogers, radiology registrar1,
  2. Tarig Adlan, radiology registrar1,
  3. George Page, junior clinical fellow2
  1. 1Peninsula Radiology Academy, Plymouth International Business Park, Plymouth PL6 5WR, UK
  2. 2King’s College Hospital, Denmark Hill, London SE5 9RS, UK
  1. Correspondence to: P Rogers Patrick.rogers{at}nhs.net
  • Accepted 30 June 2014

Learning points

Early pancreatitis
  • Ultrasound is indicated in the first 24 hours, mainly to identify gallstones as the cause of pancreatitis rather than to contribute to the diagnosis

  • Early endoscopic retrograde cholangiopancreatography (ERCP) should be considered in patients with gallstone induced acute pancreatitis if cholangitis and biliary obstruction are suspected

Deteriorating pancreatitis
  • To stage, and identify complications in, patients with persisting organ failure, signs of sepsis, or deterioration in clinical status 3-7 days after admission, a contrast enhanced computed tomography (CE-CT) scan should be considered

  • Early CE-CT (<72 hours after presentation) may underestimate the extent of necrosis as there is often a lag effect between disease extent and radiological appearances, therefore giving false assurance and less reliable surgical information on the extent of pancreatic necrosis

Obstructive pancreatitis
  • Despite the high spatial resolution of CE-CT, detection of gallstones within the common bile duct can be limited by their isodensity to the bile fluid; however, sensitivity to stones is very good and similar to that of magnetic resonance imaging

  • ERCP and endoscopic ultrasound are yet more sensitive but are invasive

Severe pancreatitis
  • CE-CT remains the preferred imaging modality for severe pancreatitis; its ready availability and use in subsequent interventional procedures, with excellent depiction of any complications, makes it the front runner

  • Magnetic resonance imaging has a growing evidence base, but it is not used widely yet

An active 73 year old patient with a history of cholecystectomy, hypothyroidism, and hypertension presented to the emergency department with a five hour history of severe epigastric pain. Her admission blood tests showed an amylase of 782 U/L and a white cell count of 21.2×103/µL, with a neutrophil count of 17.5×103/µL. The patient’s initial modified Glasgow score for predicting the severity of pancreatitis on admission was two, scoring on both age and white cell count. A repeat Glasgow score the following day …

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