Skip to main content
SpringerLink
Log in

Perfusion CT is superior to angiography in predicting pancreatic necrosis in patients with severe acute pancreatitis

  • Original Article—Liver, Pancreas, and Biliary Tract
  • Published:
Journal of Gastroenterology Aims and scope Submit manuscript

Abstract

Background

We performed perfusion computed tomography (P-CT) and angiography of the pancreas in patients with severe acute pancreatitis (SAP) and compared the usefulness of these two methods in predicting the development of pancreatic necrosis.

Methods

We compared P-CT and angiography results taken within 3 days after symptom onset in 21 SAP patients. We divided the pancreas into three areas, the head, body, and tail, and examined each area for perfusion defects (via P-CT) and arterial vasospasms (by angiography). Three weeks later, all patients underwent contrast-enhanced CT to determine whether pancreatic necrosis had developed.

Results

Of the 21 SAP patients, 16 exhibited perfusion defects, while 17 proved positive for vasospasms in at least one area. Fourteen patients developed pancreatic necrosis. Of the 63 pancreatic areas from the 21 SAP patients, perfusion defects appeared in 25 areas (39.7%), 24 of which showed vasospasms (96.0%). Angiography showed 33 areas with vasospasms (52.4%), of which 24 showed perfusion defects (72.7%). Of the 25 areas with perfusion defects, 21 developed pancreatic necrosis (84.0%). Of the 33 areas with vasospasms, 21 developed necrosis (63.6%). Pancreatic necrosis developed only in the areas positive both for perfusion defects and for vasospasms. No areas without perfusion defect or vasospasms developed pancreatic necrosis. P-CT predicted the development of pancreatic necrosis with significantly higher accuracy than angiography.

Conclusion

While both P-CT and angiography are useful in predicting the development of pancreatic necrosis in patients with SAP, P-CT appears to be more accurate for this purpose.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Abbreviations

CT:

Computed tomography

P-CT:

Perfusion CT

CECT:

Contrast-enhanced CT

SAP:

Severe acute pancreatitis

H.U:

Hounsfield unit

References

  1. Sekimoto M, Takada T, Kawarada Y, Hirata K, Mayumi T, Yoshida M, et al. JPN guidelines for the management of acute pancreatitis: epidemiology, etiology, natural history, and outcome predictors in acute pancreatitis. J Hepatobiliary Pancreat Surg. 2006;13:10–24.

    Article  PubMed  Google Scholar 

  2. Beger HG, Isenmann R. Diagnosis, objective assessment of severity, and management of acute pancreatitis. Santorini Consensus Conference. Int J Pancreatol. 1999;26:1–2 (discussion 2–3).

    Article  CAS  PubMed  Google Scholar 

  3. Takeda K, Mikami Y, Fukuyama S, Egawa S, Sunamura M, Ishibashi T, et al. Pancreatic ischemia associated with vasospasm in the early phase of human acute necrotizing pancreatitis. Pancreas. 2005;30:40–9.

    Article  PubMed  Google Scholar 

  4. Inoue K, Hirota M, Beppu T, Ishiko T, Kimura Y, Maeda K, et al. Angiographic features in acute pancreatitis: the severity of abdominal vessel ischemic change reflects the severity of acute pancreatitis. JOP. 2003;4:207–13.

    PubMed  Google Scholar 

  5. Cuthbertson CM, Christophi C. Disturbances of the microcirculation in acute pancreatitis. Br J Surg. 2006;93:518–30.

    Article  CAS  PubMed  Google Scholar 

  6. Tsuji Y, Watanabe Y, Matsueda K, Yamamoto H, Ishida E, Yamamoto H. Usefulness of perfusion computed tomography for early detection of pancreatic ischemia in severe acute pancreatitis. J Gastroenterol Hepatol. 2006;21:1506–8.

    Article  PubMed  Google Scholar 

  7. Tsuji Y, Yamamoto H, Yazumi S, Watanabe Y, Matsueda K, Yamamoto H, et al. Perfusion computerized tomography can predict pancreatic necrosis in early stages of severe acute pancreatitis. Clin Gastroenterol Hepatol. 2007;5:1484–92.

    Article  PubMed  Google Scholar 

  8. Bize PE, Platon A, Becker CD, Poletti PA. Perfusion measurement in acute pancreatitis using dynamic perfusion MDCT. AJR Am J Roentgenol. 2006;186:114–8.

    Article  PubMed  Google Scholar 

  9. Park MS, Klotz E, Kim MJ, Song SY, Park SW, Cha SW, et al. Perfusion CT: noninvasive surrogate marker for stratification of pancreatic cancer response to concurrent chemo- and radiation therapy. Radiology. 2009;250:110–7.

    Article  PubMed  Google Scholar 

  10. Sheiman RG, Sitek A. Feasibility of measurement of pancreatic perfusion parameters with single-compartment kinetic model applied to dynamic contrast-enhanced CT images. Radiology. 2008;249:878–82.

    Article  PubMed  Google Scholar 

  11. d’Assignies G, Couvelard A, Bahrami S, Vullierme MP, Hammel P, Hentic O, et al. Pancreatic endocrine tumors: tumor blood flow assessed with perfusion CT reflects angiogenesis and correlates with prognostic factors. Radiology. 2009;250(2):407–16.

    Article  PubMed  Google Scholar 

  12. Balthazar EJ. Staging of acute pancreatitis. Radiol Clin North Am. 2002;40:1199–209.

    Article  PubMed  Google Scholar 

  13. Balthazar EJ, Freeny PC, van Sonnenberg E. Imaging and intervention in acute pancreatitis. Radiology. 1994;193:297–306.

    CAS  PubMed  Google Scholar 

  14. UK guidelines for the management of acute pancreatitis. Gut 2005;54(Suppl 3):iii1–iii9.

  15. Bollen TL, van Santvoort HC, Besselink MG, van Leeuwen MS, Horvath KD, Freeny PC, et al. The Atlanta classification of acute pancreatitis revisited. Br J Surg. 2008;95:6–21.

    Article  CAS  PubMed  Google Scholar 

  16. Takeda K, Yamauchi J, Shibuya K, Sunamura M, Mikami Y, Matsuno S. Benefit of continuous regional arterial infusion of protease inhibitor and antibiotic in the management of acute necrotizing pancreatitis. Pancreatology. 2001;1:668–73.

    Article  CAS  PubMed  Google Scholar 

  17. Takeda K, Matsuno S, Sunamura M, Kakugawa Y. Continuous regional arterial infusion of protease inhibitor and antibiotics in acute necrotizing pancreatitis. Am J Surg. 1996;171:394–8.

    Article  CAS  PubMed  Google Scholar 

  18. Takeda K. Antiproteases in the treatment of acute necrotizing pancreatitis: continuous regional arterial infusion. JOP. 2007;8:526–32.

    PubMed  Google Scholar 

  19. Eckerwall GE, Axelsson JB, Andersson RG. Early nasogastric feeding in predicted severe acute pancreatitis: a clinical, randomized study. Ann Surg. 2006;244:959–65. discussion 965–967.

    Article  PubMed  Google Scholar 

  20. Tsuji Y, Koizumi K, Isoda H, Ueno K, Tada S, Chiba T. The radiological exposure of pancreatic perfusion CT. Pancreas. 2009 (in press).

  21. Tsushima Y, Blomley JK, Kusano S, Endo K. The portal component of hepatic perfusion measured by dynamic CT: an indicator of hepatic parenchymal damage. Dig Dis Sci. 1999;44:1632–8.

    Article  CAS  PubMed  Google Scholar 

  22. Miles KA, Hayball MP, Dixon AK. Measurement of human pancreatic perfusion using dynamic computed tomography with perfusion imaging. Br J Radiol. 1995;68:471–5.

    Article  CAS  PubMed  Google Scholar 

  23. Tsushima Y, Kusano S. Age-dependent decline in parenchymal perfusion in the normal human pancreas: measurement by dynamic computed tomography. Pancreas. 1998;17:148–52.

    Article  CAS  PubMed  Google Scholar 

  24. Abe H, Murakami T, Kubota M, Kim T, Hori M, Kudo M, et al. Quantitative tissue blood flow evaluation of pancreatic tumor: comparison between xenon CT technique and perfusion CT technique based on deconvolution analysis. Radiat Med. 2005;23:364–70.

    PubMed  Google Scholar 

  25. Wintermark M, Ko NU, Smith WS, Liu S, Higashida RT, Dillon WP. Vasospasm after subarachnoid hemorrhage: utility of perfusion CT and CT angiography on diagnosis and management. AJNR Am J Neuroradiol. 2006;27:26–34.

    CAS  PubMed  Google Scholar 

  26. Axel L. Cerebral perfusion CT techniques. Radiology. 2004;233:935 (author reply 935).

    Article  PubMed  Google Scholar 

  27. Eastwood JD, Lev MH, Azhari T, Lee TY, Barboriak DP, Delong DM, et al. CT perfusion scanning with deconvolution analysis: pilot study in patients with acute middle cerebral artery stroke. Radiology. 2002;222:227–36.

    Article  PubMed  Google Scholar 

  28. Eastwood JD, Provenzale JM, Hurwitz LM, Lee TY. Practical injection-rate CT perfusion imaging: deconvolution-derived hemodynamics in a case of stroke. Neuroradiology. 2001;43:223–6.

    Article  CAS  PubMed  Google Scholar 

  29. Sahani DV, Holalkere NS, Kambadakone A, Matthes K, Mino-Kenudson M, Brugge WR. Role of computed tomography perfusion in the evaluation of pancreatic necrosis and pancreatitis after endoscopic ultrasound-guided ablation of the pancreas in a porcine model. Pancreas. 2009;38:775–81.

    Article  PubMed  Google Scholar 

  30. Kishimoto M, Tsuji Y, Katabami N, Shimizu J, Lee KJ, Iwasaki T, et al. Measurement of canine pancreatic perfusion using dynamic computed tomography: influence of input-output vessels on deconvolution and maximum slope methods. Eur J Radiol. 2009 (Epub ahead of print).

  31. Traverso LW, Kozarek RA. Pancreatic necrosectomy: definitions and technique. J Gastrointest Surg. 2005;9:436–9.

    Article  PubMed  Google Scholar 

  32. Isenmann R, Rau B, Zoellner U, Beger HG. Management of patients with extended pancreatic necrosis. Pancreatology. 2001;1:63–8.

    Article  CAS  PubMed  Google Scholar 

  33. Inoue K, Hirota M, Kimura Y, Kuwata K, Ohmuraya M, Ogawa M. Further evidence for endothelin as an important mediator of pancreatic and intestinal ischemia in severe acute pancreatitis. Pancreas. 2003;26:218–23.

    Article  CAS  PubMed  Google Scholar 

  34. Wintermark M, Thiran JP, Maeder P, Schnyder P, Meuli R. Simultaneous measurement of regional cerebral blood flow by perfusion CT and stable xenon CT: a validation study. Am J Neuroradiol. 2001;22:905–14.

    CAS  PubMed  Google Scholar 

  35. Bai Y, Gao J, Zou DW, Li ZS. Prophylactic antibiotics in acute pancreatitis: further high-quality trials are still warranted. Am J Gastroenterol. 2008;103:104–10.

    PubMed  Google Scholar 

  36. Tsuji Y, Chiba T. Are prophylactic antibiotics really ineffective in reducing the risk of pancreatic necrosis? Am J Gastroenterol. 2008;103:2145–6.

    PubMed  Google Scholar 

  37. Manes G, Uomo I, Menchise A, Rabitti PG, Ferrara EC. Timing of antibiotics prophylaxis in acute pancreatitis; a controlled randomized study with meropenem. Am J Gastroenterol. 2006;101:1348–53.

    Article  CAS  PubMed  Google Scholar 

  38. Jafri NS, Mahid SS, Idstein SR, Hornung CA, Galandiuk S. Antibiotic prophylaxis is not protective in severe acute pancreatitis: a systematic review and meta-analysis. Am J Surg. 2009;197:806–13.

    Article  CAS  PubMed  Google Scholar 

  39. Wittau M, Hohl K, Mayer J, Henne-Bruns D, Isenmann R. The weak evidence base for antibiotic prophylaxis in severe acute pancreatitis. Hepatogastroenterology. 2008;55:2233–7.

    PubMed  Google Scholar 

  40. Besselink MG, van Santvoort HC, Boermeester MA, Nieuwenhuijs VB, van Goor H, Dejong CH, et al. Timing and impact of infections in acute pancreatitis. Br J Surg. 2009;96:267–73.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

Grant support: Japan Society for the Promotion of Science.

Conflict of interest statement.

All authors declare that they are free of any commercial affiliations or other financial interests that might lead to the appearance of conflict of interest.

Author information

Authors and Affiliations

  1. Department of Gastroenterology, Kurashiki Central Hospital, Okayama, Japan

    Yoshihisa Tsuji, Kyoko Hamaguchi, Naoki Yamamoto, Osamu Kikuchi, Kazuhiro Matsueda & Hiroshi Yamamoto

  2. Department of Radiology, Kurashiki Central Hospital, Okayama, Japan

    Yuji Watanabe, Akira Okumura & Hiroyuki Yamamoto

  3. Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Shogoinkawara-cho 54, Sakyo-ku, Kyoto, Japan

    Yoshihisa Tsuji, Kenji Ueno, Shinsuke Tada & Tsutomu Chiba

  4. Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan

    Hiroyoshi Isoda & Kaori Togashi

Authors
  1. Yoshihisa Tsuji
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kyoko Hamaguchi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yuji Watanabe
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Akira Okumura
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Hiroyoshi Isoda
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Naoki Yamamoto
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Osamu Kikuchi
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Hiroyuki Yamamoto
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Kazuhiro Matsueda
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Kenji Ueno
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Shinsuke Tada
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Kaori Togashi
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Hiroshi Yamamoto
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Tsutomu Chiba
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Tsutomu Chiba.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Tsuji, Y., Hamaguchi, K., Watanabe, Y. et al. Perfusion CT is superior to angiography in predicting pancreatic necrosis in patients with severe acute pancreatitis. J Gastroenterol 45, 1155–1162 (2010). https://doi.org/10.1007/s00535-010-0267-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00535-010-0267-8

Keywords

Search

Navigation