Acute Pancreatitis: What and When Is There Room for Imaging in the Diagnosis and Followup of Patients with Acute Inflammation of the Pancreatic Gland?

Abstract

This is a fundamentally important question because appropriate care of this disease requires careful monitoring of the patient and sometimes judicious but intrusive interventions. Certain presentations provide an impetus for pictorial representation of the presence and extent of the disease. In many institutions CT has become by force of use routine in the initial assessment of patients presenting with signs and symptoms suggestive of acute inflammation of the pancreas. As we move from the exploitative phase of imaging to a more conservationist role, every imaging protocol should be assessed for appropriateness. The purpose of this review is to consider why imaging, particularly CT, has become part and parcel of the initial workup of patients with this disease and to examine if such a notion has been established beyond doubt or is open to question. If one were to go back to the literature of 10 or 15 years ago one would see articles advocating sonography in acute pancreatitis. It should be gratifying to all of us that this examination really has no place in the acute assessment of patients with pancreatitis. One study revealed that the ability to visualize the pancreas by ultrasonography was less than 15 % in patients with acute inflammation of that organ. Thus, most of the results of ultrasound evaluation upon entry to emergency suite were that the studies were equivocal, occasioned by the presence of gas in the stomach and transverse colon, which obscured visualization of the solid pancreatic mass beneath it and below it. Moreover, sonography in this setting should be regarded as an invasive procedure because the pressure of the transducer on a patient with acute upper abdominal pain makes the discomfort worse. The only role for sonography in acute pancreatitis is to help to determine whether the etiology is related to the presence of gallstones, one of which may have passed from the gall bladder into the common bile duct and along the way blocked the pancreatic duct causing acute pancreatic inflammation. However, this need not be done initially as the main function of treatment in the early phase is to prevent serious complications and to be supportive in mild and moderate cases.