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Imaging of Pancreatitis

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Abstract

Acute pancreatitis is an acute inflammatory process of the pancreatic gland that can involve pancreatic parenchyma or distant organs. The incorporation of the revised Atlanta classification system into everyday practice would provide the use of a standardized terminology and the chance to correctly classify and recognize every imaging finding of acute pancreatitis. It refers to diagnostic criteria, clinical classification—both phases (early and late) and severity (mild, moderately severe, and severe) of acute pancreatitis—morphological classification (interstitial edematous pancreatitis and necrotizing pancreatitis), and complications (organ failure, systemic and local complications). In the revised Atlanta classification, the most important local complications are the pancreatic and peripancreatic collection, and they may be sterile or infected; we should distinguish various types of collections: acute peripancreatic fluid collection (APFC), pseudocyst, acute necrotic collection (ANC), and walled-off necrosis (WON). The parameters for this classification are the time course (<4 weeks or >4 weeks) and the presence of necrosis. Chronic pancreatitis (CP) is an inflammatory disease characterized by progressive and irreversible distortion and destruction of the pancreatic parenchyma, with progressive loss of the endocrine and exocrine function of the gland. The clinical diagnosis of chronic pancreatitis is usually achieved only in advanced disease. The etiology and the pathophysiology of chronic pancreatitis are not well defined. The TIGAR-O risk factor system lists factors associated with chronic pancreatitis. Imaging modalities in the evaluation of CP typically include enhanced computed tomography (CT), MRI with magnetic resonance cholangiopancreatography (MRCP), and ultrasound with a transabdominal or endoscopic approach. The morphological classification of chronic pancreatitis divides CP in macro- and micro-obstructive forms. In the early stages of chronic pancreatitis, pancreatic alterations are usually unspecific and inconclusive. In advanced disease, parenchymal and ductal alterations are irreversible and can be limited to the secondary ducts (small-duct form) or might extend to the main pancreatic duct (large-duct form). The consequence of the obstruction of the pancreatic ductal system is the precipitation of dense protein plugs within the ducts, which gradually calcify in small or large calcifications. Other forms of CP include paraduodenal pancreatitis, autoimmune pancreatitis, and hereditary chronic pancreatitis.

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Authors and Affiliations

  1. Department of Radiology, Policlinico G. B. Rossi – University Hospital of Verona, Verona, Italy

    Roberto Pozzi Mucelli, Riccardo Negrelli, Matteo Catania & Marco Chincarini

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  1. Roberto Pozzi Mucelli
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  2. Riccardo Negrelli
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  3. Matteo Catania
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  4. Marco Chincarini
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Editors and Affiliations

  1. Department of Radiology, Cattinara Hospital, University of Trieste, Trieste, Italy

    Maria Assunta Cova

  2. Department of Radiology, Maggiore Hospital, Trieste, Italy

    Fulvio Stacul

14.1 Electronic Supplementary Material

Interstitial edematous pancreatitis (IEP). Axial CT non-contrast phase (a) shows a normal pancreatic parenchyma. (MOV 64367 kb)

Interstitial edematous pancreatitis (IEP). Axial CT arterial phase (b) show a pancreatic parenchyma with normal enhancement. Mild inflammatory changes (stranding of the peripancreatic fat tissues) are visible. (MOV 65575 kb)

Interstitial edematous pancreatitis (IEP). Portal-venous phase (c) show a pancreatic parenchyma with normal enhancement. Mild inflammatory changes (stranding of the peripancreatic fat tissues) are visible. (MOV 99033 kb)

Combined pancreatic and peripancreatic necrosis. Axial CT non-contrast phase images (a) show a highly inhomogeneous pancreatic parenchyma of the head which results hypovascular during the pancreatic and portal-venous phases (b), with multiple hypodense areas due to necrosis that extend to the peripancreatic tissues. (MOV 90000 kb)

Combined pancreatic and peripancreatic necrosis. Axial CT non-contrast phase images (a) show a highly inhomogeneous pancreatic parenchyma of the head which results hypovascular during the pancreatic and portal-venous phases (b), with multiple hypodense areas due to necrosis that extend to the peripancreatic tissues. (MOV 244785 kb)

Pancreatic pseudocyst. Axial CT non-contrast phase (a) shows a large, hypodense and homogeneous fluid collection in the body-tail of the pancreas, 4 weeks after the first episode of acute pancreatitis. (MOV 79785 kb)

Pancreatic pseudocyst. Axial arterial-pancreatic phase (b) better show that the fluid collection is encapsulated, with no solid components. (MOV 76150 kb)

Pancreatic pseudocyst. Portal-venous phase (c) better show that the fluid collection is encapsulated, with no solid components. (MOV 142098 kb)

Pancreatic pseudocyst. In the MRI coronal T2-weighted sequence (d), the pseudocyst appears homogeneously hyperintense and well circumscribed. (MOV 10205 kb)

WON. Axial CT arterial, portal-venous and delayed phase show a heterogeneous collection with fluid components, non-liquefied debris and fat globules inside. The collection has thick enhancing walls and is by definition a WON. Furthermore this images show the presence of large amount of intraperitoneal fluid. (MOV 117617 kb)

Infected collection. Axial non-contrast (a) CT images obtained 6 weeks after onset of acute necrotizing pancreatitis, show the presence of multiple air bubbles within the heterogeneous necrotic collection. (MOV 73041 kb)

Infected collection. The infected WON extends to the left lateroconal fascia. The thick wall of the necrotic collection are better depicted during the pancreatic phase (b). The patient has also bilateral pleural effusion. (MOV 63658 kb)

Infected collection. The infected WON extends to the left lateroconal fascia. The thick wall of the necrotic collection are better depicted during the portal-venous phase (c). The patient has also bilateral pleural effusion. (MOV 68475 kb)

Axial non-contrast (a) CT images obtained 5 weeks after onset of acute pancreatitis, show the presence of multiple calcifications of the pancreatic head. (MOV 30716 kb)

Axial portal-venous phase (b), shows the presence of an infected necrotic collection within the splenic parenchyma (notice the presence of multiple air bubbles) an multiple necrotic collections (WON) localized in the peripancreatic fat of the body-tail of the gland. One of these infected collections communicates with the anterior abdominal wall. (MOV 30984 kb)

Assessment of the composition of a pancreatic fluid collection. Axial CT images on portal-venous phase (a) show an inhomogeneous pancreatic fluid collection involving the entire pancreatic gland. (MOV 8962 kb)

MRI coronal T2-weighted image (b) better demonstrates the presence of non-liquefied material suggestive for necrotic debris and permits an accurate diagnosis of WON. Notice the presence of a homogeneous fluid collection localized in the right lateroconal fascia, with no solid components, suggestive for pseudocyst. (MOV 37460 kb)

Chronic pancreatitis. Axial CT images acquired during the pancreatic phase (a) show multiple calcifications of the pancreatic head with marked dilation of the upstream main pancreatic duct which shows a tortuous path. (MOV 21200 kb)

Chronic pancreatitis. Axial CT images acquired during the portal-venous phase (b) show multiple calcifications of the pancreatic head with marked dilation of the upstream main pancreatic duct which shows a tortuous path. (MOV 44994 kb)

Chronic pancreatitis. Axial CT images acquired during the pancreatic phase (a) show multiple calcifications within the pancreatic ductal system of the head of the pancreas and a large calcification of the main pancreatic duct in the pancreatic body. The MPD is diffusely dilated, with air within the lumen. (MOV 24890 kb)

Chronic pancreatitis. Axial CT images acquired during the portal-venous phase (b) show multiple calcifications within the pancreatic ductal system of the head of the pancreas and a large calcification of the main pancreatic duct in the pancreatic body. The MPD is diffusely dilated, with air within the lumen. (MOV 47476 kb)

Chronic pancreatitis. Axial fat-suppressed T1-weighted images (a) show an atrophic pancreatic parenchyma, which appears hypointense as compared to the liver parenchyma. (MOV 2578 kb)

Chronic pancreatitis. Axial T2-weighted images (b) show an irregular dilation of the main pancreatic duct. (MOV 3650 kb)

Chronic pancreatitis. After contrast medium injection, the pancreatic parenchyma appears hypovascular during the pancreatic phase (c), with progressive delayed enhancement during the portal-venous and delayed phases (d, e). (MOV 16179 kb)

Chronic pancreatitis. After contrast medium injection, the pancreatic parenchyma appears hypovascular during the pancreatic phase (c), with progressive delayed enhancement during the portal-venous and delayed phases (d, e). (MOV 15418 kb)

Chronic pancreatitis. After contrast medium injection, the pancreatic parenchyma appears hypovascular during the pancreatic phase (c), with progressive delayed enhancement during the portal-venous and delayed phases (d, e). (MOV 15561 kb)

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Mucelli, R.P., Negrelli, R., Catania, M., Chincarini, M. (2019). Imaging of Pancreatitis. In: Cova, M., Stacul, F. (eds) Pain Imaging. Springer, Cham. https://doi.org/10.1007/978-3-319-99822-0_14

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  • DOI: https://doi.org/10.1007/978-3-319-99822-0_14

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