Computerized Tomography in the Diagnosis and Treatment of Acute Pancreatitis

  • Itamar Ashkenazi
  • Yoram KlugerEmail author
Part of the Hot Topics in Acute Care Surgery and Trauma book series (HTACST)


Acute pancreatitis is a common emergency. In the acute phase, surgery is rarely indicated. Computed tomography (CT) has a major role in the diagnosis and in the selection of proper management strategy of patients presenting with this disease. Since repeated CT may have untoward effects, the indication for CT and appropriate timing should be weighted to best meet the needs of the individual patient. In this chapter, we describe the use of CT under three subheadings, corresponding to the phases of management of this disease: diagnosis of pancreatitis, management during the acute phase, and follow-up.


  1. 1.
    Lowenfels AB, Maisonneuve P, Sullivan T. The changing character of acute pancreatitis: epidemiology, etiology, and prognosis. Curr Gastroenterol Rep. 2009;11(2):97–103.CrossRefPubMedGoogle Scholar
  2. 2.
    Yadav D, Lowenfels AB. Trends in epidemiology of the first attack of acute pancreatitis: a systematic review. Pancreas. 2006;33(4):323–30.CrossRefPubMedGoogle Scholar
  3. 3.
    O’Farrell A, Allwright S, Toomey D, Bedford D, Conlon K. Hospital admission for acute pancreatitis in Irish population, 1997–2004: could the increase be due to an increase in alcohol-related pancreatitis? J Public Health (Oxf). 2007;29(4):398–404.CrossRefGoogle Scholar
  4. 4.
    Lankisch PG, Apte M, Banks PA. Acute Pancreatitis. Lancet. 2015;386(9988):85–96.CrossRefPubMedGoogle Scholar
  5. 5.
    Bank S, Indaram A. Causes of acute and recurrent pancreatitis. Gastroenterol Clin N Am. 1999;28(3):571–89.CrossRefGoogle Scholar
  6. 6.
    Shyu J, Sainani NI, Sahni VA, Chick JF, Chauhan NR, Conwell DL, Clancy TE, Banks PA, Silverman SG. Necrotizing pancreatitis: diagnosis, imaging and intervention. Radiographics. 2014;34:1218–39.CrossRefPubMedGoogle Scholar
  7. 7.
    Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege SS. Acute pancreatitis classification working group. Gut. 2013;62(1):102–11.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Working Group IAP/APA Acute Panreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology. 2013;13:e1–15.CrossRefGoogle Scholar
  9. 9.
    Xu XD, Wang ZY, Zhang LY, Ni R, Wei FX, Han W, Zhang HH, Zhang YW, Wei ZG, Guo XH, Guo LQ, Ma JZ, Zhang YC. Acute pancreatitis classifications: basis and key goals. Medicine (Baltimore). 2015;94(48):e2182.CrossRefGoogle Scholar
  10. 10.
    Isenmann R, Buchler M, Uhl W, Malfertheiner P, Martini M, Beger HG. Pancreatic necrosis: an early finding in severe acute pancreatitis. Pancreas. 1993;8(3):358–61.CrossRefPubMedGoogle Scholar
  11. 11.
    Sakorafas GH, Tsiotos CG, Sarr MG. Extrapancreatic necrotizing pancreatitis with viable pancreas: a previously under-appreciated entity. J Am Coll Surg. 1999;188(6):643–8.CrossRefPubMedGoogle Scholar
  12. 12.
    The Italian Association for the Study of the Pancreas. Consensus guidelines on severe acute pancreatitis. Dig Liver Dis. 2015;47:532–43.CrossRefGoogle Scholar
  13. 13.
    Balthazar EJ, Robinson DL, Megibow AJ, Ranson JHC. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174(2):331–6.CrossRefPubMedGoogle Scholar
  14. 14.
    BU W, Bakker OJ, Papachristou GI, Besselink MC, Repas K, van Santvoort HC, Muddan V, Singh VK, Whitcomb DC, Gooszen HG, Banks PA. Blood urea nitrogen in the early assessment of acute pancreatitis. Arch Intern Med. 2011;17(7):669–76.Google Scholar
  15. 15.
    Islah MA, Jiffre D. A rare case of incarcerated bochdalek diaphragmatic hernia in a pregnant lady. Med J Malaysia. 2010;65(1):75–6.PubMedGoogle Scholar
  16. 16.
    Mitura K, Romanczuk M. Ruptured ectopic pregnancy mimicking acute pancreatitis. Ginekol Pol. 2009;80(5):383–5.PubMedGoogle Scholar
  17. 17.
    Nitsche R, Folsch UR, Ludtke R, Hilgers RA, Creutzfeldt W. Urgent ERCP in all cases of acute biliary pancreatitis? A prospective randomized multicenter study. Eur J Med Res. 1995;1(3):127–31.PubMedGoogle Scholar
  18. 18.
    Nesvaderani M, Eslick GD, Faraj S, Vagg D, Cox MR. Study of the early management of acute pancreatitis. Anz J Surg. 2015. doi: 10.111/ans.13330. [Epub ahead of print].
  19. 19.
    Ranson JH, Rifkind KM, Roses DF, Fink SD, Eng K, Spencer FC. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet. 1974;139(1):69–81.PubMedGoogle Scholar
  20. 20.
    Gross V, Leser H, Heinisch A, Scholmerich J. Inflammatory mediators and cytokines—new aspects of the pathophysiology and assessment of severity of acute pancreatitis? Hepato-Gastroenterology. 1993;40(6):522–30.PubMedGoogle Scholar
  21. 21.
    Yeung YP, Lam B, Yip A. APACHE system is better than Ranson system in the prediction of severity of acute pancreatitis. Hepatobiliary Pancreat Dis Int. 2006;5(2):294–9.PubMedGoogle Scholar
  22. 22.
    Bu W, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut. 2008;57(12):1698–703.CrossRefGoogle Scholar
  23. 23.
    Balthazar EJ, Freeny PC, Vansonnenberg E. Imaging and intervention in acute pancreatitis. Radiology. 1994;193(2):297–306.CrossRefPubMedGoogle Scholar
  24. 24.
    Mortele KJ, Wiesner W, Intriere L, Shankar S, Zhou KH, Kalantari BN, Perez A, van Sonnenberg E, Ross PR, Banks PA, Silverman SG. A modified CT severity index for evaluating acute pancreatitis: improved correlation with patient outcome. Am J Roentgenol. 2004;183(5):1261–5.CrossRefGoogle Scholar
  25. 25.
    Singh VK, BU W, Bollen TL, Repas K, Maurer R, Mortele KJ, Banks PA. Early systemic inflammatory response syndrome is associated with severe acute pancreatitis. Clin Gastroenterol Hepatol. 2009;7(11):1247–51.CrossRefPubMedGoogle Scholar
  26. 26.
    Mofidi R, Duff MD, Wigmore SJ, Madhavan KK, Garden OJ, Parks RW. Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis. Br J Surg. 2006;93(6):738–44.CrossRefPubMedGoogle Scholar
  27. 27.
    Foitzik T, Bassi DG, Fernandez-del Castillo C, Warshaw AL, Rattner DW. Arch Surg. 1994;129(1):706–11.CrossRefPubMedGoogle Scholar
  28. 28.
    Foitzik T, Bassi DG, Schmidt J, Lewandrowski KB, Fernandez-del Castillo C, Rattner DW, Warshaw AL. Intravenous contrast medium accentuates the severity of acute necrotizing pancreatitis in the rat. Gastroenterology. 1994;106(1):207–14.CrossRefPubMedGoogle Scholar
  29. 29.
    McMenamin DA, Gates LK Jr. A retrospective analysis of the effect of contrast-enhanced CT on the outcome of acute pancreatitis. Am J Gastroenterol. 1996;91(7):1384–7.PubMedGoogle Scholar
  30. 30.
    Sharma V, Rana SS, Sharma SK, Gupta R, Bhasin DK. Clinical outcomes and prognostic significance of early vs. late computed tomography in acute pancreatitis. Gastroenterol Rep (Oxf). 2015;3(2):144–7.CrossRefGoogle Scholar
  31. 31.
    Uhl W, Roggo A, Kirschstein T, Anghelacopoulos SE, Gloor B, Muller CA, Malfertheiner P, Buchler MW. Influence of contrast-enhanced computed tomography on course and outcome in patients with acute pancreatitis. Pancreas. 2002;24(2):191–7.CrossRefPubMedGoogle Scholar
  32. 32.
    Akinosoglou K, Gogos C. Immune-modulating therapy in acute pancreatitis: fact of fiction. Wold J Gastroenterol. 2014;20(41):15200–15.Google Scholar
  33. 33.
    Bradley EL III. A clinically based classification system for acute pancreatitis. Summary of the international symposium on acute pancreatitis, Atlanta, GA, September 11 through 13, 1992. Arch Surg. 1993;128(5):586–90.CrossRefPubMedGoogle Scholar
  34. 34.
    Bollen TL, van Santvoort HC, Besselink MG, van Es WH, Gooszen HG, van Leeuwen MS. Update on acute pancreatitis: ultrasound, computed tomography, and magnetic resonance imaging features. Semin Ultrasound CT MR. 2007;35(2):107–13.Google Scholar
  35. 35.
    Tyberg A, Karia K, Gabr M, Desai A, Doshi R, Gaidhane M, Sharaiha RZ, Kahleh M. Management of pancreatic fluid collections: a comprehensive review of the literature. World J Gastroenterol. 2016;22(7):2256–70.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Sarathi Patra P, Das K, Bhattacharyya A, Ras S, Hembram J, Sanyal S, Dhali GK. Natural resolution or intervention for fluid collections in acute severe pancreatitis. Br J Surg. 2014;101(13):1721–8.CrossRefPubMedGoogle Scholar
  37. 37.
    Turkvatan A, Erden A, Turkoglu MA, Secil M, Yuce G. Imaging of acute pancreatitis and its complications. Part 2: complications of acute pancreatitis. Diagn Intev Imaging. 2015;96(2):161–9.CrossRefGoogle Scholar
  38. 38.
    Mann DV, Hershman MJ, Hittinger R, Glazer G. Multicentre audit of death from acute pancreatitis. Br J Surg. 1994;81(6):890–3.CrossRefPubMedGoogle Scholar
  39. 39.
    Lumsden A, Bradley EL III. Secondary pancreatic infections. Surg Gynecol Obstet. 1990;170(5):459–67.PubMedGoogle Scholar
  40. 40.
    Schmid SW, Uhl W, Freiss H, Malfertheiner P, Buchler MW. The role of infection in acute pancreatitis. Gut. 1999;45(2):311–6.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Baron TH, Morgan ED. Acute necrotizing pancreatitis. N Engl J Med. 1999;340(18):1412–7.CrossRefPubMedGoogle Scholar
  42. 42.
    Dellinger EP, Tellado JM, Soto NE, Ashley SW, Barie PS, Dugernier T, Imrie CW, Johnson CD, Knaebel HP, Laterre PF, Maravi-Poma E, Kissler JJ, Sanchez-Garcia M, Utzolino S. Early antibiotic treatment for severe acute necrotizing pancreatitis: a randomized, double-blind, placebo controlled study. Ann Surg. 2007;245(5):674–83.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Forsmark CE, Toskes PP. Acute pancreatitis: medical management. Crit Care Clin. 1995;11(2):295–309.CrossRefPubMedGoogle Scholar
  44. 44.
    Gerzof SG, Banks PA, Robbins AH, Johnson WC, Spechler SJ, Wetzner SM, Snider JM, Langevin RE, Jay ME. Early diagnosis of pancreatic infection by computed tomography-guided aspiration. Gastroenterology. 1987;93(6):1315–20.CrossRefPubMedGoogle Scholar
  45. 45.
    Barie PS. A critical review of antibiotic prophylaxis in severe acute pancreatitis. Am J Surg. 1996;172(Suppl 6A):38S–43S.CrossRefPubMedGoogle Scholar
  46. 46.
    Rau B, Pralle U, Uhl W, Schoenberg MH, Beger HG. Management of sterile necrosis in instances of severe acute pancreatitis. J Am Coll Surg. 1995;181(4):279–88.PubMedGoogle Scholar
  47. 47.
    Bradley EL III. Operative vs. non-operative management in sterile necrotizing pancreatitis. HPB Surg. 1997;10(3):188–91.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Warshaw AL. To debride on not to debride—that is the question. Ann Surg. 2000;232(5):627–9.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Van Santvoort HC, Besslink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, van Goor H, Schapherder AF, van Eijck CH, Bollen T, van Ramshorst B, Nieuwenhijs VB, Timmer R, Lameris JS, Kruyt PM, Manusama ER, van der Harst E, van der Schllng GP, Karsten T, Hesselink EJ, van Laarhoven CJ, Rosman C, Bosscha K, de Wit RJ, Houdijk AP, van Leeuwen MS, Buskens E, Gooszen HG. Dutch pancreatitis study group. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010;362(16):1491–502.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Loveday BP, Petrov MS, Connor S, Rossaak JI, Mittal A, Phillips AR, Winsdor JA. A comprehensive classification of invasive procedures for treating the local complications of acute pancreatitis based on visualization, route and purpose. Pancreatology. 2011;11(4):406–13.CrossRefPubMedGoogle Scholar
  51. 51.
    Gardner TB, Coelho-Prabhu N, Gordon SR, Gelrud A, Maple JT, Papchristou GI, Freeman ML, Topazian MD, Attam R, Mackenzie TA, Baron TH. Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter U.S. series. Gastrointest Endosc. 2011;73(4):718–26.CrossRefPubMedGoogle Scholar
  52. 52.
    Gumaste VV, Pitchumoni CS. Pancreatic pseudocyst. Gastroenterologist. 1996;4(1):33–43.PubMedGoogle Scholar
  53. 53.
    Heider R, Meyer AA, Galanko JA, Behrns KE. Percutaneous drainage of pancreatic pseudocysts is associated with higher failure rate than surgical treatment in unselected patients. Ann Surg. 1999;229(6):781–9.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Lawson JM, Baillie J. Endoscopic therapy for pancreatic pseudocysts. Gastrointest Endosc Clin N Am. 1995;5(1):181–93.PubMedCrossRefGoogle Scholar
  55. 55.
    Akshintala VS, Saxena P, Zaheer A, Rana U, Hutfless SM, Lennon AM, Canto MI, Kalloo AN, Khashab MA, Singh VK. A comparative evaluation of outcomes of endoscopic versus percutaneous drainage for symptomatic pancreatic pseudocysts. Gastrointest Endosc. 2014;79(6):921–8.CrossRefPubMedGoogle Scholar
  56. 56.
    van Baal MC, van Santvoort HC, Bollen TL, Bakker OJ, Besselink MG, Gooszen HG. Systematic review of percutaneous catheter drainage as primary treatment of necrotizing pancreatitis. Br J Surg. 2011;98(1):18–27.CrossRefPubMedGoogle Scholar
  57. 57.
    Tejedor Bravo M, Justo LM, Lasala JP, Moreira Vicente VF, Ruiz AC, Scapa Mde L. Acute pancreatitis secondary to neuroendocrine pancreatic tumors: report of 3 cases and literature review. Pancreas. 2012;41(3):485–9.CrossRefPubMedGoogle Scholar
  58. 58.
    Kimura Y, Kikuyama M, Kodama Y. Acute pancreatitis as a possible indicator of pancreatic cancer: the importance of mass detection. Intern Med. 2015;54(17):2109–14.CrossRefPubMedGoogle Scholar
  59. 59.
    Cho JH, Choi JS, Hwang ET, Park JY, Jeon TJ, Kim HM, Cho JH. Usefulness of scheduled follow-up CT in discharged patients with acute pancreatitis. Pancreatology. 2015;15(6):642–6.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Hillel Yaffe Medical CenterHaderaIsrael
  2. 2.Division of General SurgeryRambam Health Care CenterHaifaIsrael

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