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COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

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Dharani Subramaniam,MBBS Gillian Leiberman,MD COMPUTED TOMOGRAPHIC COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS ANALYSIS OF PANCREATITIS NOVEMBER,2004 DHARANI SUBRAMANIAM,MBBS HARVARD MEDICAL INTERNATIONAL SRI RAMACHANDRA MEDICAL COLLEGE & RESEARCH INSTITUTE GILLIAN LEIBERMAN,MD
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Page 1: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

COMPUTED TOMOGRAPHIC COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITISANALYSIS OF PANCREATITIS

NOVEMBER,2004

DHARANI SUBRAMANIAM,MBBS

HARVARD MEDICAL INTERNATIONAL

SRI RAMACHANDRA MEDICAL COLLEGE & RESEARCH INSTITUTE

GILLIAN LEIBERMAN,MD

Page 2: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

22

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

PANCREATIC EMBRYOLOGYPANCREATIC EMBRYOLOGY

5TH WEEK 6TH WEEK

Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000.

0102030405060708090

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

EastWestNorth

Page 3: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

33

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Normal anatomy of pancreasNormal anatomy of pancreas

http://www.rush.edu/rumc/page-P00682.html

Page 4: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

44

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

PANCREATIC ANATOMYPANCREATIC ANATOMY

www.fazzioclinic.com www.mattwimsatt.com/pages/med_color_pancreas.html

Page 5: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

55

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Relations of pancreas in coronal planeRelations of pancreas in coronal plane

Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000.

Page 6: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

66

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Cross sectional anatomyCross sectional anatomy

Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000.

Page 7: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

77

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

PancreatitisPancreatitis

PANCREATITIS

ACUTE CHRONIC ACUTE ON CHRONIC

EDEMATOUS

NECROTISING

HAEMORRHAGIC

EMPHYSEMATOUS

PANCREATITIS ------- INFLAMMATION OF THE PANCREAS

Page 8: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

88

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

CAUSES OF PANCREATITISCAUSES OF PANCREATITIS

Toxin1%

Anomalies1%

Trauma2%Drugs

1%

Tryglyceridemia1%

Infection1%

Hypercalcemia1%

Tumours1%

Cholelithiasis

38%

Alcoholism

35%

Ercp 4%

Idiopathic 12%

Page 9: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

99

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

www.nursingcenter.com

PathophysiologyPathophysiology----pancreatitispancreatitis

Page 10: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

1010

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

What the eye sees before radiology doesWhat the eye sees before radiology does

Cullens sign may be seen in acute pancreatitis

www.surgical-tutor.org.uk/system/abdomen/pancreatitis.htm

Page 11: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

1111

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

www.surgical-tutor.org.uk/system/abdomen/pancreatitis.htm

Grey turner’s sign may be seen in acute Grey turner’s sign may be seen in acute pancreatitispancreatitis

Page 12: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

1212

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Patient 1Patient 1

HISTORY OF PRESENT ILLNESSHISTORY OF PRESENT ILLNESS

A 52 YEAR OLD MAN PRESENTED WITH A 52 YEAR OLD MAN PRESENTED WITH SEVERESEVERE

ABDOMINAL PAIN RADIATING TO THE ABDOMINAL PAIN RADIATING TO THE BACKBACK

NAUSEA AND VOMITTINGNAUSEA AND VOMITTINGFOR THE PAST 6 HOURSFOR THE PAST 6 HOURS

Page 13: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

1313

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

PAST HISTORYPAST HISTORY

HYPERTRYGLYCEREDIMIA +HYPERTRYGLYCEREDIMIA +HYPERLIPIDEMIA +HYPERLIPIDEMIA +HYPOTHYRODISM +HYPOTHYRODISM +

NO HISTORY OF CHRONIC ALCOHOL NO HISTORY OF CHRONIC ALCOHOL ABUSE ABUSE

NO HISTORY OF CHRONIC PANCREATITISNO HISTORY OF CHRONIC PANCREATITISNO HISTORY OF CHOLELITHIASISNO HISTORY OF CHOLELITHIASIS

Page 14: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

1414

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

MEDICATION HISTORYMEDICATION HISTORY

ZOLOFTZOLOFTSYNTHROIDSYNTHROID

Page 15: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

1515

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

SOCIAL HISTORYSOCIAL HISTORY

LIVES WITH WIFE AND 2 SONS

NON ALCOHOLIC

NON SMOKER

OCCUPATION-UNKNOWN

Page 16: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

1616

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

PHYSICAL EXAMINATIONPHYSICAL EXAMINATIONCONSCIOUS ORIENTED AND IN PAIN

DIFFUSE ABDOMINAL TENDERNESS +

MILD GUARDING +

DECREASED BREATH SOUNDS BILATERALLY IN THE BASE OF THE LUNGS

TACHYCARDIA +

TACHYPNEA +

BLOOD PRESSURE 160/90mmHg pressure

TEMPERATURE-100 DEGREES FARENHEIT

NORMAL OXYGEN SATURATION

Page 17: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

1717

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

LABORATORY STUDIESLABORATORY STUDIES

AMYLASE AMYLASE LIPASELIPASE

TRYGLYCERIDESTRYGLYCERIDES

Page 18: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

1818

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

INITIAL CT SCAN INITIAL CT SCAN NOTE THE

PERIPANCREATIC EDEMA AND FLUID

COLLECTION TYPICAL OF ACUTE

EDEMATOUS PANCREATITIS

BIDMC,PACS

Page 19: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

1919

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Bilateral Pleural EffusionBilateral Pleural Effusion

Bilateral pleural

effusion

Bidmc ,pacs

Page 20: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

2020

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Management of patient 1Management of patient 1NPONPOTPNTPNAntibioticsAntibioticsAnalgesicsAnalgesicsRespiratory supportRespiratory supportFollowFollow--upup

Page 21: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

2121

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Resolved pancreatitis in Patient 1Resolved pancreatitis in Patient 1Normal attenuating

pancreas in patient 1 after conservative management

BIDMC,PACS

Page 22: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

2222

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

IMAGING MODALITIESIMAGING MODALITIESRADIOGRAPHRADIOGRAPH

ULTRASOUNDULTRASOUND

COMPUTED TOMOGRAPHYCOMPUTED TOMOGRAPHY

MAGNETIC RESONANCE IMAGINGMAGNETIC RESONANCE IMAGING

MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHYMAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY

ENDOSCOPIC ULTRASONOGRAPHYENDOSCOPIC ULTRASONOGRAPHY

ENDOSCOPIC RETROGRADE CHOLANGIOENDOSCOPIC RETROGRADE CHOLANGIO--PANCREATOGRAPHY(ERCP)PANCREATOGRAPHY(ERCP)

CT ANGIOGRAPHYCT ANGIOGRAPHY

Page 23: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

2323

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

ACR APPROPRIATENESS ACR APPROPRIATENESS CRITERIACRITERIA

ETIOLOGY UNKNOWN,FIRST EPISODE OF PANCREATITISETIOLOGY UNKNOWN,FIRST EPISODE OF PANCREATITIS

Radiological procedureRadiological procedure Appropriateness ratingAppropriateness ratingUltrasoundUltrasound 8 8

IV contrast CTIV contrast CT 88

Gadolinium MRIGadolinium MRI 55

MRCPMRCP 55

Endoscopic UltrasoundEndoscopic Ultrasound 55APPROPRIATENESS SCALE: 1=LEAST APPROPRIATE

9=MOST APPROPRIATEAMERICAN COLLEGE OF RADIOLOGY,ACR APPROPRIATENESS CRITERIA

Page 24: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

2424

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

ROLE OF PLAIN RADIOGRAPHROLE OF PLAIN RADIOGRAPH

LIMITED ROLE-------- IT IS NONSPECIFIC IN PANCREATITIS

CLASSICAL SIGNS

COLON CUTOFF SIGN

SENTINEL LOOP SIGN

ANTRAL PAD SIGN

INVERTED 3 OR FROSTBERG SIGN

Page 25: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

2525

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Colon cutoff signColon cutoff signColon cutoff Colon cutoff sign in a 42sign in a 42-- yearyear--old man old man

with acute with acute pancreatitis. pancreatitis.

Frontal scout Frontal scout topogramtopogram for for abdominal CT abdominal CT shows abrupt shows abrupt

cutoff of colonic cutoff of colonic gas column at gas column at

the the splenicsplenic flexure (arrow). flexure (arrow).

The colon is The colon is decompressed decompressed

beyond this beyond this point. point.

www.intl radiology.rsnajnls.org/cgi/ content/full/215/2/387/F2B

Page 26: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

2626

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

COLON CUTOFF SIGN COLON CUTOFF SIGN PATHOPHYSIOLOGYPATHOPHYSIOLOGY

NonenhancedNonenhancedtransverse CT image transverse CT image shows findings of shows findings of pancreatitispancreatitis with with direct extension of direct extension of the inflammatory the inflammatory process into the process into the phrenicocolicphrenicocolicligament (arrow), ligament (arrow), which results in which results in narrowing at the narrowing at the splenicsplenic flexure. Note flexure. Note also the extension of also the extension of exudateexudate into the into the anterior anterior pararenalpararenalspace (arrowheads). space (arrowheads).

www.intl radiology.rsnajnls.org/cgi/ content/full/215/2/387/F2B

Page 27: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

2727

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Is this a mass lesion?Is this a mass lesion?Frontal radiograph from solidFrontal radiograph from solid-- column barium enema column barium enema examination in a 37examination in a 37--yearyear--old old man with man with pancreatitispancreatitis shows shows marked, eccentric luminal marked, eccentric luminal narrowing and mucosal narrowing and mucosal irregularity at the irregularity at the splenicsplenic flexure (arrows) where the flexure (arrows) where the colon returns to the colon returns to the retroperitoneumretroperitoneum. Although the . Although the appearance suggests appearance suggests malignancy, only benign malignancy, only benign inflammation extending into inflammation extending into the the phrenicocolicphrenicocolic ligament ligament from the pancreas was found from the pancreas was found at surgery and at surgery and histopathologichistopathologic examination. examination.

www.intl radiology.rsnajnls.org/cgi/ content/full/215/2/387/F2B

Page 28: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

2828

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

ROLE OF ULTRASOUND IN ACUTE ROLE OF ULTRASOUND IN ACUTE PANCREATITISPANCREATITIS

WHEN CT FAILS TO SHOW GALLSTONES OR IMPACTED WHEN CT FAILS TO SHOW GALLSTONES OR IMPACTED COMMON BILE DUCTCOMMON BILE DUCTMONITOR A RESOLVING PSEUDOCYSTMONITOR A RESOLVING PSEUDOCYST

ADAMS ENCYCLOPEDIA

Page 29: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

2929

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

MAJOR LIMITATIONS OF ULTRASOUNDMAJOR LIMITATIONS OF ULTRASOUNDBOWEL GAS BOWEL GAS INABILITY TO DEFINE THE COMPLEX SPREAD OF INFECTION INABILITY TO DEFINE THE COMPLEX SPREAD OF INFECTION

ALONG FASCIAL PLANESALONG FASCIAL PLANESCANNOT REVEAL AREAS OF PANCREATIC NECROSIS IN PATIENTS CANNOT REVEAL AREAS OF PANCREATIC NECROSIS IN PATIENTS

WITH SEVERE PANCREATITISWITH SEVERE PANCREATITISCANNOT REVEAL MANY VASCULAR AND GASTROINTESTINAL CANNOT REVEAL MANY VASCULAR AND GASTROINTESTINAL

COMPLICATIONSCOMPLICATIONSIMAGINE A PROBE ON A PATIENT WITH AN ACUTE ABDOMINAL IMAGINE A PROBE ON A PATIENT WITH AN ACUTE ABDOMINAL

PRESENTATIONPRESENTATION

ULTRASOUND TRANSDUCER

ADAMS ENCYCLOPEDIA

Page 30: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

3030

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

COMPUTED TOMOGRAPHY IS CONSIDERED THECOMPUTED TOMOGRAPHY IS CONSIDERED THE GOLD STANDARDGOLD STANDARD

IN IMAGING PANCREATITISIN IMAGING PANCREATITIS

SENSITIVITY IN ACUTE PANCREATITIS- 77%-92%

SPECIFICITY IN ACUTE PANCREATITIS- 100%

REMEMBER CT MAY APPEAR NORMAL IN 14-28% OF MILD PANCREATITIS

ADAMS ENCYCLOPEDIA

Page 31: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

3131

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

INDICATIONS OF CTINDICATIONS OF CTTO CONFIRM THE DIAGNOSIS TO CONFIRM THE DIAGNOSIS

IN SEVERE PANCREATITIS TO RULE OUT COMPLICATIONS AND IN SEVERE PANCREATITIS TO RULE OUT COMPLICATIONS AND STAGE THE DISEASESTAGE THE DISEASE

CLINICAL EVIDENCE OF SUDDEN DETERIORATION OR CLINICAL EVIDENCE OF SUDDEN DETERIORATION OR COMPLICATIONSCOMPLICATIONS

UNRESPONSIVE TO 72 HOURS OF CONSERVATIVE THERAPYUNRESPONSIVE TO 72 HOURS OF CONSERVATIVE THERAPY

GUIDE INTERVENTIONAL PROCEDURESGUIDE INTERVENTIONAL PROCEDURES

FOLLOWING INTERVENTIONAL PROCEDURESFOLLOWING INTERVENTIONAL PROCEDURES

AT THE TIME OF DISCHARGE TO RULE OUT LATE COMPLICATIONSAT THE TIME OF DISCHARGE TO RULE OUT LATE COMPLICATIONS

Page 32: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

3232

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

USES OF CT IN PANCREATITISUSES OF CT IN PANCREATITISCONFIRMATORYCONFIRMATORY

DETECT CAUSEDETECT CAUSE

STAGING AND PROGNOSISSTAGING AND PROGNOSIS

FOLLOW UPFOLLOW UP

GUIDE INTERVENTIONSGUIDE INTERVENTIONS

Page 33: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

3333

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

WHAT TO LOOK FOR IN CT?WHAT TO LOOK FOR IN CT?FOCAL HYPODENSE REGIONSFOCAL HYPODENSE REGIONS--NECROSIS/EDEMANECROSIS/EDEMA

PANCREATIC GLANDULAR ENLARGEMENTPANCREATIC GLANDULAR ENLARGEMENT

INTRAPANCREATIC FLUID COLLECTIONSINTRAPANCREATIC FLUID COLLECTIONS

PARAPANCREATIC FINDINGSPARAPANCREATIC FINDINGS----------------------------------------FLUID COLLECTIONSFLUID COLLECTIONS----------------------------------------STRANDING DENSITIESSTRANDING DENSITIES----------------------------------------THICKENING OF RETROPERITONEAL FAT&FASCIAL PLANESTHICKENING OF RETROPERITONEAL FAT&FASCIAL PLANES

THE POSSIBLE CAUSES SUCH AS GALLSTONESTHE POSSIBLE CAUSES SUCH AS GALLSTONES

SIGNS OF CHRONIC PANCREATITISSIGNS OF CHRONIC PANCREATITIS

Page 34: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

3434

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Normal pancreasNormal pancreasNormal pancreas in a post contrast CT

Bidmc pacs

Page 35: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

3535

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

TYPICAL PANCREATITISTYPICAL PANCREATITIS

PANCREAS IS EDEMATOUS BUT

ENHANCES HOMOGENOUSLY

LOW ATTENUATION

FLUID NOTICED IN THE

PERIPANCREATIC REGION

PANCREATITIS IN A CHRONIC ALCOHOL ABUSIVE PATIENT

BIDMC,PACS

Page 36: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

3636

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

ACUTE PANCREATITISACUTE PANCREATITIS

INFLAMMATION AND

EDEMA OF THE PANCREAS

MEDLINE:MEDICAL ENCYCLOPEDIA

Page 37: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

3737

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Gallstone induced pancreatitisGallstone induced pancreatitis

Gallstone-induced pancreatitis in a 27-year-old woman.Transverse CT scan obtained with intravenous and oral contrast material reveals a large, edematous, homogeneously attenuating (73-HU) pancreas (1) and peripancreatic inflammatory changes (white arrows). Although the attenuation values are low, there is no pancreatic necrosis.Calcified gallstones are seen in gallbladder (black arrow).2 = liver (140 HU).

EMIL J.BALTHAZAR,MD ACUTE PANCREATITIS:ASSESMENT OF SEVERITY WITH CLINICAL AND CT EVALUATION;RADIOLOGY2002;223:603-613

Page 38: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

3838

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Emphysematous Emphysematous pancreatitispancreatitis

Axial, enhanced Axial, enhanced CT scans of the CT scans of the upper abdomen upper abdomen show extensive show extensive

gas in the region gas in the region of the body andof the body and

tail of the tail of the pancreas with pancreas with

infiltration of the infiltration of the peripancreaticperipancreatic fatfat

www.learning radiology.com

Page 39: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

3939

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Chronic pancreatitisChronic pancreatitis

Arrows show multiple calcifications within the pancreatic duct which is dilated.

Medline medical encyclopedia

Page 40: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

4040

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

WHAT DO I LOOK FOR NEXT?WHAT DO I LOOK FOR NEXT?LOOK FOR COMPLICATIONS OF LOOK FOR COMPLICATIONS OF PANCREATITIS PANCREATITIS PSEUDOCYSTSPSEUDOCYSTSABSCESSABSCESSNECROSISNECROSISVENOUS THROMBOSISVENOUS THROMBOSISPSEUDOANEURYSMPSEUDOANEURYSMHAEMORRHAGEHAEMORRHAGEPANCREATIC PLEURAL EFFUSIONPANCREATIC PLEURAL EFFUSIONPANCREATIC ASCITESPANCREATIC ASCITES

Pseudocyst

Haemorrhage

Obstruction

Thrombosis

Rupture

Page 41: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

4141

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Pancreatic Pancreatic PseudocystPseudocyst

Pseudocyst of pancreas

Bidmc,pacs

Bidmc,pacs

Page 42: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

4242

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

PseudocystPseudocyst in in saggitalsaggital planeplane

Pseudocystof pancreas

Bidmc,pacs

Page 43: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

4343

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

PSEUDOCYST CAUSING PSEUDOCYST CAUSING OBSTRUCTIONOBSTRUCTION

CT SCANNING OF THE ABDOMEN DEMONSTRATES

DILATATION OF THE PROXIMAL TRANSVERSE

COLON

PSEUDOCYST COMPRESSING

TRANSVERSE COLON

Ileus Secondary to Pancreatic Pseudocyst : A Case Report

Süleyman Büyükberber, MD et al;TURGUT OZAL TIP MERKEZI DERGISI 1996:3(2):124-126

Page 44: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

4444

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

HAEMORHAGE INTO A HAEMORHAGE INTO A PSEUDOCYSTPSEUDOCYST

Hemorrhagic pancreatic pseudocyst

in a 57-year-old man who presented with acute abdominal pain. Axial CT scan obtained with intravenous contrast demonstrates calcifications from chronic pancreatitis in the head of the pancreas. A high-attenuation focus of blood (arrow) is seen within the low-attenuation pseudocyst, a finding that is consistent with hemorrhage.

Bidmc pacs

Page 45: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

4545

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

PANCREATIC PANCREATIC PSEUDOANEURYSMPSEUDOANEURYSM

Pseudo Aneurysm of left gastric artery

BIDMC,PACS

Page 46: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

4646

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Portal venous thrombosisPortal venous thrombosisPortal venous thrombus not

occluding the vein completely

Pseudocyst with extension into the pararenal spaces

BIDMC,PACS

BIDMC,PACS

Page 47: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

4747

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

BIDMC PACSBIDMC PACS

EXTENSION OF PSEUDOCYST IN THE PARA RENAL SPACE, REMEMBER THAT EXTENSION POSTERIORLY INTO THE PARARENAL SPACE IS RARE,IT ACTUALLY

TRACKS IN A SPACE BETWEEN GREOTA’S FASCIA AND THE LATEROCONAL FASCIA RESEMBLING AN INVOLVEMENT OF POSTERIOR PARARENAL SPACE

VassiliosVassilios raptopoulos,MD.Paulraptopoulos,MD.Paul K K Kleinman,MD.SandryKleinman,MD.Sandry Marks,jr.,DDS,PhD.MarjorieMarks,jr.,DDS,PhD.Marjorie Snyder,BS.paulSnyder,BS.paul M silverman,MD(1986)Renal M silverman,MD(1986)Renal fascialfascial pathway:Posteriorpathway:Posterior extension extension of pancreatic effusions within the anterior of pancreatic effusions within the anterior pararenalpararenal space.Radiology.158:367space.Radiology.158:367--374374

PSEUDOCYST EXTENSIONPSEUDOCYST EXTENSION

Page 48: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

4848

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

BILATERAL PLEURAL EFFUSIONBILATERAL PLEURAL EFFUSION

LEFT SIDED EFFUSSION>RIGHT

BIDMC,PACS

BIDMC,PACS

Page 49: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

4949

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

PANCREATIC ABSCESSPANCREATIC ABSCESS

Pancreatic abscess in a 40 year-old man with acute pancreatitis. Axial CT scan obtained with rapid bolus administration of intravenous contrast material shows an air-fluid level (A) in the lesser sac anterior to the underlying pancreas (arrow), whose enhancement implies viability.

Bidmc,pacs

AA

Page 50: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

5050

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

PANCREATIC NECROSIS PANCREATIC NECROSIS AREA OF FOCAL NON

ENHANCEMENT

EVIDENCE OF NECROSIS

The current case demonstrates findings of both acute and necrotizing pancreatitis.

Following a bolus injection, there is enhancement of the parenchyma in the body and tail but persistent low attenuating areas are identified in

the pancreatic head

Uhrad.com radiology teaching files

Page 51: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

5151

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Pancreatic necrosisPancreatic necrosisIf necrosis occurs, it tends to occur early in course of If necrosis occurs, it tends to occur early in course of disease disease Diagnosis depends upon clinical presentation and Diagnosis depends upon clinical presentation and presence of gas in presence of gas in retroperitoneumretroperitoneum

Diagnosis of necrosis on CTDiagnosis of necrosis on CTFocal or diffuse Focal or diffuse WellWell--marginatedmarginatedArea of Area of parenchymalparenchymal nonnon--enhancement enhancement >3cm >3cm Infected pancreatic necrosis recognized at helical CT asInfected pancreatic necrosis recognized at helical CT as

Bubbles of gas within areas of pancreas Bubbles of gas within areas of pancreas Or, collection of gas and tissue within the Or, collection of gas and tissue within the

retroperitoneumretroperitoneum

Page 52: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

5252

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Pancreatic necrosisPancreatic necrosis

E. Coli can infect necrotic pancreas E. Coli can infect necrotic pancreas Produces gas in body of pancreas and Produces gas in body of pancreas and retroperitoneumretroperitoneum

Emphysematous pancreatitis warrants Emphysematous pancreatitis warrants Early use of antibiotics Early use of antibiotics PercutaneousPercutaneous drainage of fluid collections drainage of fluid collections If no response If no response

Surgical resection of infected necrotic tissue Surgical resection of infected necrotic tissue

Carries grave prognosis Carries grave prognosis

Page 53: COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS

5353

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

PANCREATIC NECROSISPANCREATIC NECROSIS

FOCAL NONENHACING REGION OF THE

PANCREAS INVOLVING MORE

THAN 3 CM OF THE BODY OF THE

PANCREAS IN THE POST CONTRAST

CT

BIDMC,PACS

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5454

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Gillian Leiberman,MD

IS THERE ANYTHING ELSE?IS THERE ANYTHING ELSE?LOOK FOR OTHER CAUSES OF ACUTE LOOK FOR OTHER CAUSES OF ACUTE ABDOMEN/ ABDOMINAL PAINABDOMEN/ ABDOMINAL PAIN

MESENTRIC ISCHEMIA/THROMBOSISMESENTRIC ISCHEMIA/THROMBOSISPERFORATED VISCUS/ULCERPERFORATED VISCUS/ULCERBILIARY COLIC/CHOLECYSTITISBILIARY COLIC/CHOLECYSTITISDISSECTING AORTIC ANEURYSMDISSECTING AORTIC ANEURYSM

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Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Balthazar’s CT staging of pancreatitisBalthazar’s CT staging of pancreatitis

GRADEGRADE CT FINDINGCT FINDINGAA NORMAL PANCREAS NORMAL PANCREAS

BB PANCREATIC ENLARGEMENTPANCREATIC ENLARGEMENT

CC PANCREATIC INFLAMMATION PANCREATIC INFLAMMATION AND/OR PERIPANCREATIC FATAND/OR PERIPANCREATIC FAT

DD SINGLE PERIPANCREATIC FLUID SINGLE PERIPANCREATIC FLUID COLLECTIONCOLLECTION

EE TWO OR MORE FLUID TWO OR MORE FLUID COLLECTIONS AND/ OR COLLECTIONS AND/ OR RETROPERITONEAL AIRRETROPERITONEAL AIR

EMIL J.BALTHAZAR,MD ACUTE PANCREATITIS:ASSESMENT OF SEVERITY WITH CLINICAL AND CT EVALUATION;RADIOLOGY 2002;223:603-613

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Dharani Subramaniam,MBBS

Gillian Leiberman,MD

CT severity indexCT severity index

Additional points are added depending on the degree of necrosis

EMIL J.BALTHAZAR,MD ACUTE PANCREATITIS:ASSESMENT OF SEVERITY WITH CLINICAL AND CT EVALUATION;RADIOLOGY2002;223:603-613

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Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Clinical relevance of CT in grading of Clinical relevance of CT in grading of acute pancreatitis acute pancreatitis

0102030405060

grad

e A

/B/C

(no

fluid

colle

ctio

ns)

grad

e D

/E(fl

uid

colle

ctio

ns)

mortalitymorbidity

EMIL J.BALTHAZAR,MD ACUTE PANCREATITIS:ASSESMENT OF SEVERITY WITH CLINICAL AND CT EVALUATION;RADIOLOGY2002;223:603-613

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Dharani Subramaniam,MBBS

Gillian Leiberman,MD

LIMITATIONS OF CTLIMITATIONS OF CTIV CONTRAST ALLERGYIV CONTRAST ALLERGY

RENAL INSUFFICIENCYRENAL INSUFFICIENCY

LESS SENSITIVE FOR GALLSTONES LESS SENSITIVE FOR GALLSTONES THAN ULTRASOUNDTHAN ULTRASOUND

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Dharani Subramaniam,MBBS

Gillian Leiberman,MD

ROLE OF MRIROLE OF MRI

FOR THE ABOVE SAID LIMITATIONS MRI CAN BE USEDFOR THE ABOVE SAID LIMITATIONS MRI CAN BE USED

GADOLINIUM MRI IS AS GOOD ASCONTRAST ENHANCED CT GADOLINIUM MRI IS AS GOOD ASCONTRAST ENHANCED CT ESPECIALLY IN EVALUATING PANCREATIC NECROSISESPECIALLY IN EVALUATING PANCREATIC NECROSIS

PANCREATIC DUCTAL RUPTURE AND GALL STONES CAN BE PICKED PANCREATIC DUCTAL RUPTURE AND GALL STONES CAN BE PICKED UP EASILYUP EASILY

IN PANCREATIC NECROSIS MRI HAS BEEN PROVEN TO BE A BETTER IN PANCREATIC NECROSIS MRI HAS BEEN PROVEN TO BE A BETTER IMAGING MODALITY AS IT DOES NOT INCREASE THE ISCHEMIC IMAGING MODALITY AS IT DOES NOT INCREASE THE ISCHEMIC PENUMBRA AS IV CONTRAST USED IN CONTRAST ENHANCED PENUMBRA AS IV CONTRAST USED IN CONTRAST ENHANCED COMPUTED TOMOGRAPHY MAY DO.COMPUTED TOMOGRAPHY MAY DO.

DISADVANTAGESDISADVANTAGES--TIME CONSUMING AND COSTLYTIME CONSUMING AND COSTLY

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Dharani Subramaniam,MBBS

Gillian Leiberman,MD

DIFFERENTIAL DIAGNOSIS OF DIFFERENTIAL DIAGNOSIS OF PANCREATIC CYSTIC LESIONSPANCREATIC CYSTIC LESIONS

1.1. SIMPLE CYSTSIMPLE CYST2.2. PSEUDOCYSTPSEUDOCYST3.3. VON HIPPEL LINDAUVON HIPPEL LINDAU4.4. CYSTIC TUMOURSCYSTIC TUMOURS

MUCINOUS CYSTADENOMAMUCINOUS CYSTADENOMASEROUS CYSTADENOMASEROUS CYSTADENOMA

INTRADUCTAL PAPILLARY MUCINOUS CYSTADENOMAINTRADUCTAL PAPILLARY MUCINOUS CYSTADENOMACYSTIC ISLET CELL TUMOUR CYSTIC ISLET CELL TUMOUR CYSTIC TERATOMACYSTIC TERATOMACYSTIC CHORIOCARCINOMACYSTIC CHORIOCARCINOMA

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6161

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

MUCINOUS CYSDTADENOMAMUCINOUS CYSDTADENOMAMucinous

Cystadenoma

in a 56 year old

lady

Notice the

septations

within

the cyst

Bidmc,Pacs

BIDMC,PACS

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6262

Dharani Subramaniam,MBBS

Gillian Leiberman,MD

SEROUS CYSTADENOMASEROUS CYSTADENOMA

SEROUS CYSTADENOMA OF PANCREAS MULTIPLE CYSTS LESS THAN 2CM IN SIZE WITH A HONEY COMB APPEARANCE

http://www.uni-ulm.de/klinik/radklinik/rad1/intervention97/radpath/zystaeng.htm

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Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Focal pancreatic mass on CT scanFocal pancreatic mass on CT scan

Focal pancreatic mass on CT scan

Liver metastases Adenopathy

Peripancreatic invasionNo other abnormalities

Fluid in lesser sacPseudocystcalcifications

Carcinoma Pancreatitis

Characterise byMRI

MRCPERCP

FOCAL PANCREATITIS VS MASS LESION

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Dharani Subramaniam,MBBS

Gillian Leiberman,MD

Patient 2Patient 2HISTORY OF PRESENTING ILLNESSHISTORY OF PRESENTING ILLNESSTRANSFERRED FROM ANOTHER TRANSFERRED FROM ANOTHER HOSPITALHOSPITALKNOWN CASE OF ACUTE KNOWN CASE OF ACUTE PANCREATITISPANCREATITISHISTORY OF ALCOHOL ABUSE +HISTORY OF ALCOHOL ABUSE +

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Dharani Subramaniam,MBBS

Gillian Leiberman,MD

ON ARRIVALON ARRIVALCONSCIOUS AND IN PAINCONSCIOUS AND IN PAINDIFFUSE ADDOMINAL PAIN GUARDING DIFFUSE ADDOMINAL PAIN GUARDING POSITIVEPOSITIVEHEART RATE 99/MINHEART RATE 99/MINRESPIRATORY RATERESPIRATORY RATE--2222OXYGEN SATURATION OXYGEN SATURATION –– NORMALNORMAL

LABORATORYLABORATORY----AMYLASE AMYLASE LIPASELIPASE

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Dharani Subramaniam,MBBS

Gillian Leiberman,MD

INITIAL CT ON PATIENT 2INITIAL CT ON PATIENT 2

FLUID COLLECTIONS OF MODERATE FLUID COLLECTIONS OF MODERATE AMOUNTAMOUNTNEAR THE TAIL OF THE PANCREASNEAR THE TAIL OF THE PANCREASNEAR THE HEAD OF THE PANCREASNEAR THE HEAD OF THE PANCREAS2 LARGE PERIRENAL COLLECTIONS 2 LARGE PERIRENAL COLLECTIONS

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Dharani Subramaniam,MBBS

Gillian Leiberman,MD

INITIAL CT SCAN INITIAL CT SCAN --22

PSEUDOCYSTS

PERIRENAL

EXTENSIONBIDMC,PACS

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Dharani Subramaniam,MBBS

Gillian Leiberman,MD

CONDITION OF PATIENT 2CONDITION OF PATIENT 2CONDITION WORSENED DESPITE CONDITION WORSENED DESPITE CONSERVATIVE MANAGEMENTCONSERVATIVE MANAGEMENTEXPLORATIVE LAPAROTOMYEXPLORATIVE LAPAROTOMYPANCREATIC DEBRIDEMENTPANCREATIC DEBRIDEMENTPSEUDOCYST DRAINAGE PSEUDOCYST DRAINAGE SUMP DRAINSSUMP DRAINSPOSTPOST--OP MULTIPLE CT SCANSOP MULTIPLE CT SCANS-- DRAINS DRAINS REMOVED SLOWLYREMOVED SLOWLYADDITIONAL DRAINS WERE PLACEDADDITIONAL DRAINS WERE PLACED

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Dharani Subramaniam,MBBS

Gillian Leiberman,MD

CATHETER PLACEMENTCATHETER PLACEMENT

BIDMC,PACS

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Dharani Subramaniam,MBBS

Gillian Leiberman,MD

DISCHARGE OF PATIENT 2DISCHARGE OF PATIENT 2

PATIENT WAS DISCHARGED WITH 2 PATIENT WAS DISCHARGED WITH 2 DRAINS TO A REHABILITATION CENTRE DRAINS TO A REHABILITATION CENTRE ONCE HIS CLINICAL CONDITION WAS ONCE HIS CLINICAL CONDITION WAS STABLESTABLE

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REFERENCESREFERENCES1.Balthazar EJ, 1.Balthazar EJ, FreenyFreeny PC, PC, vanSonnenbergvanSonnenberg E. Imaging and intervention in acute pancreatitis. E. Imaging and intervention in acute pancreatitis. Radiology 1994;193(2):297Radiology 1994;193(2):297--300. 300. 2. Balthazar EJ, Robinson DL, 2. Balthazar EJ, Robinson DL, MegibowMegibow AJ, AJ, RansonRanson JH. Acute pancreatitis: value of CT in JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology 1990;174(2):331.establishing prognosis. Radiology 1990;174(2):331.3. 3. BegerBeger HG, Rau B, Mayer J, HG, Rau B, Mayer J, PrallePralle U. Natural course of acute pancreatitis. World J U. Natural course of acute pancreatitis. World J SurgSurg1997;21(2):130.1997;21(2):130.4. Block S, Maier W, Bittner R, et al. Identification of pancrea4. Block S, Maier W, Bittner R, et al. Identification of pancreas necrosis in severe acute s necrosis in severe acute pancreatitis: imaging procedures versus clinical staging. Gut 19pancreatitis: imaging procedures versus clinical staging. Gut 1996;27(9):103596;27(9):1035--42.42.5. 5. BoudgheneBoudghene F, L F, L HermineHermine C, Bigot JM. Arterial complications of pancreatitis: diagnosticC, Bigot JM. Arterial complications of pancreatitis: diagnostic and and therapeutic aspects in 104 cases. J therapeutic aspects in 104 cases. J VascVasc IntervInterv RadiolRadiol 1993;4(4):5511993;4(4):551--8. 8. 6. Bradley EL. A clinically based classification system for acut6. Bradley EL. A clinically based classification system for acute pancreatitis. Summary of the e pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, SeptembeInternational Symposium on Acute Pancreatitis, Atlanta, September 1992. Arch r 1992. Arch SurgSurg 1993 1993 May; 128(5): 586May; 128(5): 586--90. 90. 7. 7. ClavienClavien PA, Hauser H, Meyer P, PA, Hauser H, Meyer P, RohnerRohner A. Value of contrastA. Value of contrast--enhanced computerized enhanced computerized tomography in the early diagnosis and prognosis of acute pancreatomography in the early diagnosis and prognosis of acute pancreatitis. A prospective study of titis. A prospective study of 202 patients. Am J 202 patients. Am J SurgSurg 2000;155(3):4572000;155(3):457--66. 66. 8. Dalzell DP, 8. Dalzell DP, ScharlingScharling ES, ES, OttOtt DJ, DJ, WolfmanWolfman NT. Acute pancreatitis: the role of diagnostic NT. Acute pancreatitis: the role of diagnostic imaging. imaging. CritCrit Rev Rev DiagnDiagn Imaging 1998; 39(5): 339Imaging 1998; 39(5): 339--63. 63. 9.Emil J 9.Emil J Balthazar,MDBalthazar,MD Radiology 2002;223:603Radiology 2002;223:603--61361310. 10. FreenyFreeny PC. Incremental dynamic bolus computed tomography of acute pancPC. Incremental dynamic bolus computed tomography of acute pancreatitis. reatitis. IntInt J J PancreatolPancreatol 1993;13(3):1471993;13(3):147--58. 58. 11. Fried AM. 11. Fried AM. RetroperitoneumRetroperitoneum, pancreas, spleen, and lymph nodes. In: , pancreas, spleen, and lymph nodes. In: McGahanMcGahan JP, JP, Goldberg BB, eds. Diagnostic Ultrasound: A Logical Approach. LipGoldberg BB, eds. Diagnostic Ultrasound: A Logical Approach. Lippincottpincott--Raven; 1998: Raven; 1998: p.761p.761--85. 85. 12.Gambiez LP, Ernst OJ, 12.Gambiez LP, Ernst OJ, MerlierMerlier OA. Arterial OA. Arterial embolizationembolization for bleeding for bleeding pseudocystspseudocystscomplicating chronic pancreatitis. Arch complicating chronic pancreatitis. Arch SurgSurg 1997; 132(9):10161997; 132(9):1016--21. 21. 13.Go VLW. Etiology of pancreatitis in the United States, In: Ac13.Go VLW. Etiology of pancreatitis in the United States, In: Acute Pancreatitis: Diagnosis ute Pancreatitis: Diagnosis and Therapy, New York, Raven, 1994: p. 235and Therapy, New York, Raven, 1994: p. 235--9.9.

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REFERENCESREFERENCES14.Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & 14.Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & FebigerFebiger, 1918; , 1918; Bartleby.comBartleby.com, 2000, 200015.Kempainen 15.Kempainen E,SainioE,Sainio V,HaaipianenV,Haaipianen R,KivisaariR,Kivisaari AL,KivilaksoAL,Kivilakso E,PualakainenE,Pualakainen P.EarlyP.Early localisatinlocalisatin of necrosis by of necrosis by

contrast enhanced CT can predict outcome in severe contrast enhanced CT can predict outcome in severe pancreatitis.Brpancreatitis.Br J J SurgSurg 1996;83:9241996;83:924--929.929.16.Kim T ,Murakami 16.Kim T ,Murakami T,TakahashiT,Takahashi S,,etS,,et al.al.--Pancreatic CT Pancreatic CT imaging:Effectsimaging:Effects of different injection rates and doses of of different injection rates and doses of

contrast contrast material.Radiologymaterial.Radiology 1999;212;2191999;212;219--225.225.17.Mortele 17.Mortele KJ,MergoKJ,Mergo PJ.YaylorPJ.Yaylor HM,ErnstHM,Ernst MD,RosMD,Ros PR.RenalPR.Renal and and perirenalperirenal space involvement in acute space involvement in acute

pancreatitis:spiralpancreatitis:spiral CT findings .CT findings .AbdomAbdom Imaging 2000;25:272Imaging 2000;25:272--27827818.Neff 18.Neff C,SimeoneC,Simeone JF,WittenbergJF,Wittenberg J.InflammatoryJ.Inflammatory Pancreatic Pancreatic masses:Problemsmasses:Problems In differentiating focal pancreatitis In differentiating focal pancreatitis

from from carcinoma.Radiologycarcinoma.Radiology 1984;150:351984;150:35--38 38 19.Raptopoulos,V Renal 19.Raptopoulos,V Renal fascialfascial pathway: posterior extension of pancreatic effusions within thepathway: posterior extension of pancreatic effusions within the anterior anterior pararenalpararenal

space.Raptopoulosspace.Raptopoulos V, V, KleinmanKleinman PK, Marks S PK, Marks S JrJr, Snyder M, Paul Silverman PM.367, Snyder M, Paul Silverman PM.367--74 Radiology. 1986 74 Radiology. 1986 Feb;158(2): Feb;158(2):

20. 20. SSüüleymanleyman BBüüyyüükberberkberber MD et MD et al,Ileusal,Ileus Secondary to Pancreatic Secondary to Pancreatic PseudocystPseudocyst : A Case Report : A Case Report SSüüleymanleyman BBüüyyüükberberkberber, MD et , MD et al;TURGUTal;TURGUT OZAL TIP MERKEZI DERGISI 1996:3(2):124OZAL TIP MERKEZI DERGISI 1996:3(2):124--126126

21. Steer 21. Steer ML.PathophysiologyML.Pathophysiology and pathogenesis of acute and pathogenesis of acute pancreatitis:Inpancreatitis:In Bradley EL 111(ed) Acute Bradley EL 111(ed) Acute pancreatitis :Diagnosis and therapy .Raven press 1994,Newyork.pancreatitis :Diagnosis and therapy .Raven press 1994,Newyork.

22.Thoeni 22.Thoeni RF,BlakenbergRF,Blakenberg F.PancreaticF.Pancreatic imaging:Computedimaging:Computed tomography and Magnetic resonance tomography and Magnetic resonance imaging.Radiolimaging.Radiol ClinClin North Am 1993;31:1085North Am 1993;31:1085--11131113

23.Van Ben 23.Van Ben BiezenbosBiezenbos AR,KruytAR,Kruyt PM,BosschaPM,Bosscha K,etK,et al.Addedal.Added value of CT criteria compared to the clinical SAP scorevalue of CT criteria compared to the clinical SAP score in patients with acute in patients with acute pancreatitis.Abdomnpancreatitis.Abdomn ImagImag 1998;23:6221998;23:622--626626

24.Yeo 24.Yeo CJ,BastidasCJ,Bastidas JA,LynchJA,Lynch NyhanNyhan A,etA,et al .Natural history of pancreatic al .Natural history of pancreatic pseudocystspseudocysts documented by Computed documented by Computed tomography.Surgtomography.Surg GynecGynec ObstetObstet 1990;170;4111990;170;411--417417

25. 25. www.intlwww.intl radiology.rsnajnls.org/cgiradiology.rsnajnls.org/cgi/ content/full/215/2/387/F2B/ content/full/215/2/387/F2B26. www.uni26. www.uni--ulm.de.klinik/radklinik/rad1/intervention97/rad[ath/zystaeng.htmulm.de.klinik/radklinik/rad1/intervention97/rad[ath/zystaeng.htm..27. www.rush.edu/rumc/page27. www.rush.edu/rumc/page--p00682.htmlp00682.html

29. www.surgical-tutor.org.uk/system/abdomen/pancreatitis.htm28. www.mattwimsatt.com/pages/med_color_pancreas.html

30. www.nursing center.com

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ACKNOWLEDGEMENTSACKNOWLEDGEMENTSMANY THANKS TOMANY THANKS TODR VASSILIOS RAPTOPOLOUS,MDDR VASSILIOS RAPTOPOLOUS,MDDR MICHAEL GOLDFINGER,MDDR MICHAEL GOLDFINGER,MDDR LIAT APPELBAUM,MDDR LIAT APPELBAUM,MDDR GILLIAN LEIBERMAN,MDDR GILLIAN LEIBERMAN,MDPAMELA LEPKOWSKIPAMELA LEPKOWSKILARRY BARBARASLARRY BARBARAS


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