Pancreatitis (Acute)
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This pathway provides guidance on the use of imaging to investigate adult patients with suspected acute pancreatitis, including confirming the diagnosis, investigating for underlying etiology and assessing for associated complications.
Date reviewed: May 2018
Date of next review: October 2023
Published: December 2018
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Pathway
Pathway Diagram
- Exclude an underlying cause (e.g. gallstones)
- Assess severity
- Detect complications
Images
Teaching Points
Teaching Points
Role of Imaging in acute pancreatitis
- Exclude an underlying cause (e.g. gallstones)
- Assess severity
- Detect complications
- Guide treatment of complications (e.g. fluid collection drainage)
Evaluating the Cause of Acute Pancreatitis
- The two most common causes of acute pancreatitis are gallstones and alcohol
- If these have been ruled out, then rarer causes can be considered
- Extensive or invasive investigations for other causes are not recommended for patients 40 years and younger presenting with a first episode of pancreatitis as recurrence is rare 1-3
- If gallstone and alcohol-induced pancreatitis have been excluded, then CT can be considered in patients who are 40 or older to investigate for pancreatic malignancy. 2, 4-6 Only 1-2% of acute pancreatitis is caused by pancreatic cancer. In the acute phase, tumour can be masked by inflammation or necrosis but secondary signs may suggest an underlying carcinoma 7
- Further investigation is advised regardless of age in patients with more than one episode of acute pancreatitis, taking into consideration the greater risk of morbidity and possible progression to chronic pancreatitis 4-6, 8
- EUS is recommended as the first investigation in patients with pancreatitis of unknown cause and a normal abdominal ultrasound 9
- If no cause is demonstrated on EUS, patients may proceed to MRCP or sMRCP. In high-risk patients, MRCP may be preferred to EUS because it is non-invasive, however the choice of test will depend on availability and local experience 10
- Diagnostic ERCP has been mostly replaced by EUS and MRCP; ERCP should be considered a therapeutic intervention when required 9-13
Assessing Severity and Complications of Acute Pancreatitis
- CT is recommended in severe acute pancreatitis to assess the degree of pancreatic necrosis
- It is also recommended to assess for complications such as fluid collections
Endoscopic Retrograde Cholangiopancreatography (ERCP)
- Indications include:
- Severe pancreatitis of proven or suspected gallstone etiology
- Presence of cholangitis
- Presence of jaundice
References
References
Date of literature search: December 2017 - May 2018
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Yadav D, O'Connell M, Papachristou GI. Natural history following the first attack of acute pancreatitis. Am J Gastroenterol. 2012;107(7):1096-103. (Level II evidence). View the reference
- American Gastroenterological Association Institute. AGA Institute medical position statement on acute pancreatitis. Gastroenterology. 2007;132(5):2019-21. (Guideline). View the reference
- Spanier BW, Dijkgraaf MG, Bruno MJ. Epidemiology, aetiology and outcome of acute and chronic pancreatitis: an update. Best Pract Res Clin Gastroenterol. 2008;22(1):45-63. (Review article). View the reference
- Lowenfels AB, Maisonneuve P, Sullivan T. The changing character of acute pancreatitis: epidemiology, etiology, and prognosis. Curr Gastroenterol Rep. 2009;11(2):97-103. (Review article). View the reference
- Bank S, Indaram A. Causes of acute and recurrent pancreatitis. Clinical considerations and clues to diagnosis. Gastroenterol Clin North Am. 1999;28(3):571-89, viii. (Review article). View the reference
- Banks PA. Epidemiology, natural history, and predictors of disease outcome in acute and chronic pancreatitis. Gastrointest Endosc. 2002;56(6 Suppl):S226-30. (Review article). View the reference
- Frampas E, Morla O, Regenet N, Eugène T, Dupas B, Meurette G. A solid pancreatic mass: Tumour or inflammation? Diagnostic and interventional imaging. 2013;94(7):741-55. (Review article). View the reference
- Lee JK, Enns R. Review of idiopathic pancreatitis. World Journal of Gastroenterology : WJG. 2007;13(47):6296-313. (Review article). View the reference
- Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology. 2013;13(4 Suppl 2):e1-15. (Guideline). View the reference
- Verma D, Kapadia A, Eisen GM, Adler DG. EUS vs MRCP for detection of choledocholithiasis. Gastrointest Endosc. 2006;64(2):248-54. (Level II evidence). View the reference
- Giljaca V, Gurusamy KS, Takwoingi Y, Higgie D, Poropat G, Stimac D, et al. Endoscopic ultrasound versus magnetic resonance cholangiopancreatography for common bile duct stones. Cochrane Database Syst Rev. 2015(2):Cd011549. View the reference
- Kondo S, Isayama H, Akahane M, Toda N, Sasahira N, Nakai Y, et al. Detection of common bile duct stones: comparison between endoscopic ultrasonography, magnetic resonance cholangiography, and helical-computed-tomographic cholangiography. Eur J Radiol. 2005;54(2):271-5. (Level III evidence). View the reference
- Md PS, Md UN. Role of ERCP in patients with idiopathic recurrent acute pancreatitis. Current treatment options in gastroenterology. 2016;14(3):327-39. (Review article).View the reference
- UK Working Party on Acute Pancreatitis. UK guidelines for the management of acute pancreatitis. Gut. 2005;54 Suppl 3:iii1-9. (Guideline).View the reference
- Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102-11. (Guideline).View the reference
- Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002;223(3):603-13. (Review article).View the reference
- Dalzell DP, Scharling ES, Ott DJ, Wolfman NT. Acute pancreatitis: the role of diagnostic imaging. Crit Rev Diagn Imaging. 1998;39(5):339-63. (Review article).View the reference
- Silverstein W, Isikoff MB, Hill MC, Barkin J. Diagnostic imaging of acute pancreatitis: prospective study using CT and sonography. AJR Am J Roentgenol. 1981;137(3):497-502. (Level II-III evidence).View the reference
- McKay AJ, Imrie CW, O'Neill J, Duncan JG. Is an early ultrasound scan of value in acute pancreatitis? Br J Surg. 1982;69(7):369-72. (Level II-III evidence).View the reference
- Jacobs JE, Birnbaum BA. Computed tomography evaluation of acute pancreatitis. Semin Roentgenol. 2001;36(2):92-8. (Review article).View the reference
- Balthazar EJ, Freeny PC, vanSonnenberg E. Imaging and intervention in acute pancreatitis. Radiology. 1994;193(2):297-306. (Guidelines).View the reference
- Mortele KJ, Ip IK, Wu BU, Conwell DL, Banks PA, Khorasani R. Acute pancreatitis: imaging utilization practices in an urban teaching hospital--analysis of trends with assessment of independent predictors in correlation with patient outcomes. Radiology. 2011;258(1):174-81. (Level II evidence).View the reference
- Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174(2):331-6. (Level II-III evidence).View the reference
- Mariani A, Arcidiacono PG, Curioni S, Giussani A, Testoni PA. Diagnostic yield of ERCP and secretin-enhanced MRCP and EUS in patients with acute recurrent pancreatitis of unknown aetiology. Dig Liver Dis. 2009;41(10):753-8. (Level II evidence).View the reference
- Ortega AR, Gomez-Rodriguez R, Romero M, Fernandez-Zapardiel S, Cespedes Mdel M, Carrobles JM. Prospective comparison of endoscopic ultrasonography and magnetic resonance cholangiopancreatography in the etiological diagnosis of "idiopathic" acute pancreatitis. Pancreas. 2011;40(2):289-94. (Level II-III evidence).View the reference
- Somani P, Sunkara T, Sharma M. Role of endoscopic ultrasound in idiopathic pancreatitis. World J Gastroenterol. 2017;23(38):6952-61. (Review article).View the reference
- Sugiyama M, Atomi Y. Acute biliary pancreatitis: the roles of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography. Surgery. 1998;124(1):14-21. (Level II-III evidence).View the reference
- Liu CL, Lo CM, Chan JK, Poon RT, Lam CM, Fan ST, et al. Detection of choledocholithiasis by EUS in acute pancreatitis: a prospective evaluation in 100 consecutive patients. Gastrointest Endosc. 2001;54(3):325-30. (Level II evidence). View the reference
- Chak A, Hawes RH, Cooper GS, Hoffman B, Catalano MF, Wong RC, et al. Prospective assessment of the utility of EUS in the evaluation of gallstone pancreatitis. Gastrointest Endosc. 1999;49(5):599-604. (Level II-III evidence).View the reference
- Stabuc B, Drobne D, Ferkolj I, Gruden A, Jereb J, Kolar G, et al. Acute biliary pancreatitis: detection of common bile duct stones with endoscopic ultrasound. Eur J Gastroenterol Hepatol. 2008;20(12):1171-5. (Level II-III evidence).View the reference
- Sharma M, Pathak A, Rameshbabu CS, Rai P, Kirnake V, Shoukat A. Imaging of pancreas divisum by linear-array endoscopic ultrasonography. Endoscopic Ultrasound. 2016. (Review article);5(1):21-9.View the reference
- Kushnir VM, Wani SB, Fowler K, Menias C, Varma R, Narra V, et al. Sensitivity of endoscopic ultrasound, multidetector computed tomography, and magnetic resonance cholangiopancreatography in the diagnosis of pancreas divisum: a tertiary center experience. Pancreas. 2013;42(3):436-41. (Level II-III evidence).View the reference
- Klapman JB, Chang KJ, Lee JG, Nguyen P. Negative predictive value of endoscopic ultrasound in a large series of patients with a clinical suspicion of pancreatic cancer. Am J Gastroenterol. 2005;100(12):2658-61. (Level II evidence).View the reference
- Byrne MF, Jowell PS. Gastrointestinal imaging: endoscopic ultrasound. Gastroenterology. 2002;122(6):1631-48. (Review article).View the reference
- Dahan P, Andant C, Levy P, Amouyal P, Amouyal G, Dumont M, et al. Prospective evaluation of endoscopic ultrasonography and microscopic examination of duodenal bile in the diagnosis of cholecystolithiasis in 45 patients with normal conventional ultrasonography. Gut. 1996;38(2):277-81. (Level II evidence).View the reference
- Yattoo GN, Waiz GA, Feroze AS, Showkat Z, Gul J. The efficacy of magnetic resonance cholangiopancreatography in assessing the etiology of acute idiopathic pancreatitis. Int J Hepatobiliary Pancreat Dis. 2014;4:32-9. (Level III evidence). View the reference
- Levy MJ, Geenen JE. Idiopathic acute recurrent pancreatitis. Am J Gastroenterol. 2001;96(9):2540-55. (Review article).View the reference
- Safari MT, Miri MB, Ebadi S, Shahrokh S, Alizadeh AHM. Comparing the roles of EUS, ERCP and MRCP in idiopathic acute recurrent pancreatitis. Clinical Medicine Insights Gastroenterology. 2016;9:35-9. (Review article).View the reference
- Lee SL, Kim HK, Choi HH, Jeon BS, Kim TH, Choi JM, et al. Diagnostic value of magnetic resonance cholangiopancreatography to detect bile duct stones in acute biliary pancreatitis. Pancreatology. 2018;18(1):22-8. (Level II-III evidence).View the reference
- Manfredi R, Pozzi Mucelli R. Secretin-enhanced MR imaging of the pancreas. Radiology. 2016;279(1):29-43. (Review article).View the reference
- Makary MA, Duncan MD, Harmon JW, Freeswick PD, Bender JS, Bohlman M, et al. The role of magnetic resonance cholangiography in the management of patients with gallstone pancreatitis. Ann Surg. 2005;241(1):119-24. (Level III evidence).View the reference
- Gosset J, Deviere J, Matos C. Magnetic resonance imaging of acute pancreatitis: the pancreatogram. JOP. 2004;5(1):48-50. (Level IV evidence).View the reference
- Barish MA, Yucel EK, Ferrucci JT. Magnetic resonance cholangiopancreatography. N Engl J Med. 1999;341(4):258-64. (Review article).View the reference
- Neoptolemos JP, Carr-Locke DL, London NJ, Bailey IA, James D, Fossard DP. Controlled trial of urgent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy versus conservative treatment for acute pancreatitis due to gallstones. Lancet. 1988;2(8618):979-83. (Level III evidence).View the reference
- Fan ST, Lai EC, Mok FP, Lo CM, Zheng SS, Wong J. Early treatment of acute biliary pancreatitis by endoscopic papillotomy. N Engl J Med. 1993;328(4):228-32. (Level II evidence).View the reference
- Neoptolemos JP, Carr-Locke DL, Leese T, James D. Acute cholangitis in association with acute pancreatitis: incidence, clinical features and outcome in relation to ERCP and endoscopic sphincterotomy. Br J Surg. 1987;74(12):1103-6. View the reference
- Carnes ML, Romagnuolo J, Cotton PB. Miss rate of pancreas divisum by magnetic resonance cholangiopancreatography in clinical practice. Pancreas. 2008;37(2):151-3. (Level II-III evidence).View the reference
- Rosso E, Alexakis N, Ghaneh P, Lombard M, Smart HL, Evans J, et al. Pancreatic pseudocyst in chronic pancreatitis: endoscopic and surgical treatment. Dig Surg. 2003;20(5):397-406. (Review article). View the reference
- Udd M, Kylänpää L, Halttunen J. Management of difficult bile duct cannulation in ERCP. World Journal of Gastrointestinal Endoscopy. 2010;2(3):97-103. (Reveiw article).View the reference
- Hurter D, De Vries C, Potgieter P, Barry R, Botha F, Joubert G. Accuracy of MRCP compared to ERCP in the diagnosis of bile duct disorders. 2008. 2008;12(1) (Level II-III evidence).View the reference
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