Pancreatitis (Acute)

Pathway

Images

Image Gallery Note: These images open in a new page
1		Acute Necrotising Pancreatitis Image 1 (Computed Tomography): Acute necrotising pancreatitis showing pancreatic oedema (yellow arrow) and necrosis (white arrow).
2a		Gastric Ulcer (differential diagnosis for acute pancreatitis) Image 2a and 2b (Computed Tomography): Axial and coronal views showing a bubble of gas (arrow) outside the lumen of the greater curve of the stomach consistent with a perforated gastric ulcer.
>2b

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

1. 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
2. American Gastroenterological Association Institute. AGA Institute medical position statement on acute pancreatitis. Gastroenterology. 2007;132(5):2019-21. (Guideline). View the reference
3. 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
4. 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
5. 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
6. 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
7. 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
8. Lee JK, Enns R. Review of idiopathic pancreatitis. World Journal of Gastroenterology : WJG. 2007;13(47):6296-313. (Review article). View the reference
9. 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
10. 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
11. 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
12. 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
13. 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
14. 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
15. 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
16. Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002;223(3):603-13. (Review article).View the reference
17. 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
18. 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
19. 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
20. Jacobs JE, Birnbaum BA. Computed tomography evaluation of acute pancreatitis. Semin Roentgenol. 2001;36(2):92-8. (Review article).View the reference
21. Balthazar EJ, Freeny PC, vanSonnenberg E. Imaging and intervention in acute pancreatitis. Radiology. 1994;193(2):297-306. (Guidelines).View the reference
22. 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
23. 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
24. 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
25. 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
26. 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
27. 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
28. 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
29. 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
30. 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
31. 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
32. 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
33. 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
34. Byrne MF, Jowell PS. Gastrointestinal imaging: endoscopic ultrasound. Gastroenterology. 2002;122(6):1631-48. (Review article).View the reference
35. 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
36. 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
37. Levy MJ, Geenen JE. Idiopathic acute recurrent pancreatitis. Am J Gastroenterol. 2001;96(9):2540-55. (Review article).View the reference
38. 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
39. 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
40. Manfredi R, Pozzi Mucelli R. Secretin-enhanced MR imaging of the pancreas. Radiology. 2016;279(1):29-43. (Review article).View the reference
41. 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
42. 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
43. Barish MA, Yucel EK, Ferrucci JT. Magnetic resonance cholangiopancreatography. N Engl J Med. 1999;341(4):258-64. (Review article).View the reference
44. 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
45. 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
46. 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
47. 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
48. 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
49. 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
50. 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

Information for Consumers

Information for Consumers