Utility of 128-slice Multi-detector Spiral Computed Tomography in Detecting Spectrum of Involvement in Acute Pancreatitis

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1 Originl Article Print ISSN: Online ISSN: X DOI: /ijss/2017/353 Utility of 128-slice Multi-detector Spirl Computed Tomogrphy in Detecting Spectrum of Involvement in Acute Pncretitis Bhrtkumr Mudlgi 1, Mnohr Kchre 2, Akshy Kulkrni 3 1 Associte Professor, Deprtment of Rdiology, Mirj-Pndhrpur Rod, Government Medicl College, Mirj, Mhrshtr, Indi, 2 Professor, Deprtment of Rdiology, Mirj-Pndhrpur Rod, Government Medicl College, Mirj, Mhrshtr, Indi, 3 Senior Resident, Deprtment of Rdiology, Mirj-Pndhrpur Rod, Government Medicl College, Mirj, Mhrshtr, Indi Astrct Introduction: Computed tomogrphy (CT) hs proved to e invlule, noninvsive, technique for detiled ssessment of pncres during its cute inflmmtory stge. Detiled evlution, proper stging on scoring sis nd prediction of moridity nd mortlity re possile with the help of dvnced high-resolution multi-detector multislice CT scnner. The purpose of this study is to determine the role nd efficcy of CT scn in evluting spectrum of extent of involvement of pncres in cute phse irrespective of the etiology. This ws cross-sectionl retrospective study of 3 yers durtion. Aims nd Ojectives: To evlute the extent of involvement of pncretic prenchym in cute phse of prenchyml inflmmtion nd to dignose common erly nd lte complictions with the prediction of moridity nd mortlity. Mteril nd Methods: This ws cross-sectionl retrospective study conducted t Government Medil College, Mirj, from June 2014 to My A totl of 150 ptients of different ge groups presenting with signs nd symptoms of cute pncretitis nd with those with ltered pncretic function test were included in this study. Dignosis ws confirmed on clinicl, iochemicl mrker (rised serum mylse nd lipse levels), imging findings nd response to the tretment. Results: In our study, cute pncretitis ws more common in mles (68%) compred to femle popultion (32%). Most common ge group ffected y this pthology ws yers ge group (58%), nd lest common ge group ws more thn 80 yers (<7%). Most common etiology in mles ws lcohol use (39%) nd in femles were gll stones (39%) ge group popultion ws most commonly ffected y lcohol induced pncretitis while ge group ws most commonly ffected y gll stones disese. Other cuses were seen in <40 ge group. The most common finding of cute pncretitis on CT scn ws cute erly interstitil edemtous pncretitis (31.4%). Ductl disruption ws the lest common finding (2%). CT severity index ws mild in 38% cses nd moderte to severe in 31% ech. Conclusion: Erly dignosis nd ssessment of extent of prenchyml involvement with n ssessment of compliction nd prediction of moridity nd mortlity clerly remins chllenge in cute pncretitis. CT proves itself s gold stndrd in such emergency sitution nd true winner ove ll other modlities thus helping the physicins in qulity result oriented cre of these ptients. Key words: Compliction, Computed tomogrphy, Computed tomogrphy severity index, Pncres, Prognosis, Rdiologicl dignosis Access this rticle online Month of Sumission : Month of Peer Review : Month of Acceptnce : Month of Pulishing : INTRODUCTION Continuous rdiologicl innovtions hve led to vilility of high end, stte of rt, multi-detector, multislice, nd spirl computed tomogrphy (CT) scnners for regulr use in clinicl prctice to evlute ech orgn in detil with the highest sptil nd temporl resolution with miniml Corresponding Author: Bhrtkumr Mudlgi, Adi-Siy Bunglow, Dhnnjy Housing Society, Behind Civil Hospitl, Sngli, Mhrshtr, Indi. Phone: Tel.: E-mil: drhrt76@gmil.com 145 Interntionl Journl of Scientific Study July 2017 Vol 5 Issue 4

2 Mudlgi, et l.: CT in cute pncretitis possile dose nd time for the investigtion. These noninvsive techniques re extremely helpful not only to imge orgn with smll possile slice thickness (up to 0.6 mm) ut lso hs helped us to detect most of the erly s well s lte complictions of inflmmtion of pncres. Of course, the credit goes to numer of scientists for their contriution from dvent of remrkle technology to till dte modifiction nd innovtions resulting in mking these user-friendly Softwres. At this ckground, it s lso necessry to rememer nd slute Godfrey Hounsfield of UK who introduced this technology in 1972 on the sis different of numer mthemticl equtions nd lgorithms nd mde n importnt historic development which further evolved till dte into high end scnners in terms of slices, source (single or dul source), detector dynmics nd fst itertive reconstruction reducing remrkly the scn times nd incresing the resolution s well s the ptient throughput in the deprtment of rdiology. These technicl dvntges hve help the rdiologist nd physicin to evlute the pncretic prenchym which ws the most difficult retroperitonel orgn to imge with conventionl imging. Acute pncretitis is common prolem with vried etiology nd extent of involvement. Acute pncretitis refers to n cute inflmmtion of pncretic prenchym due to the injury of pncretic cinr cells with multifctoril etiology. CT imging is extremely useful for confirming dignosis nd to see for the degree of prenchyml injury with prediction of moridity nd mortlity on the sis of modified CT severity index (CTSI). New Atlnt clssifiction cn lso e used for proper nomenclture of the pthologicl involvement on CT scn nd properly clssify pncretitis s well s decrese in inter rdiologist vritions. US nd mgnetic resonnce imging (MRI) hve limited ilities for detiled evlution of this retroperitonel orgn. The ims nd ojective of this study re to determine the efficiency of CT scn in evluting the spectrum of involvement of pncres, properly clssifying them nd predicting the severity of the disese for prognostiction of this lifethretening disese. MATERIAL AND METHODS This ws cross-sectionl retrospective study conducted t Government Medil College, Mirj, from June 2015 to My A totl of 150 ptients of different ge groups presenting with signs nd symptoms of cute pncretitis nd with those with ltered pncretic function test were included in this study. Dignosis ws confirmed on clinicl, iochemicl mrker (rised serum mylse nd lipse levels), imging findings nd response to the tretment. Study Are The study re includes Mirj city nd districts in vicinity including peripherl smll town nd villges. Study Popultion A totl of 150 ptients of vried ge groups presenting with clinicl signs nd symptoms of cute pncretitis with rised serum mylse nd lipse levels were included in the study. Inclusion Criteri Ptients referred for CT of pncres, who were highly suspected to hve cute inflmmtion. Ptient who were lredy dignosed pncretitis nd were scnned to ssess the extent of complictions. Exclusion Criteri Ptient who were known the cse of chronic pncretitis. Ptients presenting with ltered renl functions in whom only plin scn ws performed. Ptient with contrst llergy. Scns with poor imge qulities showing rtifcts due to poor reth hold hmpering optiml evlution. Equipment Used Multi-detector (128-slice) spirl CT, siemens somtom definition AS+, siemens medicl systems, Forchheim, Germny. Protocol Used Triphsic contrst study of domen nd pelvis ws performed fter cquiring topogrm. Axil imges were otined, nd the cquired dt were reconstructed into isotropic coronl nd sgittl plnes. The slice thickness used ws 0.6 mm. All these imges were interpreted in rteril, venous nd delyed phses. The contrst ws injected using Dul Injector (Stellnt, Medrd Dul Hed Injector, USA). Aout 100 ml of non-ionic contrst (Iohexol 300 ml I/ml) ws injected through ntecuitl vein t flow rte of 4 ml/s followed y sline injection of 40 ml t 3.5 ml/s. Arteril phse imges were cquired with dely of s using cre olus technique venous phse nd delyed phse imges were cquired t dely of s nd s, respectively, fter intrvenous. Injection of contrst revised Atlnt clssifiction 2012 ws used for leling correctly the pthologies of pncres. Stging of disese ws performed using modified CTSI which helped in predicting moridity nd mortlity of the disese. OBSERVATION Axil CT scns with reconstruction in coronl nd sgittl plnes in rteril, venous nd delyed phses Interntionl Journl of Scientific Study July 2017 Vol 5 Issue 4 146

3 Mudlgi, et l.: CT in cute pncretitis were performed in 150 ptients who hd high index of suspicious of cute pncretitis on the sis of clinicl signs, symptoms nd ltered pncretic function tests. The results re enumerted in Tles 1-5. RESULTS A totl of 150 ptients with clinicl nd rdiologicl dignosis of pncretitis were included in this study. There ws cler sex predilection towrd mles with M:F rtio of 2:1. Of the totl numer, 102 (68%) were mles nd 48 (32%) were femles s shown in Tle ge groups were more lile to pncretitis thn other ge groups (Tle 2). Alcohol use nd gll stones were the most common etiologicl fctors (39% ech). However, lcohol use ws most common custive gent in mles (53 out of 59) nd gll stones in femles (34 out of 59). <4% hd other rre cuses of pncretitis while no custive gent could e found in 14.7% cse (Tle 3). Alcohol induced Tle 1: Gender distriution Gender n (%) Femle 48 (32) Mle 102 (68) Grnd totl 150 (100) pncretitis ws commonly seen t ge group of yers irrespective of sex while gll stone pncretitis ws seen commonly t ge group of yers (Tle 4). Degree of involvement ws tulted using modified CTSI. Aout 38% ptients hd mild degree of involvement while moderte to severe involvement ws seen in 38% ge. The prediction of moridity nd mortlity is shown in Figure 1 s per CTSI. Most common CT imging findings were cute interstitil edem of pncres (31%). Vrious complictions were enlisted (Tle 5) in ccordnce with New Atlnt clssifiction 2012 (Figure 2). Acute peripncretic fluid collections (APFCs) were the most common compliction (12.7%). In most of the ptient irrespective of ge, sex who hd mild degree of pncretitis ccording to modified CTSI the predicted moridity nd mortlity ws 3% nd 8%, respectively (Tle 6). DISCUSSION Acute pncretitis is one of the most common cuses of the upper dominl pin, wherein the clinicl signs nd symptoms re insensitive to ssess the degree of orgn involvement nd to predict moridity nd mortlity. 1,2 The involvement of djcent nd remote tissue nd orgns lso Tle 2: Age nd gender distriution Age distriution Femle Mle Totl ove Grnd totl Tle 3: Distriution y etiopthology Etiology Femle Mle Totl (%) Alcohol (39) Gllstones (39) Hypertriglyceridemi (3.3) Congenitl nomlies (2) Trum (2) Idiopthic (14.7) Figure 1: Revised Atlnt clssifiction of fluid collections in cute pncretitis. ANC: Acute necrotic collection, APFC: Acute peripncretic fluid collection, WON: Wlled-off necrosis Tle 4: Age distriution of etiologies Age rnge Alcohol Gllstones Hypertriglyceridemi Congenitl nomlies Trum Idiopthic ove Grnd totl Interntionl Journl of Scientific Study July 2017 Vol 5 Issue 4

4 Mudlgi, et l.: CT in cute pncretitis hs n lrming concern which needs to e ddressed y roust nd relile imging technique. The incidence of cute pncretitis is 5-17 cse per 100,000 per yer. Biliry clculi re the most common cuse in women nd lcohol use is most common cuse in men for cute s well s recurrent pncretitis. Newer dvnced CT imging hs emerged to e gold stndrd in imging of pncres. To dd on this CT technique hs lso proved cler winner in predicting the cuses of cute pncretitis. 3 Clinicl signs nd symptoms long with three-fold rise in serum mylse nd lipse nd CT findings form Tripod in confirming dignosis of pncretitis nd its sequele. Furthermore, iochemicl mrkers re rised in other pthologies s well proving them to e very insensitive. Mny systems to clssify pncretitis hve een developed cliniclly such s Acute Physiology nd Chronic Helth Evlution II (APACHE II), nd Rnson s Criteri which predicts the severity of pncretitis with score of more thn three indicting cute severe pncretitis. However, their utility is detle nd less sensitive. CTSI is commonly used to evlute nd estimte pncretic injury 1 nd to predict moridity nd mortlity (Figure 1). Algorithmic pproch to the cre of ptients with necrotizing pncretitis cn e uilt up. 4 The revised Atlnt clssifiction (Figure 3) cn e used precisely to descrie findings in cute pncretitis, stndrdize terminology cross specilties nd help in the tretment plnning, defines cute pncretitis s interstitil edemtous pncretitis or necrotizing pncretitis. 10 It lso ctegories the vrious pncretic nd peripncretic collections nd helps us to pln tretment depending on the stge of the disese. Tle 5: CT fetures of cute pncretitis Fetures n (%) Interstitil edem 47 (31.4) Necrosis 19 (12.6) Pncretic scess 7 (4.6) Ductl disruption 3 (2) Vsculr thromosis 17 (11.4) Extrpncretic ft necrosis 17 (11.4) APFC 19 (12.7) Pseudo cyst 16 (10.6) WON 5 (3.3) CT: Computed tomogrphy, WON: Wlled off necrosis, APFC: Acute peripncretic fluid collection Proper Triphsic imging protocols re extremely useful to study vriety of detils regrding degree of involvement of pncretic prenchym, peripncretic tissues nd orgns nd surrounding rteriovenous luminl involvement. Noncontrst scns re often not useful especilly to predict necrosis 2 nd hence cn prevent dditionl rdition exposure. Scnning using cre olus technique with injection dely of 25-30, s, nd 120 s help us in cquiring rw dt in rteril, venous, nd delyed phses. 1 This dt re effectively reconstructed using 0.6 mm slice thickness in xil, coronl, nd sgittl isotropic imges. Although under dete, intrvenous contrst usge clerly outweighs the potentil risk of its injection. Imging Perls In interstitil edemtous pncretitis (Figure 4), this orgn shows diffuse enlrgement with slight heterogeneous enhncement. These findings re more commonly seen Figure 2: Contrst-enhnced computed tomogrphy (CECT) in 46-yer-old womn with epigstric pin. ( nd ), Axil nd coronl CECT venous phse imge shows extrpncretic ft necrosis/sponifiction noted in the lesser sc (long rrows, nd ) Severity index Percentge moridity Percentge mortlity Tle 6: Distriution of cses ccording to CT severity index with prediction of moridity nd mortlity Score n (%) Moridity (%) Mortlity (%) 0 2 (mild) 57 (38) (moderte) 46 (31) (severe) 47 (31) CT: Computed tomogrphy Figure 3: Computed tomogrphy severity index Interntionl Journl of Scientific Study July 2017 Vol 5 Issue 4 148

5 Mudlgi, et l.: CT in cute pncretitis Figure 4: Contrst-enhnced computed tomogrphy (CECT) in 45-yer-old mn with dominl pin nd rised mylse lipse. ( nd ) Axil CECT venous phse imge shows enlrged nd edemtous pncres with loss of norml ftty loultion nd peripncretic ft strnding, edem nd free fluid (rrow, ). Coronl CECT venous phse imge shows chnges of cute edemtous interstitil pncretitis with extension of fluid noted in the lesser sc (long rrow, ) nd long trnsverse mesocolon (short rrow, ) c Figure 7: Contrst-enhnced computed tomogrphy (CECT) in 32-yer-old mn with lcohol use, severe nuse, vomiting, nd dominl pin. (, nd c) Axil CECT venous phse imge shows hypottenuting collection suggestive of pseudo cyst formtion nterior to the pncres (long rrow, ). Coronl CECT venous phse imge shows prtilly ostructing nonenhncing filling defect suggestive of cute thromus is noted in the extrheptic min portl vein (long rrow, ) Sgittl CECT venous phse imge shows focl re of ductl disruption directly connecting with the pseudo cyst of pncres (long rrow, c) Figure 5: Contrst-enhnced computed tomogrphy (CECT) in 34-yer-old mn with epigstric pin rditing to ck. ( nd ) Axil CECT venous phse imge shows severely hypo/ nonenhncing re suggestive of necrosis (long rrow, ) with >60% involvement with significnt peripncretic inflmmtion (short rrow, ). Coronl CECT venous phse imge shows etter delinetion of extension of necrotic fluid throughout the ody nd til of pncres (long rrow, ) Figure 6: Contrst-enhnced computed tomogrphy (CECT) in 28-yer-old mn with severe the upper dominl pin. ( nd ) Axil CECT, venous phse imge, shows prtilly ostructing filling defect suggestive of thromosis in the distl prt of the splenic vein just efore its confluence with superior mesenteric vein (long rrow, ). Chnges of cute edemtous interstitil pncretitis re lso seen. Coronl curved reconstruction imge shows extent of the thromus in entire splenic vein (long rrow, ) if scns re performed 5-7 dys fter onset of symptoms. In necrotizing pncretitis Revised Atlnt Clssifiction identified three forms. In first one, there would e vrile Figure 8: Contrst-enhnced computed tomogrphy (CECT) in 41-yer-old women with epigstric pin nd ltered pncretic function test. nd, olique xil CECT venous phse imge shows well encpsulted hypottenuting lesion suggestive of wlled-off pncretic necrosis in the hed nd uncinte process of pncres (long rrow, ). Coronl CECT venous phse imge shows etter delinetion of the wlled-off necrosis of pncres 4 weeks fter necrotizing pncretitis degree of necrosis which is seen s heterogeneous nonenhncing re (Figure 5) with or without miniml peripncretic involvement. In the second form, there would e predominnt extrpncretic necrosis (Figure 6) with miniml prenchyml necrosis. The third form is the most common nd shows vrile degree nd severity of pncretic nd extrpncretic necrosis. Interstitil edemtous pncretitis is often ssocited with APFC which develop into pseudo cysts overtime (Figure 7). On the other hnd, necrotizing pncretitis is ssocited with pncretic nd extrpncretic cute necrotic collection (ANC) which overtime develop into wlled-off pncretic necrosis (Figure 8). The ANC cn get infected (scess formtion) (Figure 2). Air specks in the collection re most sensitive mker for scess formtions s is n enhncement of the wlls of delyed phse imge. Vsculr thromosis (Figure 6 nd 7) nd 149 Interntionl Journl of Scientific Study July 2017 Vol 5 Issue 4

6 Mudlgi, et l.: CT in cute pncretitis CONCLUSION Figure 9: Contrst-enhnced computed tomogrphy (CECT) in 22-yer-old womn with fever nd severe dominl pin. ( nd ), Axil nd coronl CECT venous phse imge shows severe necrosis of pncres with prenchym replced y collection showing significnt peripherl enhncement nd few ir specks (short rrow, ) within suggestive of pncretic scess formtion (long rrows, nd ) pseudoneurysms cn further complicte the course nd nturl prognosis of disese. Portl vein, splenic vein re more commonly involved thn other vsculr chnnels round (Figure 9). In study conducted y Cppell et l. cute pncretitis ws most common in ge groups. They lso predicted the mle to femle predilection of 2:1. 11 In our present study, similr findings could e reported. Similrly, Bnk et l. reported lcohol use in mles nd gllstones in femles to e the most common etiopthologicl fctor for this dredful disese 9,11 Zho et l. 12 pulished reference to new Revised Atlnt Clssifiction to ring down the inter oserver reporting vritions to descrie nd ctegorized disese with huge spectrum of involvement. Blthzhr et l. in formulted CTSI criteri to prognosticte the disese. 1,2,3,5 Mny uthors including Ju et l. hve emphsized tht USG nd MRI hve limited dvntges over CT imging. 8 We hve successfully re-emphsized the findings coted y Blthzr et l. 6 on the extreme utility of CT imging in cute pncretitis. CTSI is clerly superior to Rnson criteri nd APACHE scoring system in predicting outcome in cute pncretitis. 7 There re limittions to our study s we hve not included cses of cute on chronic pncretitis which might ltered the results of spectrum of involvement. We lso do not hve follow-up of ptients clinicl course, extent of moridity nd mortlity fter the scn ws performed. There is considerle utility of Triphsic contrst enhnced CT scn for evlution of pncres during its cute inflmmtion nd follow-up to rule out complictions of the sme. Esy vilility, multiplnr cpilities fst scnning techniques, hve surely plyed mjor role in understnding chnges in inflmmtion of pncres during cute inflmmtion nd to follow-up to know the extent of compliction nd thus predicting the moridity nd mortlity of the disese thus helping the clinicins for proper counseling of the ptient nd their fmilies. In view of wide spectrum of findings. CT scns hve helped us to ccurtely stge the disese with high ccurcy. CT remins gold stndrd nd sensitive modlity for detection, ccurte dignosis nd determine for exct extent of compliction of cute pncretitis. Predicting moridity nd mortlity hve proved to e more sensitive thn the clinicl criteri on the ses of CTSI. 1 Thus, CT hs n extreme utility without ny dout in evluting disese of cutely inflmed pncres with its erly nd remote noninvsively. REFERENCES 1. Blthzr EJ, Roinson DL, Megiow AJ, Rnson JH. Acute pncretitis: Vlue of CT in estlishing prognosis. Rdiology 1990;174: Css JD, Díz R, Vlders G, Mriscl A, Cudrs P. Prognostic vlue of CT in the erly ssessment of ptients with cute pncretitis. AJR Am J Roentgenol 2004;182: Blthzr EJ. Acute pncretitis: Assessment of severity with clinicl nd CT evlution. Rdiology 2002;223: Shyu JY, Sinni NI, Shni VA, Chick JF, Chuhn NR, Conwell DL, et l. Necrotizing pncretitis: Dignosis, imging, nd intervention. Rdiogrphics 2014;34: Alhjeri A, Erwin S. Acute pncretitis: Vlue nd impct of CT severity index. Adom Imging 2008;33: Blthzr EJ, Rnson JH, Nidich DP, Megiow AJ, Cccvle R, Cooper MM. Acute pncretitis: Prognostic vlue of CT. Rdiology 1985;156: Trintopoulou C, Lytrs D, Mnitis P, Chrysovergis D, Mnes K, Sifs I, et l. Computed tomogrphy versus cute physiology nd chronic helth evlution II score in predicting severity of cute pncretitis: A prospective, comprtive study with sttisticl evlution. Pncres 2007;35: Ju S, Chen F, Liu S, Zheng K, Teng G. Vlue of CT nd clinicl criteri in ssessment of ptients with cute pncretitis. Eur J Rdiol 2006;57: Bnk S, Indrm A. Cuses of cute nd recurrent pncretitis. Clinicl considertions nd clues to dignosis. Gstroenterol Clin N Am 1999;28:571-89, viii. 10. Bollen TL. Acute pncretitis: Interntionl clssifiction nd nomenclture. Clin Rdiol 2016;71: Cppell MS. Acute pncretitis: Etiology, clinicl presenttion, dignosis, nd therpy. Med Clin North Am 2008;92: , ix-x. 12. Zho K, Adm SZ, Keswni RN, Horowitz JM, Miller FH. Acute pncretitis: Revised tlnt clssifiction nd the role of cross-sectionl imging. AJR Am J Roentgenol 2015;205:W How to cite this rticle: Mudlgi B, Kchre M, Kulkrni A. Utility of 128-slice Multi-Detector Spirl Computed Tomogrphy in Detecting Spectrum of Involvement in Acute Pncretitis. Int J Sci Stud 2017;5(4): Source of Support: Nil, Conflict of Interest: None declred. Interntionl Journl of Scientific Study July 2017 Vol 5 Issue 4 150