Acute Pancreatitis: Review of Updated Atlanta Classification and Its Advantages

Transcription

1 Acute Pancreatitis: Review of Updated Atlanta Classification and Its Advantages Poster No.: C-1880 Congress: ECR 2014 Type: Educational Exhibit Authors: U. Koç, B. De#irmenci, A. R. Aktas; Isparta/TR Keywords: Inflammation, Education and training, Acute, elearning, Education, CT, Pancreas, Abdomen DOI: /ecr2014/C-1880 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 21

2 Learning objectives -To understand 2012 revision of the Atlanta classification and new terminology -To manage patient present with acute pancreatitis as a radiologist in case of new morphological classification via Contrast Enhanced Computed Tomography(CECT) Images for this section: Fig. 1: Normal Anatomy of Pancreas via charcoal drawing Page 2 of 21

3 Fig. 2: Pathologic Illustration via Charcoal Drawing(Necrosis and Oedema) Page 3 of 21

4 Fig. 3: Acute oedematous pancreatitis Page 4 of 21

5 Fig. 4: Acute necrotizing pancreatitis Page 5 of 21

6 Background Pancreatic inflamatory disease may be cluster as acute pancreatitis and chronic pancreatitis. Acute pancreatitis is characterized by sudden inflammation and discrete episode of injury, can be followed by necrosis of pancreas parencyma, pancreatic fat and peripancreatic tissues. Repeated episodes of inflammation, necrosis and apoptosis processes ended up with chronic inflammation and fibrosis which is the characteristics of chronic pancreatitis(1). Due to lacking a capsule of the pancreas, the inflammation and necrosis can be spread. The acute pancreatitis is diagnosed clinically by the symptoms of acute onset severe pain in the abdomen or back, nause and vomiting, accompanied by biochemical and radiological findings(2). It can result in severe complications locally or systematically and have high mortality rate in spite of treatment. CE-CT is an important initial assesment modality for acute pancreatitis. CE-CT scan is required to differentiate degree of severity. In case of determining severity of pancreatitis via CE-CT, CT severity index is grading system developed in the early 1990s and Atlanta classification introduced in 1992(3-4). However 1992 classification CT features have made confusion so that it has not been utilized universally and revised 2012(5). Revised Atlanta classification update the terminology and provide functional clinical and morphologic classification which is good for communication between clinicians and radiologist(5-6). Images for this section: Page 6 of 21

7 Table 1: Causes of Acute Pancreatitis Page 7 of 21

8 Table 2: Local complications of Acute Pancreatitis Page 8 of 21

9 Findings and procedure details Understanding of acute pancreatitis, its course, complications and the features of the disease on cross-sectional imaging has been improved in these last 20 years. At one hand lack of stratification and confusion of reporting based on old Atlanta and CT severity index, on the other hand improvement at understanding of acute pancreatitis made working group decide to revised the Atlanta classification via virtual international multidisciplinary consensus conference over the internet(5-6). This revised classification includes diagnosis, types of acute pancreatitis, severity, and description of pancreatic and peripancreatic collections(5). Let's make our roadmap as a radiologist; Step 1: Get an information from clinicians or hospital database about patient history and laboratory findings(table 3) Step 2: If any need for CE-CT, radiologist on call. And from that time, the adventure of acute pancreatitis process is started for radiologist(table 4-5). Step 3: What type is that? Interstitial oedematous or Necrotising(Figure 5-8)? Step 4: If any need for CE-CT to evaluate complications of acute pancreatitis, what are the processes radiologist may come across(figure 9-14). The vast majority of patients present as interstitial oedematous form which has diffuse or focal enlargement of the pancreas because of inflammatory oedema. On the other hand, approx. %5-10 of patients developed necrosis of the pancreatic parencyma, peripancreatic area or both(5). Necrosis may not be recognized on CECT imaging during the first few days(7). But impairment of pancreatic perfusion may be clue for ongoing necrosis. The revised Atlanta classification cluster acute pancreatitis as early or late phases that reflect dynamic period, lasts only 1 week for early phase, and weeks to months for late phase(5). It is the results of understanding of the etiopathogenesis of acute pancreatitis in these last 20 years. The early phase is mainly classified functionally by clinical scoring systems like Marshall. The late phase is classified morphologically as local complications seen on CE-CT. Furthermore, the severity of disease classify as three degrees; mild, moderate severe and severe(5). Identification severity of disease is very important for clinical management. As a part of this, CE-CT findings at the begining and afterwards make contribution at definition of severity. Pancreatic abscess, hemorrrhagic and phlegmon terms Page 9 of 21

10 are not used in the current classification(5). Local complications are now beter understood and described. After recognizing patern and local complications via CE-CT, it shows a key role for clinicians at the management of disease. In case of severity, mild acute pancreatitis is managed conservatively. Moderate severe or severe acute pancreatitis is defined as transient(< 48 hr) or persistent(> 48 hr) organ failure, also associate with local and/or systemic complications; have significant morbity and mortality rate need longer stay at hospital or intensive care unit and intervention. The main difference between modere severe and severe is moderate severe is not associated with persistent organ failure(5). As an interventional radiologist, we can use CE-CT for image-guided drainage procedures such as percutaneously or percutaneous cystgastrostomy(8). The indications are symptomatic collections which are mass effect, causing pain or have become infected; pseudocysts larger than 5 cm, are not resolve spontaneously, that have been present for longer than 6 weeks(9-10). These drainage procedures that can be used alternative to surgical debridement, have been found effective at one of clinical experience and observational study(11). Images for this section: Table 3: Diagnosis of Acute Pancreatitis Page 10 of 21

11 Table 4: What type is that? Table 5: Definition of Pancreatic and Peripancreatic Collections Page 11 of 21

12 Fig. 5: A 60-year-old man with acute interstitial oedematous pancreatitis. There is peripancreatic fat stranding(small arrow) and minimal peripancreatic fluid(long arrow). Fig. 6: Curved MPR CT images of 61-year old man with acute interstitial oedematous pancreatitis. The pancreas enhances completely but has a heterogenous apperance because of oedema. There is peripancreatic fluid and peripancreatic fat stranding. Page 12 of 21

13 Fig. 7: A 58-year-old woman with acute necrotizing pancreatitis. There is focal non-enhancement area of pancreas head which shows necrosis(star). There is also peripancreatic necrosis area adjacent to pancreatic necrosis area(arrows). Fig. 8: A 30-year-old man with necrotizing pancreatit. There is non-enhancement area at the pancreatic tail(star) and peripancreatic fat stranding adjacent to this area through left perirenal area(arrowhead). Part of corpus has oedematous enlargement(arrow). Page 13 of 21

14 Fig. 9: A 18-old-man with acute interstitial oedematous pancreatitis and acute peripancreatic, subhepatic pericolecystic, paraduodenal, paracolic fluid,pelvic collections(arrows). The pancreas enhances completely, is enlarged. Page 14 of 21

15 Fig. 10: Acute necrotizan collection in a 30 year-old man with acute necrotizing pancreatit involving only pancreatic tail. Note enhancement of the other sites of pancreas except from tail and heterogeneous collection which has a slightly greater attenuation non-liquid areas(arrow). Page 15 of 21

16 Fig. 11: A 69-old woman presented with acute interstitial pancreatitis(a). 1 week later her CE-CT demostrates that worsening of acute pancreatitis and increasing peripancreatic fluid collections(stars)(b,c). 1 month later at site of lesser sac there is a formation of pseudocyst(arrows). Page 16 of 21

17 Fig. 12: A 33-year old woman with pseudocyst after an episode of acute interstitial pancreatitis oc CT. Note well-circumscribed, homogeneous fluid collection, anteriorly compresses stomach(star). Page 17 of 21

18 Fig. 13: 51-year old woman presented with impairment of pancreas perfusion with peripancreatic fluid collections(a, b). After 1 weeks of the disease diffuse non-enhancing area of pancreas paranchyma consistent with acute necrotic collection with acute necrotizing pancreatitis(c). Two months later heterogenous, fully encapsulated collection is noted(walled-off necrosis). Non-liquid components of high attenuation in the collection are seen(arrows). Only pancreatic head enhances. Page 18 of 21

19 Fig. 14: A 60 year old man with walled-off necrosis(a,b). Note that a largely heterogeneous liquefied collection in the bed of the pancreas with non- liquid components representing areas of trapped fat(arrow). The percutaneous drainage catheter are seen in the areas of walled of necrosis(c,d). Page 19 of 21

20 Conclusion In our opinion, this classification will provide good communication between the clinicians and radiologist to predict the outcome of patients. After started to use common in daily practise, feedbacks between clinicians and radiologist make better understanding of this classifications and allow to compare practises in order to create new treatment roadmap. Furthermore, all radiologist should be aware of treatment options, can be done by interventional radiology. Personal information References 1.Harrison Textbook of Internal Medicine 18th ed Pdf. Chapter 313:Acute and Chronic pancreatitis. 2.Cecil Textbook of Internal Medicine 24th ed. Pdf.Chapter 146: Pancreatitis. 3. Balthazar EJ, Robinson DL, Megibow AJ, et al. Acute pancreatitis: value of CT in establishing prognosis. Radiology 1990;174(2): Bradley III EL. A clinically based classification system for acute pancreatitis.summary of the international symposium on acute pancreatitis, Atlanta, Ga, September 11 through 13, Arch Surg 1993;128 (5): Peter A Banks, Thomas L Bollen, Christos Dervenis, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus.gut2013; 62: Micheal G Sarr,Peter A Banks, Thomas L Bollen et al. The New Revised Classification of Acute Pancreatitis Surg Clin N Am 2013; Bollen TL, Singh VK, Maurer R, et al. A comparative evaluation of radiologic and clinical scoring systems in the early prediction of severity of acute pancreatitis. Am J Gastroenterol 2012;107: Page 20 of 21

21 8.N.Bharwani et al.acute pancreatitis: The role of imaging in diagnosis and management. Clinical Radiology ; VanSonnenberg E, Wittich GR, Casola G, et al. Percutaneous drainage of infected and noninfected pancreatic pseudocysts: experience in 101 cases. Radiology 1989;170(3 Pt 1): Lee MJ, Wittich GR, Mueller PR. Percutaneous intervention in acute pancreatitis. Radiographics 1998;18(3): Mortele KJ, Girshman J, Szejnfeld D, et al. CT-guided percutaneous catheter drainage of acute necrotizing pancreatitis: clinical experience and observations in patients with sterile and infected necrosis. AJR Am J Roentgenol 2009;192(1): Thoeni R. The Revised Atlanta Classification of Acute Pancreatitis: Its importance for the radiologist and its effect on treatment. Radiology 2012; 262(3) Page 21 of 21