急性胰腺炎并发症影像学评估

Complications of Acute Complications of Acute Pancreatitis: Radiologic Pancreatitis: Radiologic EvaluationEvaluation AllonAllon Beck, Harvard Medical School, Beck, Harvard Medical School, Year IIIYear III Gillian Lieberman, MDGillian Lieberman, MD January 2005Allon Beck, HMS III Gillian Lieberman, MD ObjectivesObjectives ŠŠ Anatomy of the pancreasAnatomy of the pancreas ŠŠ Overview of pancreatitisOverview of pancreatitis ŠŠ Role of imaging in pancreatitisRole of imaging in pancreatitis ŠŠ Illustrative cases with complicationsIllustrative cases with complications Allon Beck, HMS III Gillian Lieberman, MD 2 Pancreas anatomyPancreas anatomy Liver Gall Bladder Duodenum Allon Beck, HMS III Gillian Lieberman, MD Right and Left gastroepiploic arteries Stomach Pancreas Spleen Celiac trunk Common hepatic artery Splenic artery Superior Mesenteric Artery Aorta From Virtual Hospital: http://www.vh.org/adult/provider/anatomy/atlasofanatomy/ Left gastric artery 3 Anatomy cont’d: posterior viewAnatomy cont’d: posterior view Allon Beck, HMS III Gillian Lieberman, MD From Virtual Hospital: http://www.vh.org/adult/provider/anatomy/atlasofanatomy/ Spleen Liver Pancreas Duodenum IVC Splenic artery Splenic vein Inferior Mesenteric Vein 4 Acute PancreatitisAcute Pancreatitis ŠŠ Approx. 185,000 cases/yr in USApprox. 185,000 cases/yr in US ŠŠ 75% caused by 75% caused by EtOHEtOH and gallstonesand gallstones ŠŠ Other causes:Other causes: ŠŠ Drugs Drugs ((ddIddI, , metronidazolemetronidazole, , furosemidefurosemide, , valproicvalproic acid…)acid…) (2(2--5%)5%) ŠŠ HypertriglyceridemiaHypertriglyceridemia (>1000 mg/(>1000 mg/dLdL)) (1(1--4%)4%) ŠŠ HypercalcemiaHypercalcemia ŠŠ Infection Infection (Mumps, viral (Mumps, viral hephep, , coxsackieviruscoxsackievirus, , ascariasisascariasis)) ŠŠ Pancreas Pancreas divisumdivisum ŠŠ (Scorpion venom)(Scorpion venom) Allon Beck, HMS III Gillian Lieberman, MD 5 Patient 1: Patient SDPatient 1: Patient SD Allon Beck, HMS III Gillian Lieberman, MD 6 Patient SDPatient SD ŠŠ 58 58 y/oy/o F presents w/1 week of acute F presents w/1 week of acute epigastricepigastric pain, worse w/fatty foodspain, worse w/fatty foods ŠŠ PMHxPMHx: HTN, hypothyroidism, depression: HTN, hypothyroidism, depression ŠŠ SHxSHx: 30+ years : 30+ years EtOHEtOH abuseabuse ŠŠ PE: Temp: 99.8. No PE: Temp: 99.8. No organomegalyorganomegaly, , ascitesascites. O/W unremarkable. O/W unremarkable ŠŠ Labs: WNL except: WBC: 14.8; Amy: 215; Labs: WNL except: WBC: 14.8; Amy: 215; Lipase: >2000Lipase: >2000 ŠŠ U/S: Gallstones, no dilatation of CBD.U/S: Gallstones, no dilatation of CBD. Allon Beck, HMS III Gillian Lieberman, MD 7 DiagnosisDiagnosis ŠŠ HxHx: : EtOHEtOH and/or and/or cholelithiasischolelithiasis, previous , previous episodesepisodes ŠŠ Abdominal/Abdominal/epigastricepigastric pain +/pain +/-- radiation to radiation to backback ŠŠ Elevated serum lipase (amylase), Elevated serum lipase (amylase), leukocytosisleukocytosis, , hypocalcemiahypocalcemia, hyperglycemia, hyperglycemia Allon Beck, HMS III Gillian Lieberman, MD 8 Role of ImagingRole of Imaging Abdominal Plain Film Abdominal Plain Film ŠŠ Usually to Usually to r/or/o other causes of abdominal other causes of abdominal pain pain –– esp. perforated esp. perforated viscusviscus ŠŠ May show nonspecific focal May show nonspecific focal ileusileus due to due to irritation: “sentinel loop.”irritation: “sentinel loop.” Allon Beck, HMS III Gillian Lieberman, MD 9 Allon Beck, HMS III Gillian Lieberman, MD 10 From Pickhardt, Radiology: 2000 Coned-down Abdominal X-Ray Shows dilated colon with abrupt cutoff: Colon cutoff sign, indicative of inflammation Role of Imaging IIRole of Imaging II UltrasoundUltrasound ŠŠ Can show Can show cholelithiasischolelithiasis, dilated bile ducts, dilated bile ducts ŠŠ Absence of findings does not Absence of findings does not r/or/o gallstonegallstone-- induced pancreatitisinduced pancreatitis ŠŠ Findings do not clinch diagnosisFindings do not clinch diagnosis ŠŠ Pancreatitis associated with Pancreatitis associated with cholelithiasischolelithiasis usually warrants usually warrants cholecystectomycholecystectomy ŠŠ Limited by bowel gas, depth of pancreasLimited by bowel gas, depth of pancreas ŠŠ Endoscopic US can show Endoscopic US can show pseudocystpseudocyst Allon Beck, HMS III Gillian Lieberman, MD 11 Allon Beck, HMS III Gillian Lieberman, MD 12 Abdominal Ultrasound: Cholelithiasis Images from BIDMC PACS Findings: Multiple echogenic gallstones, no CBD dilatation. Pancreas poorly visualized Endoscopic US: Pancreatic Endoscopic US: Pancreatic PseudocystPseudocyst Allon Beck, HMS III Gillian Lieberman, MD 13 From: Digestive Disease Center, Medical University of South Carolina http://www.ddc.musc.edu/ Looking posteriorly from the fundus of the stomach Shows homogenously anechoic region with through-transmission, with poorly defined walls, consistent with a pseudocyst. Role of Imaging III: CTRole of Imaging III: CT ŠŠ Most commonly used modality to image Most commonly used modality to image pancreaspancreas ŠŠ Can accurately visualize pancreatitisCan accurately visualize pancreatitis-- induced changes:induced changes: ŠŠMinimal edemaMinimal edema ŠŠ PseudocystsPseudocysts ŠŠ HemorrhageHemorrhage ŠŠ NecrosisNecrosis ŠŠ Erosion into adjacent structuresErosion into adjacent structures Allon Beck, HMS III Gillian Lieberman, MD 14 Role of Imaging III: CT cont’dRole of Imaging III: CT cont’d ŠŠ Diagnostic changes can sometimes be Diagnostic changes can sometimes be visualized when serological tests are visualized when serological tests are negativenegative ŠŠ Major use: When diagnosis is uncertain or Major use: When diagnosis is uncertain or when complications are known or when complications are known or suspectedsuspected Allon Beck, HMS III Gillian Lieberman, MD 15 Patient SD’s CT:Patient SD’s CT: Allon Beck, HMS III Gillian Lieberman, MD 16 Allon Beck, HMS III Gillian Lieberman, MD 17 BIDMC PACS Patient SD’s CT: Cont’dPatient SD’s CT: Cont’d ŠŠ Findings: Findings: ŠŠ Distended GB (white arrows)Distended GB (white arrows) ŠŠ Extensive Extensive peripancreaticperipancreatic stranding and free stranding and free fluid (yellow arrows)fluid (yellow arrows) ŠŠ Pancreas enhances homogeneously: no Pancreas enhances homogeneously: no evidence of necrosis, hemorrhage, or evidence of necrosis, hemorrhage, or pseudocystpseudocyst ŠŠ CT Diagnosis: Mild pancreatitisCT Diagnosis: Mild pancreatitis Allon Beck, HMS III Gillian Lieberman, MD 18 A more severe case…A more severe case… Allon Beck, HMS III Gillian Lieberman, MD 19 Patient NAPatient NA ŠŠ 55 55 y/oy/o F presents with 2 days of 7/10 F presents with 2 days of 7/10 epigastricepigastric and RUQ pain, nausea, vomitingand RUQ pain, nausea, vomiting ŠŠ SHxSHx: Occasional : Occasional EtOHEtOH ŠŠ Labs included elevated Labs included elevated bilirubinbilirubin, elevated , elevated amylase and elevated lipase, WBC count amylase and elevated lipase, WBC count of 19.of 19. ŠŠ CT:CT: Allon Beck, HMS III Gillian Lieberman, MD 20 Patient Patient NA’sNA’s CTCT Allon Beck, HMS III Gillian Lieberman, MD 21 BIDMC PACS FindingsFindings ŠŠ IllIll--defined nondefined non--enhancing lowenhancing low--attenuation attenuation area in body of pancreas w/o defined wall area in body of pancreas w/o defined wall (blue circles)(blue circles) ŠŠ Marked Marked peripancreaticperipancreatic stranding (yellow stranding (yellow arrows)arrows) ŠŠ Dilated pancreatic duct (red arrow)Dilated pancreatic duct (red arrow) ŠŠ CT Diagnosis: Necrotizing pancreatitisCT Diagnosis: Necrotizing pancreatitis Allon Beck, HMS III Gillian Lieberman, MD 22 6 weeks later…6 weeks later… Allon Beck, HMS III Gillian Lieberman, MD 23 BIDMC PACS Large pseudocyst Role of Imaging IV: MRIRole of Imaging IV: MRI ŠŠ Better softBetter soft--tissue contrast than CTtissue contrast than CT ŠŠ Gadolinium contrast safer than iodine, Gadolinium contrast safer than iodine, safe in renal failuresafe in renal failure ŠŠ Some evidence iodine contrast can Some evidence iodine contrast can exacerbate pancreatitisexacerbate pancreatitis ŠŠ Better differentiation of subtle lesionsBetter differentiation of subtle lesions ŠŠ Better evaluation of residual tissue when Better evaluation of residual tissue when extensive necrosis has occurredextensive necrosis has occurred Allon Beck, HMS III Gillian Lieberman, MD 24 MRIMRI Allon Beck, HMS III Gillian Lieberman, MD 25 Images courtesy of Dr. Pedrosa T2WI Coronal Fat Sat T2 Coronal Fat Sat T2 Peripancreatic edema (bright on T2 – yellow arrows) Filling defect in bile duct (blue arrows) CT vs. MRICT vs. MRI Allon Beck, HMS III Gillian Lieberman, MD 26 Courtesy of Dr. Pedrosa Minimal edema around Gerota’s fascia (yellow arrow) CT vs. MRI cont’dCT vs. MRI cont’d Allon Beck, HMS III Gillian Lieberman, MD 27 Courtesy of Dr. Pedrosa Pancreatic duct dilatation (yellow arrow) Heterogeneous tail enhancement (green arrow) Late and heterogeneous tail enhancement (blue arrows) T2WI T2WI Arterial phase Allon Beck, HMS III Gillian Lieberman, MD 28 CT vs. MRI cont’d CT vs. MRI cont’d –– 6 weeks later6 weeks later Courtesy of Dr. Pedrosa T2WI Peripancreatic edema (yellow arrows) Less tail enhancement (green circle) Heterogeneous area between body and tail (blue arrow) Diagnosis: Necrotic pancreatitis, not seen on CT. CT vs. MRI cont’dCT vs. MRI cont’d Allon Beck, HMS III Gillian Lieberman, MD 29 Courtesy of Dr. Pedrosa CT: Large fluid collection displacing stomach anteriorly (blue arrows) Small area of parenchymal enhancement (red arrow) MR: Gallstones clearly visible (green arrow) Diffusely necrotic pancreatic parenchyma visible (yellow arrows) – not visible on CT MRCP: Patent pancreatic duct (orange arrow) – ERCP not necessary! – not visible on CT T2WICT MRCP MRI cont’d MRI cont’d –– evaluation of residual evaluation of residual pancreatic parenchymapancreatic parenchyma Allon Beck, HMS III Gillian Lieberman, MD 30 Courtesy of Dr. Pedrosa T2WI T2WI with contrast Left image: some pancreatic parenchyma (green arrows), no change with contrast – likely necrotic. Is any functional tissue left?... Allon Beck, HMS III Gillian Lieberman, MD 31 MRI cont’d MRI cont’d –– subtraction of subtraction of contrast and noncontrast and non--contrast imagescontrast images Courtesy of Dr. Pedrosa Most of pancreatic parenchyma is lost in subtraction (green arrows) – it has no blood supply and is necrotic. One small area remains (red arrow) that enhanced with contrast but not without – it has blood supply and is likely functional. ConclusionsConclusions ŠŠ Imaging is useful if diagnosis is unclearImaging is useful if diagnosis is unclear ŠŠ Ultrasound is used to evaluate for Ultrasound is used to evaluate for cholelithiasischolelithiasis, , begin begin w/uw/u for for cholecystectomycholecystectomy if indicatedif indicated ŠŠ CT with and without contrast if complications are CT with and without contrast if complications are suspected (severe or prolonged course), or to suspected (severe or prolonged course), or to f/uf/u known complicationsknown complications ŠŠ MR used if patient has iodine allergy or renal MR used if patient has iodine allergy or renal failure, or for subtle findings not ascertainable failure, or for subtle findings not ascertainable on CTon CT Allon Beck, HMS III Gillian Lieberman, MD 32 ReferencesReferences Virtual Hospital: http://www.vh.org/adult/provider/anatomy/atlasofanatomy/ Steer ML, Waxman I, and Freedman S. Medical Progress: Chronic Pancreatitis. N Engl J Med 1995; 332:1482-1490 Lee JKT, Lee JKT, SagelSagel SS, Stanly RJ (1989). SS, Stanly RJ (1989). Computed body tomography with Computed body tomography with MRI correlationMRI correlation. (Ch. 14: Pancreas) New York, Raven Press.. (Ch. 14: Pancreas) New York, Raven Press. BruggeBrugge WR, Van Dam J. Medical Progress: Pancreatic and WR, Van Dam J. Medical Progress: Pancreatic and BiliaryBiliary Endoscopy. Endoscopy. N N EnglEngl J Med J Med 1999; 341:18081999; 341:1808--18161816 BraunwaldBraunwald E. et al (2001). E. et al (2001). Harrison’s Principles of Internal Medicine, 15Harrison’s Principles of Internal Medicine, 15thth ed. ed. (Ch. 304: Acute and Chronic Pancreatitis.) McGraw(Ch. 304: Acute and Chronic Pancreatitis.) McGraw--Hill.Hill. PickhardtPickhardt PJ. Signs In Imaging: The Colon Cutoff Sign. PJ. Signs In Imaging: The Colon Cutoff Sign. Radiology.Radiology. 2000; 2000; 215: 387215: 387--389.389. Digestive Disease Atlas, Medical University of South Carolina: Digestive Disease Atlas, Medical University of South Carolina: http://www.ddc.musc.edu/ddc_pro/pro_development/atlases/EUS/benihttp://www.ddc.musc.edu/ddc_pro/pro_development/atlases/EUS/benign.htmgn.htm Allon Beck, HMS III Gillian Lieberman, MD 33 AcknowledgementsAcknowledgements ŠŠ Dr. Ivan Dr. Ivan PedrosaPedrosa ŠŠ Dr. Bettina Dr. Bettina SiewertSiewert ŠŠ Dr. Gillian LiebermanDr. Gillian Lieberman ŠŠ Pamela Pamela LepkowskiLepkowski ŠŠ Larry BarbarasLarry Barbaras Allon Beck, HMS III Gillian Lieberman, MD 34 Complications of Acute Pancreatitis: Radiologic Evaluation Objectives Pancreas anatomy Anatomy cont’d: posterior view Acute Pancreatitis Patient 1: Patient SD Patient SD Diagnosis Role of Imaging Slide Number 10 Role of Imaging II Abdominal Ultrasound: Cholelithiasis Endoscopic US: Pancreatic Pseudocyst Role of Imaging III: CT Role of Imaging III: CT cont’d Patient SD’s CT: Slide Number 17 Patient SD’s CT: Cont’d A more severe case… Patient NA Patient NA’s CT Findings 6 weeks later… Role of Imaging IV: MRI MRI CT vs. MRI CT vs. MRI cont’d CT vs. MRI cont’d – 6 weeks later CT vs. MRI cont’d MRI cont’d – evaluation of residual pancreatic parenchyma MRI cont’d – subtraction of contrast and non-contrast images Conclusions References Acknowledgements