Necrotizing Pancreatitis: Diagnosis, Imaging, and Intervention

Abstract

Acute necrotizing pancreatitis is a severe form of acute pancreatitis characterized by necrosis in and around the pancreas and is associated with high rates of morbidity and mortality. Although acute interstitial edematous pancreatitis is diagnosed primarily on the basis of signs, symptoms, and laboratory test findings, the diagnosis and severity assessment of acute necrotizing pancreatitis are based in large part on imaging findings. On the basis of the revised Atlanta classification system of 2012, necrotizing pancreatitis is subdivided anatomically into parenchymal, peripancreatic, and combined subtypes, and temporally into clinical early (within 1 week of onset) and late (>1 week after onset) phases. Associated collections are categorized as "acute necrotic" or "walled off" and can be sterile or infected. Imaging, primarily computed tomography and magnetic resonance imaging, plays an essential role in the diagnosis of necrotizing pancreatitis and the identification of complications, including infection, bowel and biliary obstruction, hemorrhage, pseudoaneurysm formation, and venous thrombosis. Imaging is also used to help triage patients and guide both temporizing and definitive management. A "step-up" method for the management of necrotizing pancreatitis that makes use of imaging-guided percutaneous catheter drainage of fluid collections prior to endoscopic or surgical necrosectomy has been shown to improve clinical outcomes. The authors present an algorithmic approach to the care of patients with necrotizing pancreatitis and review the use of imaging and interventional techniques in the diagnosis and management of this pathologic condition.

Revised Atlanta Classification for Acute Pancreatitis: A Pictorial Essay

“…A detailed discussion of these complications is beyond the scope of this article, as their evaluation is not specified under the revised Atlanta classification. We direct the reader to other excellent publications that describe these complications (25). Figure 14.…”

Hemorrhagic-Necrotizing Pancreatitis – An Unusual Complication of Mediterranean Spotted Fever

“…It is subdivided anatomically into parenchymal, peripancreatic, and mixed subtypes, and based on clinical progression over time -into early and late clinical phases [4]. The early clinical pancreatitis is associated with a high rate of morbidity and mortality, which is most often due to systemic inflammatory response syndrome (SIRS), associated with systemic organ dysfunction and organ failure [5].…”

“…Аcute pancreatitis is diagnosed primarily on the basis of signs, symptoms, and laboratory tests. It is defined clinically as a disorder that includes epigastric in location and radiating to the back abdominal pain, with serum amylase (or lipase) levels more than three times the normal [5]. If these findings are present, some authors consider that imaging is not necessary to make the diagnosis, because its role is limited during the early phase [5].…”

“…It is defined clinically as a disorder that includes epigastric in location and radiating to the back abdominal pain, with serum amylase (or lipase) levels more than three times the normal [5]. If these findings are present, some authors consider that imaging is not necessary to make the diagnosis, because its role is limited during the early phase [5]. In the 2 nd case of our report, acute pancreatitis was suspected due to the presence of abdominal tenderness and a very high level of serum amylase.…”

Imaging of Acute Pancreatitis

“…ANCs resolve spontaneously in 20% of patients, become superinfected in about 20%, and develop into sterile WONs (see later discussion) in approximately 60%. 42,43 Walled-off necrosis In the subacute phase of necrotizing pancreatitis, the ANC evolves over time into a WON. A thickened, nonepithelialized wall that surrounds the collection containing fluid and nonliquid material defines the interface between the viable fat and the necrosis.…”