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Serial Computed Tomography Scanning in Acute Pancreatitis: a Prospective Study

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Serial Computed Tomography Scanning in Acute Pancreatitis: a Prospective Study Gut: first published as 10.1136/gut.30.3.397 on 1 March 1989. Downloaded from Gt,t, 1989, 30, 397-403 Serial computed tomography scanning in acute pancreatitis: a prospective study N J M LONDON, J P NEOPTOLEMOS, J LAVELLE, I BAILEY, AND D JAMES From the Departments ofSurgery and Radiology, Clinical Sciences Building, Leicester Royal Infirmary, Leicester SUMMARY One hundred and two patients with acute pancreatitis had abdominal computed tomography (CT) scans within 72 hours of admission, at one week and at six weeks. Twenty eight attacks were clinically severe, 74 clinically mild. Ninety three (91%) admission scans, 85 (84%) one week scans, and 52 (51%) six week scans were abnormal. The aetiology of the pancreatitis could be inferred from 28 (27%) of admission scans, the CT sign offatty liver having a sensitivity of 21% and specificity of 100% for alcoholic aetiology. The sensitivity of CT for gall stone aetiology was 34%, specificity 100%. The pancreatic size indices (max anteroposterior measurement of headXmax anteroposterior measurement of body) of those patients with severe attacks were significantly greater than those with mild attacks on admission, at one week and at six weeks (p<0004). Fourteen pseudocysts were detected by CT, five (36%) of which were clinically apparent. The pseudocyst size indices (max anteroposteriorxmax transverse measurement) of the pseudocysts which were clinically apparent were significantly greater than those which were not apparent (p<0O01) and only those pseudocysts with a size index 3 15 cm2 required treatment. http://gut.bmj.com/ Although there have been numerous studies of CT pancreatitis was based on a serum amylase of greater scanning in acute pancreatitis, there have not been than 1000 IU/I (Phadebas Method) in the presence of any reports of serial CT scanning of the disease. The a compatible clinical picture. Computed tomography purpose of this prospective study was to obtain CT scans were done within 72 hours of admission, at one on October 4, 2021 by guest. Protected copyright. scans of patients with acute pancreatitis on admission week and at six weeks. All scans were done on a GE to hospital, at one week, and at six weeks and to 8800 scanner and reported 'blind' by a single con- thereby document the natural history of the local sultant radiologist. The admission scan consisted of disease process. We also wished to study the ability of a plain abdominal scan followed by a contrast- CT to diagnose acute pancreatitis and its local enhanced scan taking 10 mm contiguous cuts during complications and to compare the serial CT appear- an intravenous infusion of 100 ml Niopam 370. The ances of the pancreata of those patients with mild and one week and six week scans were not contrast severe attacks. enhanced. Pancreatic enhancement on the admission scan was defined as increased, normal or decreased Methods compared with the enhancement of the liver and spleen. It was noted for all scans whether there was PATIENTS loss of peripancreatic tissue planes and the maximum Patients admitted to the Leicester Royal Infirmary anteroposterior measurement (in centimetres) of the with a diagnosis of acute pancreatitis during the pancreatic head, body, and tail were recorded. These period May 1984 to December 1986 were referred for measurements were taken opposite the right hand abdominal CT scanning. The diagnosis of acute border of the lumbar vertebrae, the left hand border of the aorta and the left renal hilum respectively. The Address for correspondence: Mr N J M Londoni, Dept of Surgery. I elcester measurements from 50 scans were repeated by an Royal Infirmary, PO Box 65, Leicester LE2 7LX. independent observer in order to determine their Accepted for publication 25 August 1988. reproducibility. The 'pancreatic size index' was 397 Gut: first published as 10.1136/gut.30.3.397 on 1 March 1989. Downloaded from 398 London, Neoptolemos, Lavelle, Bailey, and James calculated as previously described' (the product of Table 1 Details ofallpatients admitted during the study the head and body measurements, cm2). The visual- period and ofthose who did and did not have a series ofthree isation of the pancreas was recorded as good, fair, CTscans or poor. The presence or absence of gall stones and any other pertinent abnormalities were noted. If All patients Scannedx3 Not scannedx3 a pancreatic was present then the pseudocyst Patients (n) 152 (1)0) 102 (67) 50 (33) maximum anteroposterior and transverse measure- Median age (range), yrs 64 (19-9t)) 62 (25-90) 63 (19-88) ments were taken (centimetres). The product Clinical severity of these two measurements was defined as the Severe 45 3)) 28* (27) 17* (34) Mild 1t)7 (70) 74 (73) 33 (66) 'pseudocyst size index'. A severe outcome from Deaths 13 (9) It (1) 12t (24) pancreatitis was defined as death or a major systemic Men 77 (51) 56 (55) 21 (42) or local complications. The diagnosis of gall stone Women 75 (49) 46 (45) 29 (58) pancreatitis was based on the findings of gall stones Aetiology of pancreatitis Biliary 90 (59) 62 (60) 28 (56) at laparotomy, necropsy, or their unequivocal Alcohol 32(21) 19(18) 13 (26) detection by ultrasonography or ERCP. The absence Idiopathic 16(11) 1) (12) 6(12) of gall stones was based on at least three ultrasound Ca pancreas 3 (2) 3(3) examinations and one ERCP. Post E sphincterotomy 3(2) 3(3) t) Hyperlipidemia 2(1-3) 2(2) Continuous variables were analysed by the two- Polyarteritis nodosa 1 ()-8) 1(1) tailed Mann-Whitney U test for unpaired data and by Parathyroidectomy 2 (13) I(1) 1(2)I() I()(2) the Wilcoxon's matched-pairs signed-rank test for Systemic lupus I ()-8) 1 (2) paired data. Discrete variables were analysed by the Trauma 1 ()-8) X2 test with Yates's correction when the expected Figures in parentheses are percentages. number of observations was small. Sensitivity and *Not significant, X2; tp<0-0()1. specificity were calculated as described by McNeil et al.2 Statistical significance was assumed to be p<005. Table 2 Major complications ofpatients with severe attacks Results ofpancreatitis One hundred and fifty two patients with acute Complicationi Patients (n) http://gut.bmj.com/ pancreatitis were admitted to the Leicester Royal the 31 month of the Respiratory failure 8 Infirmary during period study. Renal failure 4 One hundred and two patients (67%) completed Pancreatic abscess 5 (1)* a series of three abdominal CT scans. All the Pseudocyst 5 'admission scans' were obtained within 72 hours. The Pneumonia 3 ,one week' scans were done seven to 10 after Pseudo-obstruction I days Duodenal obstruction I admission, the 'six week' scans at 40-46 days. The D. intravascular coagulation I on October 4, 2021 by guest. Protected copyright. details of all patients admitted during the study period and of those patients who did and did not (1)* One patient with a pancreatic abscess died. complete a series of three CT scans are given in Table 1. The major complications of those patients with severe attacks of pancreatitis and a comparison of the Table 3 Comparison ofthe details ofthose patients with details of the severe and mild groups amongst the 102 mild and severe attacks ofpancreatitis amongst the 102 patients who had a series of three CT scans are given patients who had three CT scans in Tables 2 and 3. Figure 1 and Tables 4 and 5 Clinical severits document the CT findings on admission, at one and at six weeks. It can be seen that only six (6%) patients Severe (n =28) Mild (n= 74) had CT scans which remained normal for admission through to six weeks. All six patients had an Patients (n) 28 (27-4) 74 (72-6) Median age (range), yrs 685 (27t-90-t) 58t) (25t-90t0)) admission serum amylase of >2000 IU/I, the Men 12 (43) 44 (59) aetiology of the pancreatitis was biliary in three, Women 16 (57) 3) (51) idiopathic in two and alcohol in one. Two of the three Aetiology of pancreatitis patients with biliary pancreatitis had an endoscopic Biliary 14 (50) 48 (65) Alcohol 8 (29) 11 (15) sphincterotomy for common bile duct stones. There Idiopathic 1 (3) 7 (9) did not appear to be any doubt about the clinical Others 5 (18) 8 (11) diagnosis of pancreatitis in any of these six patients. The aetiology of pancreatitis could be inferred Figures in parentheses are percentages. Gut: first published as 10.1136/gut.30.3.397 on 1 March 1989. Downloaded from Serial computed tomography scanning in acute pancreatitis: a prospectivestudy 399 Abnormal Normal There were five patients who developed pancreatic Admission 9 abscesses. Three of these were diagnosed by CT, two 10 3 on the basis of metastatic hepatic abscesses and one on the basis of adjacent abdominal wall oedema. 1 week scan 86 16 Intrapancreatic gas was not seen in any of the five 1-34 1 cases of pancreatic abscess. There were 14 pseudo- cysts diagnosed by CT, five (36%) of which were 6 weeks scar. 52 50 clinically apparent. The timing of appearance and 51 series of scans remained abnormal regression of these pseudocysts is illustrated in Figure from adrnission to six weeks. Six series of scans remained normal from 3. The pseudocyst size indices of the pseudocysts admission to six weeks. which were clinically apparent were significantly Fig. Number ofabnormal and normal CT scans on greater than those which were not (p<0-01, Mann- admission, at one week and at six weeks (n= 102). Table 5 Details ofabnormal admission, one week and six weeks scans from 28 (27%) of admission scans. The sensitivity for gall bladder stones was 21/62=34%, the specificity Admissionl 40/40= 100%.
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