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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1649_Библиотеки_им_академика_М_И_Перельмана.pdf
Radiology of Acute Pancreatitis and Its Complications
161
Figure 9. Contrast-enhanced CT – coronal reconstruction: pseudoaneurysm of inferior
pancreaticoduodenal artery.
Endovascular techniques utilized include coiling, covered stent exclusion,
thrombin injection, gel-foam injection, gluing, plug deployment, particle
injection, and polyvinyl alcohol injection. Transabdominal coiling and
thrombin injection under ultrasound or fluoroscopic guidance have also been
employed [22].
The endovascular approach to pancreatitis-associated pseudoaneurysms
depends on the location and morphology of the pseudoaneurysm [29]. In cases
where the configuration of the pseudoaneurysm neck is suboptimal or where
there is a high risk of non-target embolization, a covered stent can be placed to
exclude the pseudoaneurysm from the circulation.
Stent-graft implantation is usually limited to straight and proximal
segments of visceral arteries.
Liquid embolic material (Onyx) has also been used for treatment of
haemorrhage caused by pancreatitis [50].
Kamil Zeleňák and Martin Števík
162
Figure 10. CTA (CT angiography) – VRT (volume rendering technique) confirmed
pseudoaneurysm of inferior pancreaticoduodenal artery.
Image-guided intervention has an important role in the management of
late complications of acute pancreatitis which significantly add to the degree
of morbidity. Image-guided drainage procedures have been found to be an
effective alternative to surgical debridement in patients with pancreatitis-
associated complications [37]. Indications for drainage include: symptomatic
collections which are exerting mass effect, causing pain or have become
infected [46].
Pseudocysts larger than 5 centimetres that have been present for longer
than six weeks, are unlikely to resolve spontaneously [34]. According to a
recent study, compared with percutaneous drainage, endoscopic drainage of
symptomatic pancreatic fluid collections was associated with higher rates of
treatment success, and lower rates of reintervention, including surgery and
shorter lengths of hospital stay [30].
Endoscopic Retrograde Cholangiopancreatography
Because of its risks this is not indicated in mild biliary acute pancreatitis.
In contrast, an absolute indication is acute biliary pancreatitis and cholangitis.
An MRCP is preferred to view an anatomy and abnormalities of the biliary
tract and pancreatic duct.
Radiology of Acute Pancreatitis and Its Complications
163
Figure 11. Angiography of superior mesenteric artery: pseudoaneurysm of inferior
pancreaticoduodenal artery before embolization.
Figure 12. Angiography of superior mesenteric artery: pseudoaneurysm of inferior
pancreaticoduodenal artery after embolization.
Kamil Zeleňák and Martin Števík
164
Figure 13. 5-year follow-up magnetic resonance – T1−WI fat-suppressed technique:
complete occlusion of treated PSA without recanalization. Implanted coils are
hypointense (arrow).
COMPLICATIONS OF ACUTE PANCREATITIS
In addition to systemic complications, such as respiratory, cardiac, renal
failure and other biochemical and coagulation disorders, other local
complications may also occur in acute pancreatitis. Local complications are
classified by their content of pure fluid, and those containing a proportion of
solid content. Distinction is made between an acute collection which does not
have a demarcated and clearly defined wall and a collection bounded by
inflammatory granulation and fibrotic wall. Another complication could be
haemorrhage, formation of pseudoaneurysm and venous thrombosis.
Radiological description should include the presence or absence of local
complications [35].
Fluid Collections
Acute pancreatic fluid collection (APFC): collections of enzyme-rich
pancreatic juice develop around the pancreas as a result of interstitial
pancreatitis without necrosis in the first 4 weeks of illness. Most of them
Radiology of Acute Pancreatitis and Its Complications
165
remain sterile and gradually disappear spontaneously in 50% of cases.
Location may by intrapancreatic, anterior pararenal space, lesser sac or
anywhere in the abdomen, in solid organs or in the chest.
Pseudocyst: not reabsorbed APFC inflammatory circumscribed wall after
4 weeks of onset of the disease arises rupture of the pancreatic duct and
therefore has a high amylose content. It may arise in terrain of interstitial as
well as necrotic acute pancreatitis. Pseudocysts present as rounded, well-
encapsulated fluid collections of varying attenuation (0−25 HU). There is
contrast encement in the cyst wall, septations are uncommon. Most frequently
pseudocysts are located close to the pancreas, but may also be found in the
liver, spleen or mediastinum. Some of them will require a catheter or surgical
drainage [18].
Solid, Semi-Solid Locoregional Complications
The Atlantic revised classification distinguishes between acute necrotic
collection and walled-off necrosis. They develop in the field of necrotic acute
pancreatitis 4 or more weeks after the onset of the disease [49].
Acute necrotizing collection − necrotic material includes pancreatic and/or
peripancreatic materials and variable amounts of liquid material.
Walled-off necrosis − necrotic collection of the pancreatic and / or
peripancreatic tissue, with the radiologically clearly marked wall.
The infection – abscess (most often from the gastrointestinal tract) occurs
in one-third of cases with severe acute pancreatitis. Diagnosis is either
radiological, gas bubbles in the peripancreatic region or by fine needle
aspiration (FNA) of the necrotic material [38].
Thrombosis splenic and the portal vein and spleen lesions − their
consequence is prehepatic portal hypertension. Spleen lesions include fluid
collections inside the spleen, pseudocysts, vascular injury, infarction or
haemorrhage.
Haemorrhage - occurs due to erosion of blood vessels (pancreatic
duodenal artery, splenic artery branch) by extravasation of proteolytic enzyme.
CT occasionally shows a circumscribed peripancreatic fluid collection of high
attenuation of more than 60 HU. Possible treatment could be embolization.
Pseudoaneurysm – autodigestion of arterial walls by pancreatic enzyme,
mass is lined by fibrous tissue and communicates with parent artery
(Figure 14).
Kamil Zeleňák and Martin Števík
166
Extrapancreatic complications could be ileus, bowel ischaemia,
gastroparesis, pseudoaneurysm, cholecystitis, fluidothorax or ascites.
Figure 14. Axial (A) and coronal (B) CT image of interstitial oedematous pancreatitis
in a 52-year-old man. CT shows normal enhancement of the pancreas (asterix) with a
fluid collection extending into both anterior pararenal compartment and the root of the
transverse mesocolon (white arrows). Acute peripancreatic fluid collection (<4weeks).
The fluid collection lacks a well-defined wall and conforms to the anatomic space in
which it arises. The acute peripancreatic fluid collection resolved spontaneously. (B)
CT shows also pancreatitis-associated pseudoaneurysms (black arrow). Grade D
(Balthazar), modified CTSI 6 - moderate acute pancreatitis.
Radiology of Acute Pancreatitis and Its Complications
167
THERAPY
All forms of acute pancreatitis are a serious illness. Besides drugs therapy,
supportive and in indicated cases surgical treatment, interventional radiology
also has its unique place. Infected pancreatic necrosis remains the most
important indication for intervention to prevent the development of sepsis,
which is the most common cause of death in acute pancreatitis (Figure 15).
The ideal procedure is percutaneous retroperitoneal drainage under
radiological control or transluminal endoscopic drainage [11]. If this procedure
is unsuccessful or insufficient, the flow returns to the least invasive
necrosectomy and the last one the opened necrosectomy. It is recommended to
wait a minimum for four weeks from the onset of the disease, before drainage
or necrosectomy. Interventions in acute pancreatitis without a proven
pancreatic infection are indicated 1: in the event of obstruction of the stomach,
colon and biliary tract; 2: syndromes of interrupted pancreatic duct; 3: rare
cases of bleeding, intestinal ischaemia, or abdominal compartment syndrome
[44].
Figure 15. Axial CT image. Several peripancreatic fluid collections (black asterix)
were seen on a CT scan of the abdomen in a 38-years-old male patient with
complicated acute pancreatitis, ascites (AS). Seven weeks after onset the percutaneous
drainage procedures of peripancreatic fluid collection was performed (arrow). CT
image-guided drainage procedures have been found to be an effective alternative to
surgical debridement in patients with pancreatitis-associated complications. Indications
for drainage was infected collection between stomach and liver with mass effect (white
asterix).
Kamil Zeleňák and Martin Števík
168
After overcoming biliary AP, cholecystectomy is indicated six weeks from
the beginning of severe acute pancreatitis in order to prevent a recurrence.
However, the shortest possible interval is recommended after overcoming mild
biliary AP [6].
CONCLUSION
In the diagnosis of acute abdomen, normal pancreas and normal
retroperitoneal structures on the contrast enhanced computed tomography
exclude a serious form of acute pancreatitis [31]. For patients over 40 years at
the first episode of acute pancreatitis a CT scan should be realized in order to
exclude tumour lesion [12]. The differential diagnosis should be pancreatic
lymphoma (subtype non-Hodgkin’s lymphoma), ulcer perforation of the
stomach back wall, pancreatic ductal adenocarcinoma. Universal and clearly
anchored classification is essential for communication between clinicians and
radiology. Prognostic indicators and systems enabling faster recognition of
symptoms of developing severe acute pancreatitis are factors contributing to
the reduction of the proportion of fatal disease progression [45]. Minimally
invasive interventional procedures are the methods of choice, and they are
used to avoid complications and risks associated with open surgery.
ACKNOWLEDGMENTS
Acknowledgements of the author MŠ: This work was supported with the
project “PACS system in Research and Develpoment,” ITMS code:
26210120004, co-financed from EU sources (ERDF).
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