Gregory T. Sica

Relationship of necrosis to organ failure in severe acute pancreatitis.

BACKGROUND & AIMS Pancreatic necrosis and organ failure are principal determinants of severity in acute pancreatitis. The purpose of this study was to determine the relationship of necrosis to organ failure in severe acute pancreatitis. METHODS Patients with necrotizing pancreatitis from May 1992 to January 1996 were retrospectively studied. Pancreatic necrosis was identified by characteristic findings on dynamic contrast-enhanced computerized tomography scan and infected necrosis by computerized tomography-guided percutaneous aspiration. Organ dysfunction was defined in accordance with the Atlanta symposium. RESULTS Organ failure was present in only 26 of 51 patients (51%). There was no difference in the prevalence of organ failure in infected necrosis compared with sterile necrosis (approximately 50% in both groups). Patients with increased amounts of necrosis did not have an increased prevalence of organ failure or infected necrosis compared with those with lesser amounts of necrosis. Patients with organ failure had an increased morbidity and mortality compared with those without organ failure. CONCLUSIONS Organ failure occurred in only one half of patients with necrotizing pancreatitis. Because organ failure increases the severity of illness, studies of patients with necrotizing pancreatitis must stratify for organ failure to facilitate interpretation of results.

Is severity of necrotizing pancreatitis increased in extended necrosis and infected necrosis

Introduction We previously reported that organ failure occurs in 50% of patients with necrotizing pancreatitis, that extended pancreatic necrosis (greater than 50% necrosis) is not associated with an increased prevalence of organ failure or infected necrosis, and that the prevalence of organ failure is similar in sterile necrosis and infected necrosis. Aims To analyze these relations in a larger group of patients and to evaluate other factors that might have prognostic significance. Methodology We reviewed 1,110 consecutive cases of acute pancreatitis between January 1, 1995, and January 1, 2000. Necrosis was documented by contrast-enhanced CT. A p value less than 0.05 was considered significant. Results Ninety-nine patients (9%) had necrotizing pancreatitis; 52% had organ failure. Patients with extended pancreatic necrosis did not have increased prevalence of organ failure or infected necrosis but did have an increased need for intubation and an increased mortality rate associated with multiple organ failure. Patients with infected necrosis did not have an increased prevalence of organ failure but did have a marginally increased prevalence of multiple organ failure and increased need for intubation. Overall mortality was 14% and was markedly increased among patients with organ failure at admission (47%) and among patients who had multiple organ failure during the hospitalization (49%). Conclusion Although severity of necrotizing pancreatitis was somewhat increased in extended pancreatic necrosis and infected necrosis, mortality was more strongly linked to organ failure at admission and multiple organ failure during hospitalization.

CT-guided aspiration of suspected pancreatic infection

SummaryWe have performed CT-guided percutaneous needle aspiration in 104 patients with severe pancreatitis strongly suspected of harboring pancreatic infection on the basis of systemic toxicity and CT findings (Balthazar CT grade D or E). Of these 104 patients, 51 (49%) were documented with pancreatic infection. Gram stain was positive in 54 of 58 infected aspirates, and culture was positive in all 58. Klebsiella,Escherichia coli, andStaphylococcus aureus were the most frequent organisms. Eighty-six percent of infected processes contained only one organism. Overall, pancreatic infection was documented by GPA within the first 2 wk in approx one-half of patients. There were no complications. The overall rate of infection decreased from 60 (1980–1987) to 34% (1988–1995) (p=0.01). This change was caused by a reduction in the rate of infected necrosis from 67 to 32% (p=0.015). The overall mortality rate remained at 20%. The mortality of sterile pancreatitis was not different from infected pancreatitis (p=0.14). We conclude that GPA is a safe, accurate method of diagnosis of pancreatic infection. The rate of pancreatic infectoon appears to be decreasing. The overall mortality of severe pancreatitis among patients suspected of harboring pancreatic infection has remained unchanged because of the high mortality associated with both infected necrosis and severe sterile necrosis.

Does mortality occur early or late in acute pancreatitis

SummaryAbstract: Several prior studies have suggested that 80% of deaths in acute pancreatitis occur late as a result of pan-creatic infection. Others have suggested that approx half of deaths occur early as a result of multisystem organ failure. The aim of the present study was to determine the timing of mortality of acute pancreatitis at a large tertiary-care hospital in the United States.Methods: Patients with a diagnosis of acute pancreatitis (ICD-9 code 577.0) admitted to Brigham and Women’s Hospital from October 1, 1982 to June 30, 1995 were retrospectively studied to determine total mortality, frequency of early vs late deaths, and clinical features of patients with early (≤14 d after admission) or late deaths (>14 d after admission).Results: The overall mortality of acute pancreatitis was 2.1% (17 deaths among 805 patients). Eight deaths (47%) occurred within the first 14 d of hospitalization (median d 8, range 1–11 d), whereas 9 occurred after 14 d (median d 56, range 19–81). Early deaths resulted primarily from organ failure. Late deaths occurred postoperatively in 8 patients with infected or sterile necrosis and 1 patient with infected necrosis treated medically. Conclusion: Approximately half of deaths in acute pancreatitis occur within the first 14 d owing to organ failure and the remainder of deaths occur later because of complications associated with necrotizing pancreatitis. Improvement in mortality in the future will require innovative approaches to counteract early organ failure and late complications of necrotizing pancreatitis.

Magnetic resonance imaging in patients with pancreatitis: Evaluation of signal intensity and enhancement changes

To evaluate the utility of unenhanced and enhanced T1‐weighted fat‐suppressed (T1‐FS) magnetic resonance imaging (MRI) in detecting pancreatitis.

Imaging of cystic diseases of the pancreas

Although the majority of cystic lesions of the pancreas seen in clinical practice represent postinflammatory pseudocysts, it is important for the radiologist to be knowledgeable of the wide spectrum of cystic masses of the pancreas and the variable prognoses they possess. As a result of similarities in the imaging features of these lesions, a definitive diagnosis is often not possible. By combining imaging features with clinical history, a reasonable differential diagnosis can be offered to the referring physician. In some cases, biopsy or fluid aspiration may be required prior to surgery. In a patient without the appropriate history of pancreatitis and the presence of a cystic pancreatic mass, it is incumbent upon the radiologist to offer alternative diagnoses of cystic neoplasms of the pancreas.

MR imaging evaluation of renal cell carcinoma

Abstract.Background: This study examines the minimally required imaging protocol needed for detection and staging of renal cell carcinoma (RCC). Methods: In 81 patients (21 women, 60 men; mean age = 62 years) with 85 RCCs, T1-weighted (T1WI), contrast-enhanced T1-weighted (Gd-T1WI), T2-weighted (T2WI), and gradient recalled echo–fast low flip angle shot (GRE/FLASH) images were evaluated alone and in combination. Surgical–pathological findings were available in all patients and were considered the standard of reference. Results: Tumor detection for lesions smaller than 3 cm was better on Gd-T1WI than on any other sequence, but only the comparison with noncontrast T1WI and GRE/FLASH was statistically significant (detection: T1WI = 33%, Gd-TIWI = 80%, T2WI = 60%, GRE = 47%). The respective accuracies of T1WI, Gd-T1WI, T2WI, and GRE/FLASH images were 81%, 78%, 71%, and 62% for evaluating local tumor extension; 90%, 88%, 89%, and 85% for lymphadenopathy; and 89%, 81%, 91%, and 95% for renal vein thrombus. The combination of T1WI and GRE sequences rendered the highest overall staging accuracy. Conclusion: For tumor detection, contrast-enhanced T1WI is necessary for lesions smaller than 3 cm. For tumor staging, although the addition of GRE results in significant improvement in the evaluation of venous thrombus, any combination of two sequences will result in similar accuracy, and the use of multiple sequences is not necessary.

Computed tomography and magnetic resonance imaging of hepatic metastases.

The detection and characterization of liver metastases is well performed with either computed tomography or magnetic resonance imaging. The administration of intravenous contrast is essential for almost all indications, with multiphasic imaging aiding in lesion characterization and detection. The use of multidetected CT (MDCT) provides the ability for optimized vascular and multiplanar imaging, but has also resulted in increased examination complexity. Tissue-specific MR contrast agents can yield the highest rate of lesion detection and thus may be useful in presurgical planning.

Isolated Calf Vein Thrombosis

Abstract Rationale and Objectives The authors performed this study to compare magnetic resonance (MR) venography and conventional venography in the diagnosis of deep venous thrombosis (DVT) in the calf after sonography. Materials and Methods Sonography was performed in 595 patients who were suspected of having lower-extremity DVT. Patients with positive above-knee duplex sonograms, allergy to iodinated contrast material, renal insufficiency, or cardiac pacemakers and patients who were obese were excluded. The remaining 73 patients were asked to undergo MR venography and conventional venography. All studies were to be performed within 48 hours of the clinical diagnosis and according to standard clinical practice. Images were interpreted by radiologists who were blinded to the results of other modalities. Two separate analyses were performed: one in which conventional venography was used as the standard of reference, and one in which the presence of at least two positive studies for thrombus was considered diagnostic. Results Although 36 patients agreed to participate in the study, only 14 underwent MR venography and conventional venography within 48 hours of the clinical diagnosis. With use of any two positive studies for confirmation, acute DVT was diagnosed in three patients. Conventional venography depicted two of the three cases, whereas sonography and MR venography each depicted all three. The findings were concordant in only five of the 14 patients. Conclusion Moderate discrepancy among modalities was demonstrated. This suggests radiologists should undertake comparisons among these three modalities for the detection of calf DVT. In patients with a high clinical suspicion, a second modality may be useful if the initial study is negative.

Von Hippel-Lindau disease complicated by acute pancreatitis and Evan’s syndrome

SummaryVon Hippel-Lindau syndrome (VHL) is an autosomal dominant disorder characterized by renal cysts, retinal angiomas, central nervous system hemangioblastomas, and pancreatic cysts. Evan’s syndrome is a hematologic disorder characterized by autoimmune thrombocytopenia and autoimmune hemolytic anemia. We present the first case of acute pancreatitis and Evan’s syndrome that developed in a patient with von Hippel-Lindau syndrome.