V W Wing

Pancreatic abscess: Impact of computerized tomography on early diagnosis and surgery☆

Pancreatic abscess continues to be a lethal complication of acute pancreatitis, with mortality rates of 40 percent in recent surgical series. A major factor contributing to this high mortality has been delay in diagnosis. When combined with diagnostic needle aspiration, computerized tomographic scanning has greatly enhanced the early detection of pancreatic abscesses. In a 4 year period at our institutions, 21 patients with proved pancreatic abscesses were evaluated early in their clinical course by computerized tomography. On follow-up ranging from 7 months to 3 1/2 years, there were only four deaths for a mortality rate of 19 percent. Many of the surviving patients had a long and protracted clinical course (mean length of hospitalization was 56 days) and reoperation for recurrent abscess or gastrointestinal complications was required in eight patients (38 percent). Computerized tomography proved to be of considerable value in localizing the site of de novo or recurrent pancreatic abscess and in detecting postoperative complications. An aggressive approach encompassing early computerized tomographic scanning with diagnostic needle aspiration appears to be a factor in the improved survival rate of these patients.

Computed tomography of blunt trauma to the gallbladder.

The CT findings are reviewed in two patients with injuries to the gallbladder following blunt abdominal trauma. In one patient with a laceration of the cystic artery a large intraluminal clot was identified within the gallbladder associated with extensive hemoperitoneum. Another patient presented with extensive bile leakage into the peritoneal cavity 72 h after blunt trauma due to laceration of the fundus of the gallbladder. The clinical features of blunt trauma to the gallbladder and the utility of CT in this entity are reviewed.

Computed tomography and plain film appearance of a bony sequestration: significance and differential diagnosis

Bony sequestration has been reported in osteomyelitis, eosinophilic granuloma, and fibrosarcoma. Thirty-eight examples of radiographically apparent bony sequestra were collected to examine the validity of this differential diagnosis. Apparent sequestra were found in osteomyelitis (59%), fibrosarcoma or fibrosarcoma-like entities (13%), eosinophilic granuloma (8%), and osteoid osteoma (21%). Although osteoid osteoma does not contain a true bony sequestrum, the partially calcified nidus was radiographically mistaken for a sequestrum in eight (21%) of our cases and, therefore, should be considered when an apparent sequestrum is visualized. Computed tomography enhanced visualization of a sequestrum in 19 of 22 cases and is recommended as an adjunct to conventional radiography when the presence of a sequestrum will alter therapy.

Ultrasound in acute pancreatic trauma.

The ultrasound findings are reviewed in 4 patients with surgically proven acute pancreatic trauma. Despite technically adequate sonograms, pancreatic injuries were not prospectively diagnosed in any of the patients. Computed tomography (CT) performed shortly after ultrasound demonstrated changes of traumatic pancreatitis in each case. Because of the subtlety of the ultrasound findings, CT appears to be the preferred method for evaluating suspected pancreatic trauma.

Improved survival with early CT diagnosis of pancreatic abscess

Until recently pancreatic abscess was often a lethal complication of acute pancreatitis. A major factor contributing to this high mortality has been delay in diagnosis. When combined with diagnostic needle aspiration, computed tomography (CT) has greatly enhanced the early detection of pancreatic abscesses. In the past 5 years at our institutions 23 patients with proven pancreatic abscesses were evaluated early in their clinical course by CT. In follow-up ranging from 4 months to 4 1/2 years there were only 4 deaths: a mortality rate of 17%. Many of the surviving patients had a long and protracted clinical course (mean length of hospitalization, 58 days) and reoperation for recurrent abscess or gastrointestinal complications was required in 9 patients (39%). Computed tomography proved helpful both in localizing the site of de novo or recurrent pancreatic abscess and in detecting postoperative complications. An aggressive approach to early CT scanning with diagnostic needle aspiration appears to be a factor in the improved survival of these patients.

Computed tomography of thick-walled gallbladder mimicking pericholecystic fluid

We have recently encountered four patients in whom pericholecystic fluid was suspected on CT. However, sonography revealed only a thick-walled gallbladder. Helpful clues to avoid this potential interpretive pitfall are described.