Case 21 -  Pancreatitis with necrosis

This is a case of extensive pancreatits.  The entire pancreas is enlarged.  There is a massive amount of peripancreatic stranding:

• There is stranding in the lesser sac.
• Gerota's fascia is thickened on the left and right. 
• Stranding extends into the root of the mesentery (surrounding the SMA and SMV)
• Stranding in the porta hepatatis.
• Stranding in the pericholecytstic region.  

You can see several small stones in the gall bladder.  A layering hyperdensity suggests a sludge-bile level.  The the common duct appears within normal limits.

The amylase was 1218 and the lipase was 5488 so the clinicians knew he had pancreatitis.  What does this scan add?  The splenic and portal veins remain patent.  The celiac axis and SMA are intact without pseudoaneurysm.  These vessels are at risk given the extensive inflammation that surrounds them.  However, parts of the pancreas show decreased enhancement.  This is the appearance of necrotizing pancreatisis.  I changed the windows to accentuate the finding. Necrotizing pancreatitis has a higher morbidity than noncomplicated pancreatitis.  The ordering physician will want to be aware of this finding.  It will likely change the way they monitor the patient.

Ultrasound confirmed the sludge but did not see any stones.  Six weeks later this patient returned for a scan and had a huge pseudocyst in the lesser sac.  Pseudocysts will be discussed in another case.

Take home point

• Heterogeneous enhancement of the pancreas suggests pancreatic necrosis.  Necrotizing pancreatitis has high morbidity.  The surgeons will want to know about this finding.