Pancreatitis

The diagnosis of acute pancreatitis is based on clinical presentation, serum amylase and lipase levels and imaging studies. In chronic pancreatitis, the inflammation worsens over time and becomes chronic, leading to permanent damage and fibrosis of the pancreas.

Pancreatitis can occur as an acute illness or with a chronic course. Acute pancreatitis is characterized by considerable abdominal pain symptoms lasting from several days to a few weeks. Overview 1 lists the symptoms [4,5].

Chronic pancreatitis manifests itself with repeated upper abdominal pain, nausea, vomiting, maldigestion, fatty stools and weight loss. Upper abdominal pain can vary in intensity and episodes can last from many hours to several days. As the disease progresses, the pain becomes chronic, usually more severe after meals and less severe when sitting upright or leaning forward. This leads to irreversible destruction of the organ structure and function. Gene mutations have been identified that predispose individuals to the development of acute pancreatitis. People with cystic fibrosis or who have a genetic predisposition to cystic fibrosis are at increased risk of developing acute or chronic pancreatitis.

Alcohol consumption and cigarette smoking are the main causes of chronic pancreatitis in over 70% of cases. Cholecysto- and choledocholithiasis also play an important role as triggers of inflammation. The upper abdominal pain can be permanent or non-existent.

The diagnosis is based on the symptoms, the presence of acute pancreatitis and alcohol consumption in the medical history, imaging examination procedures and functional tests of the pancreas or clarification of the inflammation-specific laboratory values.

Treatment includes avoiding alcohol and cigarettes, dietary measures, taking pancreatic enzyme supplements and measures to relieve pain [1,2].

X-ray examinations have no value in the initial diagnosis of pancreatitis. In the case of severe abdominal pain, an abdominal overview image can visualize functional disturbances of the gastrointestinal passage without providing concrete indications of the cause (Fig. 4)

Sonography is a ubiquitously available imaging tool that can lead to a rapid diagnosis of acute pancreatitis [6,7], provided that the examination conditions are adequate (overlapping of stomach, intestinal contents/air with limited assessability, gastric and intestinal atony in acute inflammation). If the diagnosis cannot be confirmed sonographically in the case of corresponding clinical symptoms and laboratory constellations, further imaging clarification is required.

Computed tomography is the cross-sectional imaging procedure of choice. In addition to a short examination time, both edematous and necrotizing pancreatitis can be reliably visualized, and chronic courses with parenchymal calcifications and pseudocysts can be differentiated. Ascites is visualized, as well as gastrointestinal atony with stagnant intestinal loops and fluid retention.

Magnetic resonance imaging has deficits in the detection of the early stage of edematous pancreatitis, but can detect the necrotizing form very well and identify hemorrhagic courses with FS T1w. Problems can occur in the detection of small calcifications [3].

Case study

Case example 1 (Fig. 1A to 1E) documents the course of chronic recurrent pancreatitis in a patient who was 69 years old at her last CT scan. A pseudocyst of the corpus of the pancreas had progressed in size with a clear impression of the back wall of the stomach.

Case 2 demonstrates (Fig. 2A, B) alcohol-induced acute pancreatitis in a 54-year-old man with severe upper abdominal pain and reduced general condition. The pancreas showed a pronounced inflammatory edematous change on CT, the organ boundaries were blurred and the adjacent fatty tissue was infiltrated.

Case 3 shows chronic pancreatitis in a 56-year-old patient with alcohol abuse and considerable atrophy of the organ with multiple coarse calcifications. Inflammatory mucosal swelling with wall thickening was also detectable in the duodenojejunal flexure (Fig. 3A, B).

In case 4, an abdominal overview radiograph shows numerous standing bowel loops with mirror images in a patient with abdominal pain and reduced peristalsis of unknown cause (Fig. 4).

Take-Home-Messages

Pancreatitis can occur as an acute or chronic inflammation, the course can be mild or even life-threatening.
Medical history, symptoms, imaging examination procedures and laboratory diagnostics are important for making a diagnosis.
Computed tomography is the imaging method with the most comprehensive diagnostic information and is less susceptible to artifacts.
Excessive alcohol and nicotine consumption are the main causes of pancreatitis.
Treatment is primarily conservative with physical rest, medication and dietary measures.

Literature:

Bartel M: Acute pancreatitis. www.msdmanuals.com/de/profi/gastrointestinale-erkrankungen/pankreatitis/akute-pankreatitis,(last accessed 22.04.2024)
Bartel M: Chronic pancreatitis. www.%C3%(last accessed 22.04.2024)
Burgener FA, et al: Differential diagnostics in MRI. Georg Thieme Verlag Stuttgart, New York 2002: pp. 546.
“Pancreatitis”, https://de.wikipedia.org/wiki,(last accessed 22.04.2024)
Deximed, https://deximed.de,(last accessed 22.04.2024).
“Acute pancreatitis”, https://sonographiebilder.de/akute-pankreatitis,(last accessed 22.04.2024)
Schmidt G, Görg C: Kursbuch Ultraschall, 2008, www.thieme-connect.de/products/ebooks/book/10.1055/b-002-11384,(last accessed 22.04.2024).