Identifying a Biliary Origin of Acute Pancreatitis Using CT
2021; Radiological Society of North America; Volume: 302; Issue: 1 Linguagem: Inglês
10.1148/radiol.2021212066
ISSN1527-1315
Autores Tópico(s)Pancreatic and Hepatic Oncology Research
ResumoHomeRadiologyVol. 302, No. 1 PreviousNext Reviews and CommentaryFree AccessEditorialIdentifying a Biliary Origin of Acute Pancreatitis Using CTKevin J. Chang Kevin J. Chang Author AffiliationsFrom the Department of Radiology, Boston University School of Medicine, 820 Harrison Ave, FGH 4001, Boston MA 02118; and Department of Radiology, Brown University Alpert Medical School, Providence, RI.Address correspondence to the author (e-mail: [email protected]).Kevin J. Chang Published Online:Oct 12 2021https://doi.org/10.1148/radiol.2021212066MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In See also the article by Zver and Calame et al in this issue.Dr Chang is an associate professor of radiology at Boston University School of Medicine and adjunct associate professor of diagnostic imaging at Brown University Alpert Medical School. He is also director of MRI and associate section chief of abdominal imaging at Boston Medical Center. Previously, he was director of CT at Mass General Brigham Newton-Wellesley and a partner at Rhode Island Medical Imaging. He remains a strong advocate for colorectal cancer screening, treatment, and CT colonography.Download as PowerPointOpen in Image Viewer The diagnosis of acute pancreatitis typically requires two out of three criteria: abdominal pain typical for pancreatitis, elevated serum lipase or amylase level three times higher than the normal upper limit, or supportive imaging findings at CT, MRI, or US. If the first two criteria are present, imaging is generally not necessary. However, as gallstones remain the most frequent cause of acute pancreatitis (1,2), imaging may play an early role in guiding management.The diagnosis of acute biliary pancreatitis should prompt early endoscopic retrograde cholangiopancreatography (ERCP) and/or cholecystectomy to remove choledochal and gallbladder calculi and prevent or reduce future recurrence and complications (3–5). In these cases, prompt imaging is crucial to guide treatment. With many institutions having limited emergent access to MRI with MR cholangiopancreatography (MRCP) and endoscopic US, both of which excel at depicting choledochal calculi, CT and transabdominal US have become the mainstay in initial radiologic imaging. Although US is an excellent modality for gallstone detection, sensitivity for gallstones decreases in acute biliary pancreatitis due to bowel distension and ileus (6). The sensitivity of US in the detection of choledocholithiasis also remains limited (7). Contrast-enhanced CT is often also being used for CT severity index scoring of acute pancreatitis (8). CT is ideally suited for early evaluation of a biliary origin of pancreatitis, despite its limited ability to depict noncalcified gallstones.In this issue of Radiology, Zver and Calame and colleagues (9) report on their creation of a combined clinical and CT feature nomogram-based model to predict early diagnosis of acute biliary pancreatitis in a retrospective study of consecutive patients evaluated with multiphase contrast-enhanced CT during the initial episode of acute pancreatitis. A total of 271 patients were included in the study sample, with an additional 51 tested in a validation cohort. CT features independently associated with acute biliary pancreatitis included the presence of cholelithiasis, choledochal wall hyperenhancement, nonsteatotic nonenhanced liver attenuation, and lack of duodenal wall thickening, while clinical features included older age and serum alanine aminotransferase level. In their study population, nonenhanced liver hypoattenuation and duodenal wall thickening were more indicative of an alcoholic rather than biliary origin. Their diagnostic approach showed an area under the curve of 0.94 in the study population and had better performance than the use of clinical or CT features alone. The model was further tested and proven in a validation cohort, with a resultant area under the curve of 0.91.CT is relatively unreliable in the detection of noncalcified gallstones and choledocholithiasis. However, Zver and Calame et al showed that other previously overlooked CT features, such as choledochal wall hyperenhancement (suggestive of cholangitis) and the absence of hepatic steatosis and duodenal wall thickening (features of alcoholic pancreatitis), may be combined with patient age and serum alanine aminotransferase level to predict a biliary origin of acute pancreatitis. Their algorithm could quantify the probability of acute biliary pancreatitis, potentially bypassing the need for MRI with MRCP and endoscopic US, expedite ERCP and surgical management, and decrease medical costs. The model could serve to improve the use of CT in diagnosing acute biliary pancreatitis and may prove helpful in patients who are unable or too ill to undergo MRI.This was a retrospective single-center study and is likely heavily influenced by the prevalence of causes for acute pancreatitis specific to a patient population, especially of alcoholic pancreatitis. Additional study and verification will be needed to see if this approach can be extended to other localities and populations. In addition, the authors’ model is predicated on the use of multiphase pre- and postcontrast CT, a protocol that is not frequently used in the pancreatitis work-up unless a mass is suspected. The CT arterial phase allowed the authors to evaluate the impact of other potential CT features on the diagnosis of acute biliary pancreatitis (eg, liver perfusional changes, duodenal papillary hyperenhancement, and gallbladder wall hyperenhancement). However, it remains to be seen whether their algorithm could potentially be applied to a single portal phase abdominal CT examination. Finally, whether CT alone could supplant MRI with MRCP or endoscopic US in more rapidly and accurately diagnosing acute biliary pancreatitis will require further study. Personally, I believe MRI will continue to play an important role in direct visualization and confirmation of choledocholithiasis before ERCP, as well as in depiction of ductal abnormalities such as pancreas divisum and strictures. In addition, given the prevalence of nonalcoholic fatty liver disease in the United States, the presence of hepatic steatosis may not necessarily decrease the likelihood of a biliary cause of pancreatitis as suggested by the authors’ approach.Nevertheless, CT has been showing increased performance in the diagnosis of acute biliary pancreatitis. Although not addressed in this study, dual-energy or spectral CT has also shown an improved ability to depict noncalcified gallstones, which had previously appeared isoattenuating at conventional CT (10). When combined with the other CT and clinical features described by Zver and Calame et al, dual-energy CT could show additional value as a “one-stop shop” in potentially diminishing or precluding the use of US or MRI in the diagnosis of acute biliary pancreatitis.Overall, this is a novel approach gleaning additional data points that can be incorporated into the CT evaluation and management guidance for an initial episode of acute pancreatitis. The authors’ nomogram shows potential for clinical use and earlier diagnosis and treatment of acute biliary pancreatitis.Disclosures of Conflicts of Interest: K.J.C. disclosed no relevant relationships.References1. Cho JH, Kim TN, Kim SB. Comparison of clinical course and outcome of acute pancreatitis according to the two main etiologies: alcohol and gallstone. BMC Gastroenterol 2015;15(1):87. Crossref, Medline, Google Scholar2. Forsmark CE, Baillie JAGA Institute Clinical Practice and Economics Committee; AGA Institute Governing Board. AGA Institute technical review on acute pancreatitis. Gastroenterology 2007;132(5):2022–2044. Crossref, Medline, Google Scholar3. Yadav D, O’Connell M, Papachristou GI. Natural history following the first attack of acute pancreatitis. Am J Gastroenterol 2012;107(7):1096–1103. Crossref, Medline, Google Scholar4. Tse F, Yuan Y. Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis. Cochrane Database Syst Rev 2012;(5):CD009779. Medline, Google Scholar5. da Costa DW, Bouwense SA, Schepers NJ, et al. Same-admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): a multicentre randomised controlled trial. Lancet 2015;386(10000):1261–1268. Crossref, Medline, Google Scholar6. Şurlin V, Săftoiu A, Dumitrescu D. Imaging tests for accurate diagnosis of acute biliary pancreatitis. World J Gastroenterol 2014;20(44):16544–16549. Crossref, Medline, Google Scholar7. Cucher D, Kulvatunyou N, Green DJ, Jie T, Ong ES. Gallstone pancreatitis: a review. Surg Clin North Am 2014;94(2):257–280. Crossref, Medline, Google Scholar8. Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology 1990;174(2):331–336. Link, Google Scholar9. Zver T, Calame P, Koch S, Aubry S, Vuitton L, Delabrousse E. Early prediction of acute biliary pancreatitis using clinical and abdominal CT features. Radiology 2021. https://doi.org/10.1148/radiol.2021210607. Published online October 12, 2021. Link, Google Scholar10. Uyeda JW, Richardson IJ, Sodickson AD. Making the invisible visible: improving conspicuity of noncalcified gallstones using dual-energy CT. Abdom Radiol (NY) 2017;42(12):2933–2939. Crossref, Medline, Google ScholarArticle HistoryReceived: Aug 13 2021Revision requested: Aug 25 2021Revision received: Aug 26 2021Accepted: Aug 31 2021Published online: Oct 12 2021Published in print: Jan 2022 FiguresReferencesRelatedDetailsAccompanying This ArticleEarly Prediction of Acute Biliary Pancreatitis Using Clinical and Abdominal CT FeaturesOct 12 2021RadiologyRecommended Articles Early Prediction of Acute Biliary Pancreatitis Using Clinical and Abdominal CT FeaturesRadiology2021Volume: 302Issue: 1pp. 118-126Multimodality Imaging, including Dual-Energy CT, in the Evaluation of Gallbladder DiseaseRadioGraphics2018Volume: 38Issue: 1pp. 75-89Will Dual-Energy CT Become the Reference Standard to Evaluate Gallstone Disease?Radiology2019Volume: 292Issue: 2pp. 407-408Risk-stratified versus Non–Risk-stratified Diagnostic Testing for Management of Suspected Acute Biliary Obstruction: Comparative Effectiveness, Costs, and the Role of MR CholangiopancreatographyRadiology2017Volume: 284Issue: 2pp. 468-481Beyond the Liver Function Tests: A Radiologist's Guide to the Liver Blood TestsRadioGraphics2021Volume: 42Issue: 1pp. 125-142See More RSNA Education Exhibits Choosing the Best Test for Biliary Imaging: Re-Examining the Role of MRCPDigital Posters2019Gallstones Gone Crazy: An Imaging Panorama of Gallstone ComplicationsDigital Posters2019What to Look For? 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