Pancreatitis-imaging approach

Table 1 Indications to perform contrast-enhanced computed tomography[58]

Types	Indications
Initial imaging	1 When the diagnosis of acute pancreatitis is uncertain 2 Patients with hyperamylasemia, severe clinical pancreatitis, abdominal distention and tenderness, fever > 102°, and leukocytosis for the detection of complications 3 Ranson score > 3 or APACHE score > 8 4 Patients who fail to improve after 72 h of conservative medical therapy 5 Acute change in clinical status, such as new fever, pain, and shock after successful initial medical therapy
Followup imaging	1 Acute change in clinical status suggesting complication 2 7-10 d after presentation if CT severity score is 3-10 at presentation or grade 3 To determine response to treatment after surgery or interventional radiologic procedures to document response to treatment. 4 Before discharge of patients with severe acute pancreatitis

Table 2 MCTSI scoring ystem[39]

Prognostic Indicators	Characteristics	MCTSI1
Pancreatic inflammation	Normal pancreas	0
	Pancreatic ± peripancreatic inflammatory changes	2
	One or more collection or peripancreatic fat necrosis	4
Pancreatic necrosis	No necrosis	0
	< 30%	2
	> 30%	4
Extrapancreatic complications (pleural effusions, ascites, vascular, gastrointestinal, etc.)		2

¹Scores ≥ 5 are associated with higher morbidity and mortality.

Table 3 MR severity index scoring system[69]

Prognostic Indicators	Characteristics	MRSI
Pancreatic inflammation	Normal pancreas	0
	Focal or diffuse enlargement of the pancreas	1
	Intrinsic pancreatic abnormalities with inflammatory changes in the peripancreatic fat	2
	Single, poorly defined fluid collection	3
	Two or more poorly defined collection or presence of gas in or adjacent to the pancreas	4
Pancreatic necrosis	No necrosis	0
	< 30%	2
	30%-50%	4
	> 50%	6

Table 4 Imaging criteria for chronic pancreatitis[70]

	CT criteria	MRI/S-MRCP criteria
Moderate chronic pancreatitis	≥ 2 of the following:	Moderate pancreatogram changes
	Main duct enlarged (2-4 mm)	Main duct abnormal and
	Slight gland enlargement (up to 2 × normal)	Abnormal side branches, > 3
	Heterogeneous parenchyma
	Small cavities (< 10 mm)
	Irregular ducts
	Focal acute pancreatitis
	Increased Density of the main pancreatic duct wall
	Irregular head/body contour
Marked chronic pancreatitis	with ≥ 1 of the following	Main duct abnormal and
	Large cavities (> 10 mm)	Abnormal side branches, > 3
	Gross gland enlargement (2 × normal)	Plus one or more of the following:
	Intraductal filling defects or pancreatic calculi	Large cavity
	Duct obstruction, stricture, or gross irregularity	Obstruction
	Contiguous organ invasion	Filling defects
		Severe dilatation or irregularity

Table 5 Differentiating imaging features between chronic pancreatitis and pancreatic adenocarcinoma

Chronic pancreatitis	Pancreatic adenocarcinoma
Preserved glandular, feathery or marbled texture similar to that of the remaining pancreas	Definable, circumscribed mass lesion is most often diagnostic for tumor, which disrupts the underlying architecture and results in loss of anatomic detail
Heterogeneous pancreatic enhancement with presence of signal void (cysts and calcifications) on immediate post-gadolinium images	Irregular, heterogeneous, diminished enhancement on postgadolinium images compared to adjacent pancreatic parenchyma
Irregular dilatation of main pancreatic duct with gradual narrowing. Presence of multiple intraductal calcifications (the most specific finding)	Abrupt cut off of the pancreatic duct with significant proximal dilatation +/- presence of double duct sign. Very few ductal calculi compared to chronic pancreatitis
Dilatation of main pancreatic duct with and ectasia of the side branches, giving chain of lakes appearance	Minimal dilatation of side branches
No vascular encasement, significant lymphadenopathy or distant metastasis.	Vascular encasement, lymphadenopathy or distant metastasis