Baltazar

Review
Emil J. Balthazar, MD

Index terms: Pancreas, CT, 770.12111, 770.12112 Pancreatitis, 770.291 Review Published online before print 10.1148/radiol.2233010680 Radiology 2002; 223:603– 613 Abbreviations: APACHE II Acute Physiology and Chronic Health Evaluation IL interleukin TNF tumor necrosis factor
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Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation1Treatment of patients with acute pancreatitis is based on the initial assessment of disease severity. Severe pancreatitis occurs in 20%–30% of all patients with acute pancreatitis and is characterized by a protracted clinical course, multiorgan failure, and pancreatic necrosis. Early staging is based on the presence and degree of systemic failure (cardiovascular, pulmonary, renal) and on the presence andextent of pancreatic necrosis. Individual laboratory indexes (markers of pancreatic injury, markers of inflammatory response), while promising, have not yet gained clinical acceptance. Numeric grading systems with sensitivities of about 70% are commonly used today as indicators of organ failure and disease severity. Contrast material– enhanced computed tomography is used in addition to helpevaluate local pancreatic morphology and the presence and extent of pancreatic necrosis. Advantages and limitations of the clinical, laboratory, and imaging prognostic indexes are analyzed and discussed.
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From the Department of Radiology, New Bellevue Hospital, 462 First Ave, 3rd Fl, Rm 3W37-3W42, New York, NY 10016. Received March 27, 2001; revision requested May 21; revision received July 16;accepted August 9. Address correspondence to the author (e-mail: emiljmd@aol.com). RSNA, 2002

RSNA, 2002

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Once the diagnosis of acute pancreatitis is established, the treatment of patients is dependent on the early assessment of disease severity. This assessment, based on objective parameters, is crucial for predicting clinical complications and for identifying potentially lethal attacks,which are known to occur in 2%–10% of patients with acute pancreatitis (1– 8). Moreover, in the past 10 years it has been established that the increased frequency of death in acute pancreatitis is directly correlated with the development and extent of pancreatic necrosis (1– 8). Thus, the early detection of pancreatic necrosis (necrotizing pancreatitis) signifies severe disease and is being used as agrave prognostic indicator in the initial evaluation of these patients. The purpose of this review is to describe the accepted new concepts in the development of pancreatic necrosis, as well as to survey the most important individual and collective markers that have been proposed to identify patients with severe attacks of pancreatitis. The advantages and limitations of individual prognosticparameters and scoring systems will be outlined. The role of computed tomographic (CT) imaging in the initial staging of acute pancreatitis will be emphasized. This article reflects the progress made in the past decade in the staging of acute pancreatitis and underlines some of the remaining pitfalls in our staging systems.

PATHOPHYSIOLOGY AND CLINICAL FEATURES Classification
The 1992 Atlanta, Ga,International Symposium on Acute Pancreatitis has classified this entity into mild acute pancreatitis and severe acute pancreatitis (1,9). While this is not a perfect classification system, since intermediate forms of disease do occur, it has provided a more reliable basis for experimental studies and for clinical management of acute pancreatitis. The rationale of previous classifications (10 –13) hasbeen based on the extent and degree of pancreatic injury, which could only be assumed at the time of diagnosis and which could sometimes be confirmed later during surgical exploration or postmortem examination. The new classification, for the first time, defines the severity of disease in practical, clinically relevant terms. In essence, the new classification is based on the presence of multiorgan...