Acute pancreatitis

Case contributed by Edmund Godfrey
Diagnosis certain

Presentation

Epigastric pain, acute onset, radiating to the back. Vomiting. Started pegaspargase 2 weeks prior for acute lymphoblastic leukaemia.

Patient Data

Age: 25 years
Gender: Male

0 days after pain onset

ct
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Info

The pancreas is enlarged and heterogeneous. There is abnormal fluid attenuation in the retroperitoneum and a small volume of ascites.

In the context the appearances are in keeping with acute pancreatitis.

9 days after pain onset

ct
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The majority of the pancreas has been replaced by a large fluid collection, with only a small part of the head of the pancreas demonstrating enhancement. There is a small volume of ascites. There is a filling defect in the splenic vein.

The appearances are in keeping acute necrotising pancreatitis with associated splenic vein thrombosis.

Case Discussion

The imaging demonstrates acute pancreatitis secondary to pegaspargase, a drug used to treat acute lymphoblastic leukaemia. A diagnosis of acute pancreatitis can be made in the presence of 2 of the three conditions 1:

  • abdominal pain suggestive of pancreatitis

  • serum amylase or lipase >3 times the upper limit of normal

  • characteristic imaging findings of pancreatitis

In this case, because pancreatitis was not suspected clinically, serum amylase/lipase were not obtained prior to imaging. They were subsequently measured and found to be >3 times the upper limit of normal.

In cases where CT is obtained early in acute pancreatitis (< 2 days after the onset of pain), the initial CT can fail to detect the degree of pancreatic necrosis, as in this case. The subsequent CT at 9 days after the onset of pain demonstrates extensive pancreatic necrosis, involving almost the entire pancreas.

The learning points here are:

  1. serum amylase / lipase should be obtained prior to imaging where acute pancreatitis is in the differential

  2. if they are elevated, in almost all cases it is appropriate to avoid images with CT in the first 2 days

  3. CT < 2 days after the onset of pain can fail to detect the degree of pancreatic necrosis

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