| Teaching File Case - Patient: 11112|
Peer Reviewed and Certified - Approved by: Albert V Porambo - 2007-07-25 22:31:45-04
|Demographics: 75 y.o. Man|
|History & Chief complaint:|
|75 year old male with abdominal pain, nausea, and vomiting.|
|Physical exam and Laboratory:|
| Tender to palpation diffusely throughout the epigastrium.
WBC 13,000 with 95% neutrophils
|Summary of Findings:|
|Axial CT images through the abdomen reveal cholelithiasis with a small stone in the distal common bile duct (CBD). The CBD is dilated and the pancreatic head is mildly heterogeneous. Peripancreatic fat-stranding is present as is fluid within the anterior pararenal space.|
| Gallstone Pancreatitis |
|Confirmed by: History, physical and laboratory findings with supportive imaging.|
|Treatment and Followup:|
|Patient went for open cholecystectomy, CBD exploration, and T-tube placement.|
|Acute pancreatitis is an acute inflammatory condition involving the pancreas that may also involve other local or remote organs/tissues. Alcohol abuse and gallstones are the two most common causes, while less common causes include trauma, infection, iatrogenic, idiopathic, hypercalcemia, hypertriglyceridemia, and medications to name a few. Complications of acute pancreatitis include pseudocyst formation, fluid collections, abscesses, pancreatic necrosis, hemorrhage, venous thrombosis, and pseudoaneurysm formation.
Imaging has become an important tool in evaluating for acute pancreatitis and/or the complications associated with it.
Findings suggestive of acute pancreatitis on abdominal plain films include air in the duodenal C-loop, focal dilatation of a loop of proximal jejunum in the left upper quadrant (Sentinel Loop Sign), and/or distention of the colon to the transverse segment with no gas visualized distal to the splenic flexure (Colon cut-off sign).
Contrast-enhanced CT has become the imaging modality of choice in the evaluation of pancreatitis and its complications. Typical findings include diffuse enlargement of the pancreas, heterogeneous enhancement, irregular or shaggy contour, fat stranding, fascial thickening, or fluid collections with the peritoneum or retroperitoneum.
Ultrasound and MRI are useful alternatives to CT. With ultrasound, mild cases of pancreatitis may reveal a normal gland. Findings suggestive of pancreatitis include a hypoechoic, enlarged gland. Ultrasound allows for better evaluation of the biliary system. Suggestive findings with MRI include focal or diffuse enlargement and irregular contour. Hemorrhage may appear as areas of bright T1 while areas of fluid collections, abscess, or pseudocyst may appear T2 bright. Areas of necrosis may fail to enhance with Gadolinium administration.
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