1. Upper abdominal pain syndrome
Stafvergadering 21/01/2015
Laurent Van Camp
ASO Radiologie

2. Contents Upper abdominal pain: Ultrasound CT abdomen  findings
 theory
CT abdomen

3. Ultrasound Clinical information:
Upper abdominal pain, vomiting, Morbus Crohn.
Enteritis? Colitis? Cholecystitis?
♀, 25 years old, nulligravida.
R/ Pentasa (Mesalazine – 5-ASA) 4g/day
Medical history
2005 : tumorectomy breast (benign cyst).
2010 : uveïtis.
2010 : Morbus Crohn: ileitis terminalis.
2012 : peri-anal abcess.
2014: anal fistula
2014 : pelvic inflammatory disease

4. Ultrasound

5. Ultrasound

6. Ultrasound

7. Ultrasound

8. Ultrasound: case
Painfull upper abdomen upon pressure, localised over the epigastrium.
No free fluid.
Hypoechoic and swollen pancreas.
No free fluid at the pancreatic tail.
Normal gallbladder, no cholecystolithiasis.
Normal appendix (5,8 mm).

9. Ultrasound: theory acute pancreatitis
Pancreas often obscured because of gastric dilatation
‘Hyper’acute (first hours): no sonographic findings
Acute (first days ): markedly hypoechoic, swollen and enlarged.
+/- necrosis
+/- free fluid particularly splenic hilum and peripancreatic space.
Main causes: biliairy (gallstones, ductal dilatation), alcoholic (fatty liver)
Accuracy: low in the acute stage, important in follow-up
FU: thrombosis splenic or portal vein? Necrosis? Gallstones?

10. Ultrasound images

11. Cause?
Biliary: -
Alcohol: -, no fatty liver
Idiopathic?

12. Diagnosis? Diagnosis= clinical manifestation + elevated lipase
Lab-values: Lipase     1084 U/L  (13 – 60)
Probably Mesalazine-induced pancreatitis

13. CT Abdomen
No additional value in the first 72 hours for diagnosis and staging !
Can underestimate the amount of necrosis
Can be done in case of suspected perforation or complications
Can be done to exclude other causes of acute abdomen in case of doubt
After 72 hours: staging of pancreatitis:
Modified CT severity index (modified CTSI)

14. CT-grading of pancreatitis: Modified CTSI
Total points are given out of 10 to determine the grade of pancreatitis and aid treatment:
0-2: mild
4-6: moderate
8-10: severe

15. Outcome
Modified CTSI = 2  mild

16. Conclusion Imaging diagnosis of pancreatitis
Ultrasound diagnosis in acute stage!
CT after 72 hours
Main causes:
Biliary
Alcoholic
! Never forget ‘idiopathic’ causes!

17. Articles Schmidt, G. Ultrasound. Thieme Clinical companions, 2007.
Mortele1 K., Wiesner1 W., Intriere1 L., Shankar1 S., Zou1 2 KH., Kalantari1 BN., Perez3 A., vanSonnenberg1 E., Ros1 PR., Banks3 PA., Silverman SG. A Modified CT Severity Index for Evaluating Acute Pancreatitis: Improved Correlation with Patient Outcome. American Journal of Roentgenology. 2004;183:
Acute Pancreatitis, Whitcomb DC, N. Engl. J. Med., May 18, 2006; 354(20): 2142 – 2150,
Pancreatitis in inflammatory bowel diseases. Pitchumoni CS., Rubin A., Das K. J Clin Gastroenterol 2010, Apr; 44 (4):