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

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

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

Ultrasound

Ultrasound

Ultrasound

Ultrasound

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).

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?

Ultrasound images

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

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

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)

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

Outcome Modified CTSI = 2  mild

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

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