Computerized tomography-guided therapeutic percutaneous puncture catheter drainage-combined with somatostatin for severe acute pancreatitis: An analysis of efficacy and safety

BACKGROUND Severe acute pancreatitis(SAP),a condition with rapid onset,critical condition and unsatisfactory prognosis,poses a certain threat to human health,warranting optimization of relevant treatment plans to improve treatment efficacy.AIM To evaluate the efficacy and safety of computerized tomography-guided the-rapeutic percutaneous puncture catheter drainage(CT-TPPCD)combined with somatostatin(SS)in the treatment of SAP.METHODS Forty-two SAP patients admitted to The Second Affiliated Hospital of Fujian Medical University from June 2020 to June 2023 were selected.On the basis of routine treatment,20 patients received SS therapy(control group)and 22 patients were given CT-TPPCD plus SS intervention(research group).The efficacy,safety(pancreatic fistula,intra-abdominal hemorrhage,sepsis,and organ dysfunction syndrome),abdominal bloating and pain relief time,bowel recovery time,hospital stay,inflammatory indicators(C-reactive protein,interleukin-6,and pro-calcitonin),and Acute Physiology and Chronic Health Evaluation(APACHE)II score of both groups were evaluated for comparison.RESULTS Compared with the control group,the research group had a markedly higher total effective rate,faster abdominal bloating and pain relief and bowel recovery,INTRODUCTION Pancreatitis,an inflammatory disease occurring in the pancreatic tissue,is classified as either acute or chronic and is associated with high morbidity and mortality,imposing a socioeconomic burden[1,2].The pathogenesis of this disease involves early protease activation,activation of nuclear factor kappa-B-related inflammatory reactions,and infiltration of immune cells[3].Severe acute pancreatitis(SAP)is a serious condition involving systemic injury and subsequent possible organ failure,accounting for 20%of all acute pancreatitis cases[4].SAP is also characterized by rapid onset,critical illness and unsatisfactory prognosis and is correlated with serious adverse events such as systemic inflammatory response syn-drome and acute lung injury,threatening the health of patients[5,6].Therefore,timely and effective therapeutic inter-ventions are of great significance for improving patient prognosis and ensuring therapeutic effects.Somatostatin(SS),a peptide hormone that can be secreted by endocrine cells and the central nervous system,is in-volved in the regulatory mechanism of glucagon and insulin synthesis in the pancreas[7].It has complex and pleiotropic effects on the gastrointestinal tract,which can inhibit the release of gastrointestinal hormones and negatively modulate the exocrine function of the stomach,pancreas and bile,while exerting a certain influence on the absorption of the di-gestive system[8,9].SS has shown certain clinical effectiveness when applied to SAP patients and can regulate the severity of SAP and immune inflammatory responses,and this regulation is related to its influence on leukocyte apoptosis and adhesion[10,11].Computerized tomography-guided therapeutic percutaneous puncture catheter drainage(CT-TPPCD)is a surgical procedure to collect lesion fluid and pus samples from necrotic lesions and perform puncture and drainage by means of CT image examination and precise positioning[12].In the research of Liu et al[13],CT-TPPCD applied to pa-tients undergoing pancreatic surgery contributes to not only good curative effects but also a low surgical risk.Baudin et al[14]also reported that CT-TPPCD has a clinical success rate of 64.6%in patients with acute infectious necrotizing pan-creatitis,with nonfatal surgery-related complications found in only two cases,suggesting that this procedure is clinically effective and safe in the treatment of the disease.In light of the limited studies on the efficacy and safety of SS plus CT-TPPCD in SAP treatment,this study performed a relevant analysis to improve clinical outcomes in SAP patients.

Chronic pancreatitis:Pain and computed tomography/magnetic resonance imaging findings

Chronic pancreatitis(CP)is a fibroinflammatory disease characterized by irreversible destruction of pancreatic tissue.With the development of the disease,it may lead to exocrine and/or endocrine insufficiency.CP is one of the common diseases that cause abdominal pain,which will not get permanent spontaneous relief as the disease evolves.The American College of Gastroenterology clinical guidelines recommend computed tomography or magnetic resonance imaging as the first-line examination for the diagnosis of CP.CP common imaging findings include pancreatic atrophy,irregular dilatation of the pancreatic duct,calcification of pancreatic parenchyma,pancreatic duct stones,etc.In clinical practice,whether any correlations between CP-induced abdominal pain patterns(no pain/constant/intermittent pain)and corresponding imaging findings present are not well known.Therefore,this review aims to comprehensively sort out and analyze the relevant information by collecting lots of literature on this field,so as to construct a cross-bridge between the clinical manifestations and imaging manifestations of CP patients.Also,it provides an imaging basis and foundation for the classification and diagnosis of abdominal pain types in clinical CP patients.

Complementary comments on diagnosis,severity and prognosis prediction of acute pancreatitis

The radiological differential diagnosis of acute pancreatitis includes diffuse pancreatic lymphoma,diffuse autoimmune pancreatitis and groove located mass lesions that may mimic groove pancreatitis.Dual energy computed tomography and diffusion weighted magnetic resonance imaging are useful in the early diagnosis of acute pancreatitis,and dual energy computed tomography is also useful in severity assessment and prognosis prediction.Walled off necrosis is an important complication in terms of prognosis,and it is important to know its radiological findings and distinguish it from pseudocyst.

Computed tomography-based radiomics diagnostic approach for differential diagnosis between early-and late-stage pancreatic ductal adenocarcinoma

BACKGROUND One of the primary reasons for the dismal survival rates in pancreatic ductal adenocarcinoma(PDAC)is that most patients are usually diagnosed at late stages.There is an urgent unmet clinical need to identify and develop diagnostic methods that could precisely detect PDAC at its earliest stages.METHODS A total of 71 patients with pathologically proved PDAC based on surgical resection who underwent contrast-enhanced computed tomography(CT)within 30 d prior to surgery were included in the study.Tumor staging was performed in accordance with the 8th edition of the American Joint Committee on Cancer staging system.Radiomics features were extracted from the region of interest(ROI)for each patient using Analysis Kit software.The most important and predictive radiomics features were selected using Mann-Whitney U test,univar-iate logistic regression analysis,and minimum redundancy maximum relevance(MRMR)method.Random forest(RF)method was used to construct the radiomics model,and 10-times leave group out cross-validation(LGOCV)method was used to validate the robustness and reproducibility of the model.RESULTS A total of 792 radiomics features(396 from late arterial phase and 396 from portal venous phase)were extracted from the ROI for each patient using Analysis Kit software.Nine most important and predictive features were selected using Mann-Whitney U test,univariate logistic regression analysis,and MRMR method.RF method was used to construct the radiomics model with the nine most predictive radiomics features,which showed a high discriminative ability with 97.7%accuracy,97.6%sensitivity,97.8%specificity,98.4%positive predictive value,and 96.8%negative predictive value.The radiomics model was proved to be robust and reproducible using 10-times LGOCV method with an average area under the curve of 0.75 by the average performance of the 10 newly built models.CONCLUSION The radiomics model based on CT could serve as a promising non-invasive method in differential diagnosis between early and late stage PDAC.

Comparison between solid pseudopapillary neoplasms of the pancreas and pancreatic ductal adenocarcinoma with cystic changes using computed tomography

BACKGROUND Solid pseudopapillary neoplasms of the pancreas(SPN)share similar imaging findings with pancreatic ductal adenocarcinoma with cystic changes(PDAC with cystic changes),which may result in unnecessary surgery.AIM To investigate the value of computed tomography(CT)in differentiation of SPN from PDAC with cystic changes.METHODS This study retrospectively analyzed the clinical and imaging findings of 32 patients diagnosed with SPN and 14 patients diagnosed with PDAC exhibiting cystic changes,confirmed through pathological diagnosis.Quantitative and qualitative analysis was performed,including assessment of age,sex,tumor size,shape,margin,density,enhancement pattern,CT values of tumors,CT contrast enhancement ratios,“floating cloud sign,”calcification,main pancreatic duct dilatation,pancreatic atrophy,and peripancreatic invasion or distal metastasis.Multivariate logistic regression analysis was used to identify relevant features to differentiate between SPN and PDAC with cystic changes,and receiver operating characteristic curves were obtained to evaluate the diagnostic performance of each variable and their combination.RESULTS When compared to PDAC with cystic changes,SPN had a lower age(32 years vs 64 years,P<0.05)and a slightly larger size(5.41 cm vs 3.90 cm,P<0.05).SPN had a higher frequency of“floating cloud sign”and peripancreatic invasion or distal metastasis than PDAC with cystic changes(both P<0.05).No significant difference was found with respect to sex,tumor location,shape,margin,density,main pancreatic duct dilatation,calcification,pancreatic atrophy,enhancement pattern,CT values of tumors,or CT contrast enhancement ratios between the two groups(all P>0.05).The area under the receiver operating characteristic curve of the combination was 0.833(95%confidence interval:0.708-0.957)with 78.6%sensitivity,81.3%specificity,and 80.4%accuracy in differentiation of SPN from PDAC with cystic changes.CONCLUSION A larger tumor size,“floating cloud sign,”and peripancreatic invasion or distal metastasis are useful CT imaging features that are more common in SPN and may help discriminate SPN from PDAC with cystic changes.

Balthazar computed tomography severity index is superior to Ranson criteria and APACHE Ⅱ scoring system in predicting acute pancreatitis outcome

AIM： Acute pancreatitis （AP） is a process with variable involvement of regional tissues or organ systems. Multifactorial scales included the Ranson, Acute Physiology and Chronic Health Evaluation （APACHE Ⅱ） systems and Balthazar computed tomography severity index （CTSI）. The purpose of this review study was to assess the accuracy of CTSI, Ranson score, and APACHE II score in course and outcome prediction of AP. METHODS： We reviewed 121 patients who underwent helical CT within 48 h after onset of symptoms of a first episode of AP between 1999 and 2003. Fourteen inappropriate subjects were excluded; we reviewed the 107 contrastenhanced CT images to calculate the CTSI. We also reviewed their Ranson and APACHE Ⅱ score. In addition, complications, duration of hospitalization, mortality rate, and other pathology history also were our comparison parameters. RESULTS： We classified 85 patients （79%） as having mild AP （CTSI 〈5） and 22 patients （21%） as having severe AP （CTSI ≥5）. In mild group, the mean APACHE II score and Ranson score was 8.6±1.9 and 2.4±1.2, and those of severe group was 10.2±2.1 and 3.1±0.8, respectively. The most common complication was pseudocyst and abscess and it presented in 21 （20%） patients and their CTSI was 5.9±1.4. A CTSI ≥5 significantly correlated with death, complication present, and prolonged length of stay. Patients with a CTSI ≥5 were 15 times to die than those CTSI 〈5, and the prolonged length of stay and complications present were 17 times and 8 times than that in CTSI 〈5, respectively. CONCLUSION： CTSI is a useful tool in assessing the severity and outcome of AP and the CTSI ≥5 is an index in our study. Although Ranson score and APACHE II score also are choices to be the predictors for complications, mortality and the length of stay of AP, the sensitivity of them are lower than CTSI.

Computed tomography scan imaging in diagnosing acute uncomplicated pancreatitis: Usefulness vs cost

BACKGROUND Literature has suggested that imaging is over-utilized in the diagnosis of pancreatitis. If the diagnosis of acute pancreatitis(AP) is established with abdominal pain and increased serum amylase or lipase activity without systemic signs of severe disease, computed tomography(CT) imaging may not be necessary. We hypothesize that among patients with uncomplicated acute pancreatitis(AUP), there is a significant number of unwarranted CT imaging studies. This imposes increased expenditure and cost in our healthcare system and does not improve hospital stay or management of AUP.AIM To assess the overutilization and associated cost of CT imaging among patients meeting diagnostic criteria for AUP.METHODS In this Institutional Review Board-approved retrospective, single-center study,we identified all adult patients admitted with AP from January 1, 2012 through October 1, 2017. Patients were identified via International Classification of Diseases(ICD-9) code for AP(577.0) and ICD-10 codes for different etiological AP(K85.9 unspecified, K85.0 idiopathic, K85.1 biliary, K85.2 alcohol-induced, K85.3 drug-induced, and K85.8 other). Diagnosis was confirmed by chart review using established non-imaging diagnostic criteria(presence of typical abdominal pain and elevated lipase or amylase greater than 3 times upper limit of normal).Ranson criteria and BISAP scores on presentation were calculated and patients that met scores less than or equal to 2 for both were included to suggest AUP.The utilization and cost of imaging in these patients were recorded.RESULTS Between January 2012 and October 2017, 1305 patients presented to the emergency department with AP, and 405 patients(31%) met our inclusion criteria for AUP(201 males, 204 females; mean age 49 years, range 18-98). Of those, 210 patients(51.85%) underwent CT imaging. One patient(0.47%) had evidence of pancreatic necrosis, one patient had cyst formation(0.47%), and the remaining208 patients(99.05%) had either normal CT scan imaging or findings consistent with mild AP without necrosis. The average cost of CT scan imaging was $4510 with a total cost of $947056. Median length of hospitalization stay was 3 d among both groups. Combining Ranson's Criteria and BISAP score identified AUP in our patient population with an accuracy of 99.5%.CONCLUSION CT imaging is unnecessary when AUP is diagnosed clinically and biochemically.Reducing overuse of diagnostic CT scans will decrease healthcare expenditure and radiation exposure to patients.

Splanchnic vein thrombosis in necrotizing acute pancreatitis: Detection by computed tomographic venography

AIM: To assess the diagnostic accuracy of computed tomographic venography(CTV) for splanchnic vein thrombosis(SVT) detection in necrotizing acute pancreatitis(AP) patients.METHODS:Forty-three patients with necrotizing AP who underwent both CTV and digital subtraction angiography(DSA)within 3 d were analyzed in this retrospective comparative study.All CTV procedures were performed with a dual-source CT scanner.The presence and location of SVT were determined via blinded imaging data analyses.RESULTS:According to the DSA results,17(39.5%)of the total 43 patients had SVT.The sensitivity,specificity,positive and negative predictive values of CTV for SVT detection were 100%(95%CI:77.1%-100%),92.3%(95%CI:73.4%-98.7%),89.5%(95%CI:65.5%-98.2%)and 100%(95%CI:82.8%-100%),respectively.CONCLUSION:CTV is an effective examination for SVT detection in patients with necrotizing AP with high positive and negative predictive values.

Infective severe acute pancreatitis:A comparison of ^(99m)Tc-ciprofloxacin scintigraphy and computed tomography

AIM:To evaluate 99mTc-ciprofloxacin scintigraphy compared with computed tomography(CT)for detecting secondary infections associated with severe acute pancreatitis(SAP)in swine.METHODS:Six healthy swine were assigned to a normal control group(group A,n = 6).SAP was induced in group B(n = 9)and C(n = 18),followed by inoculation of the resulting pancreatic necroses with inactive Escherichia coli(E.coli)(group B)and active E.coli(group C),respectively.At 7 d after inoculation,a CT scan and a series of analyses using infecton imaging(at 0.5,1,2,3,4 and 6 h after the administration of 370 MBq of intravenous infecton)were performed.The scintigrams were visually evaluated and semi-quantitatively analyzed using region of interest assignments.The differences in infecton uptake and changes in the lesion-background radioactive count ratios(L/B)in the 3 groups were recorded and compared.After imaging detection,histopathology and bacterial examinations were performed,and infected SAP was regarded as positive.The imaging findings were compared with histopathological and bacteriological results.RESULTS:In group A,6 animals survived without infection in the pancreas.In group B,7/9 swine survived and one suffered from infection.In group C,15/18 animals survived with infection.Hence,the number of normal,non-infected and infected SAP swine was 6,6 and 16,respectively.The sensitivity,specificity,accuracy,positive predictive value and negative predictive value of the infecton method were 93.8%(15/16),91.7%(11/12),92.9%(26/28),93.8%(15/16)and 91.7%(11/12),whereas these values for CT were 12.5%(2/16),100.0%(12/12),50.0%(14/28),100.0%(2/2)and 46.2%(12/26),respectively.The changes in L/B for the infected SAP were significantly different from those of the non-infected and normal swine(P < 0.001).The mean L/B of the infectious foci at 0.5,1,2,3,4 and 6 h was 1.17 ± 0.10,1.71 ± 0.30,2.46 ± 0.45,3.36 ± 0.33,2.04 ± 0.37 and 1.1988 ± 0.09,respectively.At 3 h,the radioactive counts(2350.25 ± 602.35 k)and the mean L/B of the infectious foci were significantly higher than that at 0.5 h(P = 0.000),1 h(P = 0.000),2 h(P = 0.04),4 h(P = 0.000)and 6 h(P = 0.000).CONCLUSION:99m Tc-ciprofloxacin scintigraphy may be an effective procedure for detecting SAP secondary infections with higher sensitivity and accuracy than CT.

Endoscopic ultrasound diagnostic gain over computed tomography and magnetic resonance cholang-iopancreatography in defining etiology of idiopathic acute pancreatitis

BACKGROUND About 10%-30%of acute pancreatitis remain idiopathic(IAP)even after clinical and imaging tests,including abdominal ultrasound(US),contrast-enhanced computed tomography(CECT)and magnetic resonance cholangiopancreatography(MRCP).This is a relevant issue,as up to 20%of patients with IAP have recurrent episodes and 26%of them develop chronic pancreatitis.Few data are available on the role of EUS in clarifying the etiology of IAP after failure of one or more cross-sectional techniques.AIM To evaluate the diagnostic gain after failure of one or more previous crosssectional exams.METHODS We retrospectively collected data about consecutive patients with AP and at least one negative test between US,CECT and MRCP,who underwent linear EUS between January 2017 and December 2020.We investigated the EUS diagnostic yield and the EUS diagnostic gain over different combinations of these crosssectional imaging techniques for the etiologic diagnosis of AP.Types and frequency of EUS diagnosis were also analyzed,and EUS diagnosis was compared with the clinical parameters.After EUS,patients were followed-up for a median of 31.5 mo to detect cases of pancreatitis recurrence.RESULTS We enrolled 81 patients(63%males,mean age 61±18,23%with previous cholecystectomy,17%with recurrent pancreatitis).Overall EUS diagnostic yield for AP etiological diagnosis was 79%(20%lithiasis,31%acute on chronic pancreatitis,14%pancreatic solid or cystic lesions,5%pancreas divisum,5%autoimmune pancreatitis,5%ductal abnormalities),while 21%remained idiopathic.US,CECT and MRCP,taken alone or in combination,led to AP etiological diagnosis in 16(20%)patients;among the remaining 65 patients,49(75%)obtained a diagnosis at EUS,with an overall EUS diagnostic gain of 61%.Sixty-eight patients had negative US;among them,EUS allowed etiological diagnosis in 59(87%).Sixty-three patients had a negative CECT;among them,47(74%)obtained diagnosis with EUS.Twenty-four had a negative MRCP;among them,20(83%)had EUS diagnosis.Twenty-one had negative CT+MRCP,of which 17(81%)had EUS diagnosis,with a EUS diagnostic gain of 63%.Patients with biliary etiology and without previous cholecystectomy had higher median values of alanine aminotransferase(154 vs 25,P=0.010),aspartate aminotransferase(95 vs 29,P=0.018),direct bilirubin(1.2 vs 0.6,P=0.015),gammaglutamyl transpeptidase(180 vs 48,P=0.006)and alkaline phosphatase(150 vs 72,P=0.015)Chronic pancreatitis diagnosis was more frequent in patients with recurrent pancreatitis at baseline(82%vs 21%,P<0.001).During the follow-up,AP recurred in 3 patients,one of which remained idiopathic.CONCLUSION EUS is a good test to define AP etiology.It showed a 63%diagnostic gain over CECT+MRCP.In suitable patients,EUS should always be performed in cases of IAP.Further prospective studies are needed.

Three-dimensional computed tomography reconstruction diagnosed digestive tract perforation and acute peritonitis caused by Monopterus albus:A case report

BACKGROUND Few reports have described living foreign bodies in the human body.The current manuscript demonstrates that computed tomography(CT)is an effective tool for accurate preoperative evaluation of living foreign bodies in clinic.The threedimensional(3D)reconstruction technology could clearly display anatomical structures,lesions and adjacent organs,improving diagnostic accuracy and guiding the surgical decision-making process.CASE SUMMARY Herein we describe a 68-year-old man diagnosed with digestive tract perforation and acute peritonitis caused by a foreign body of Monopterus albus.The patient pre-sented to the emergency department with complaints of dull abdominal pain,profuse sweating and a pale complexion during work.A Monopterus albus had entered the patient’s body through the anus two hours ago.During hospitalization,the 3D reconstruction technology revealed a perforation of the middle rectum complicated with acute peritonitis and showed a clear and complete Monopterus albus bone morphology in the abdominal and pelvic cavities,with the Monopterus albus biting the mesentery.Laparoscopic examination detected a large(diameter of about 1.5 cm)perforation in the mid-rectum.It could be seen that a Monopterus albus had completely entered the abdominal cavity and had tightly bitten the mesentery of the small intestine.During the operation,the dead Monopterus albus was taken out.CONCLUSION The current manuscript demonstrates that CT is an effective tool for accurate preoperative evaluation of living foreign bodies in clinic.

Artificial intelligence software for assessing brain ischemic penumbra/core infarction on computed tomography perfusion:A real-world accuracy study

BACKGROUND With the increasingly extensive application of artificial intelligence(AI)in medical systems,the accuracy of AI in medical diagnosis in the real world deserves attention and objective evaluation.AIM To investigate the accuracy of AI diagnostic software(Shukun)in assessing ischemic penumbra/core infarction in acute ischemic stroke patients due to large vessel occlusion.METHODS From November 2021 to March 2022,consecutive acute stroke patients with large vessel occlusion who underwent mechanical thrombectomy(MT)post-Shukun AI penumbra assessment were included.Computed tomography angiography(CTA)and perfusion exams were analyzed by AI,reviewed by senior neurointerventional experts.In the case of divergences among the three experts,discussions were held to reach a final conclusion.When the results of AI were inconsistent with the neurointerventional experts’diagnosis,the diagnosis by AI was considered inaccurate.RESULTS A total of 22 patients were included in the study.The vascular recanalization rate was 90.9%,and 63.6%of patients had modified Rankin scale scores of 0-2 at the 3-month follow-up.The computed tomography(CT)perfusion diagnosis by Shukun(AI)was confirmed to be invalid in 3 patients(inaccuracy rate:13.6%).CONCLUSION AI(Shukun)has limits in assessing ischemic penumbra.Integrating clinical and imaging data(CT,CTA,and even magnetic resonance imaging)is crucial for MT decision-making.

Comments on the article about correlation between computerized tomography and surgery in acute pancreatitis

We read with great interest the article by Vege et al published in issue 34 of World J Gastroenterol 2010. The article evaluates the ability of contrast-enhanced computerized tomography (CECT) to characterize the nature of peripancreatic collections found at surgery. The results of their study indicate that most of the peripancreatic collections seen on CECT in patients with severe acute pancreatitis who require operative intervention contain necrotic tissue and CECT has a limited role in differentiating various types of collections. However, there are some points that need to be addressed, including data about the stage of acute pancreatitis in which CECT was done and the time span between CECT examination and surgery.

Acute pancreatitis:Structured report template of magnetic resonance imaging

Acute pancreatitis(AP)is a common acute abdomen disease of the digestive system.It has a potentially fatal risk because of its variable severity and various complications.With the widespread application of the Revised Atlanta Classification,new requirements for AP imaging reports are introduced.Experts in abdominal radiology and pancreatology in the United States published the first structured computed tomography reporting template for AP in 2020.However,there is no corresponding structured magnetic resonance imaging(MRI)reporting template globally.Therefore,this article focuses on the structured MRI report of AP images from our pancreatitis imaging center,which is intended to improve the systematic understanding of this disease and standardize the writing of MRI structured reports.In the meantime,we aim to promote the clinical diagnosis and assessment of MRI efficacy for AP and its multiple complications.It is further intended to facilitate academic exchanges and scientific research between different medical centers.

Computed tomographic differentiation between alcoholic and gallstone pancreatitis:Significance of distribution of infiltration or fluid collection

AIM： To evaluate the usefulness of various computed tomography （CT） findings including distribution of infiltration or fluid collection in differentiating the major etiologies of acute pancreatitis. METHODS： We reviewed 75 relatively severe cases of acute pancreatitis of alcoholic （n = 43） or biliary stone （n = 32） etiology having infiltration or fluid collection on CT. We compared the pancreatic size, CT grading, presence or absence of biliary calculi, and dilatation of pancreatic or bile duct. We also evaluated degree and the distribution of infiltration and fluid collection in each group. RESULTS： The sizes of pancreas were not different between alcohol group and stone group. Alcohol group showed higher CT grading than stone group （P 〈 0.05）. Presence of biliary stone and duct dilatation was statistically significant in differentiating etiology （P 〈 0.05）. Alcohol group showed significantly prominent peripancreatic pathology than stone group only in left peritoneal compartment （P = 0.020）. CONCLUSION： Alcoholic pancreatitis tends to form more prominent peripancreatic changes than gallstone pancreatitis in relatively severe cases. This is evident on the anterior aspect of left abdomen. Although clinical history and some CT findings usually are a major determinant of the etiology, this pattern of peripancreatic pathology may have an ancillary role in determining the etiologies of acute pancreatitis in the equivocal cases.

Computed tomography findings for predicting severe acute hepatitis with prolonged cholestasis

AIM: To evaluate the significance of computed tomography (CT) findings in relation to liver chemistry and the clinical course of acute hepatitis. METHODS: Four hundred and twelve patients with acute hepatitis who underwent enhanced CT scanning were enrolled retrospectively. Imaging findings were analyzed for the following variables: gallbladder wall thickness (GWT), arterial heterogeneity, periportal tracking, number and maximum size of lymph nodes, presence of ascites, and size of spleen. The serum levels of alanine aminotransferase, alkaline phosphatase, bilirubin, albumin, and prothrombin time were measured on the day of admission and CT scan, and laboratory data were evaluated every 2-4 d for all subjects during hospitalization. RESULTS: The mean age of patients was 34.4 years, and the most common cause of hepatitis was hepatitis A virus (77.4%). The mean GWT was 5.2 mm. The number of patients who had findings of arterial heterogeneity, periportal tracking, lymph node enlargement > 7 mm, and ascites was 294 (80.1%), 348 (84.7%), 346 (84.5%), and 56 (13.6%), respectively. On multivariate logistic regression, male gender [odds ratio (OR) = 2.569, 95%CI: 1.477-4.469, P = 0.001], toxic hepatitis (OR = 3.531, 95%CI: 1.444-8.635, P = 0.006), level of albumin (OR = 2.154, 95%CI: 1.279-3.629, P = 0.004), and GWT (OR = 1.061, 95%CI: 1.015-1.110, P = 0.009) were independent predictive factors for severe hepatitis. The level of bilirubin (OR = 1.628, 95%CI: 1.331-1.991, P < 0.001) and GWT (OR = 1.172, 95%CI: 1.024-1.342,P = 0.021) were independent factors for prolonged cholestasis in multivariate analysis. CONCLUSION: In patients with acute hepatitis, GWT on CT scan was an independent predictor of severe hepatitis and prolonged cholestasis.

Computed tomography perfusion measurements for definition of lesions in early acute stroke

Background: Perfusion computed tomography (CT) is an evolving technique in the diagnosis of acute stroke. After complex deconvolution algorithms, perfusion color maps-cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT)— are produced, they give visual confirmation of perfusion deficit in ischemic area, but some discrepancies exist regarding this technique in reliability of quantitative detection of tissue viability: penumbra (tissue at risk) that surrounds core (necrosis). Purpose: The purpose of this prospective study was to define brain tissue viability grade on the basis of the perfusion CT parameters in acute stroke patients. Material and Methods: Multimodal CT imaging protocol (unenhanced CT of the brain, CT angiography of head and neck blood vessels, followed by brain perfusion CT and 24 hours follow-up brain CT) was performed. Perfusion deficit was detected first visually, with subsequent manual quantitative and relative measurements in affected and contra-lateral hemisphere in 87 patients. Results: Visual perfusion deficit on perfusion CT images was found in 78 cases (38 female, 40 male;mean age 30 - 84 years): penumbra lesion (n = 49) and core lesion (n = 42). Both lesion types were detected by increased MTT on perfusion CT map, penumbra area showed mean values 202.40% (113% - 345% ± 57.17) and core (41% - 320% ± 64.53) in comparison to contra-lateral hemisphere. CBV mean values in penumbra group were increased up to 113.10% (45% - 276% ± 36.29) and in core decreased till 41.82% (3% - 107% ± 27.09). CBF values were decreased up to 65.63% (31% - 137% ± 22) in penumbra lesion and markedly decreased till 25.94% (4% - 79% ± 17.35) in core. Conclusion: Our study shows that perfusion CT measurements relative threshold values are recommended in definition of penumbra and core lesions in acute stroke patients.

Multi-detector computed tomography in the diagnosis and management of acute aortic syndromes

Acute aortic syndrome(AAS) is a spectrum of conditions, which may ultimately progress to potentially life-threatening aortic rupture. This syndrome encompasses aortic dissection(AD), intramural haematoma, penetrating atherosclerotic ulcer and unstable thoracic aortic aneurysms. Multi-detector CT(MDCT) is crucial for the diagnosis of AAS, especially in the emergency setting due to its speed, accuracy and ready availability. This review attends to the value of appropriate imaging protocols in obtaining good quality images that can permit a confident diagnosis of AAS. AD is the most commonly encountered AAS and also the one with maximum potential to cause catastrophic outcome if not diagnosed and managed promptly. Hence, this review briefly addresses certain relevant clinical perspectives on this condition. Differentiating the false from the true lumen in AD is often essential; a spectrum of CT findings, e.g., "beak sign", aortic "cobwebs" that allows such differentiation have been described with explicit illustrations. The value of non enhanced CT scans, especially useful in the diagnosis of an intramural hematoma has also been illustrated. Overlap in the clinical and imaging features of the various conditions presenting as AAS is not unusual. However, on most instances MDCT enables the rightdiagnosis. On select occasions MRI or trans-esophageal echocardiography may be required as a problem solving tool.

Significance of an additional unenhanced scan in computed tomography angiography of patients with suspected acute aortic syndrome

AIM To assess potential benefits of an additional unenhanced acquisition in computed tomography angiography(CTA) in patients with suspected acute aortic syndrome(AAS).METHODS A total of 103 aortic CTA(non-electrocardiography-gated, 128 slices) performed due to suspected AAS were retrospectively evaluated for acute aortic dissection(AAD), intramural hematoma(IMH), or penetrating aortic ulcer(PAU). Spiral CTA protocol consisted of an unenhanced acquisition and an arterial phase. If AAS was detected, a venous phase(delay, 90 s) was added. Images were evaluated for the presence and extent of AAD, IMH, PAU, and related complications. The diagnostic benefit of the unenhanced acquisition was evaluated concerning detection of IMH.RESULTS Fifty-six(30% women; mean age, 67 years; median, 68 years) of the screened individuals had AAD or IMH. A triphasic CT scan was conducted in 76.8%(n =43). 56% of the detected AAD were classified as Stanford type A, 44% as Stanford type B. 53.8% of the detected IMH were classified as Stanford type A, 46.2% as Stanford type B. There was no significant difference in the involvement of the ascending aorta between AAD and IMH(P = 1.0) or in the average age between AAD and IMH(P = 0.548), between Stanford type A and Stanford type B in general(P = 0.650) and between Stanford type A and Stanford type B within the entities of AAD and IMH(AAD: P = 0.785; IMH: P = 0.146). Only the unenhanced acquisitions showed a significant density difference between the adjacent lumen and the IMH(P = 0.035). Subadventitial hematoma involving the pulmonary trunk was present in 5 patients(16%) with Stanford A AAD. The difference between the median radiation exposure of a triphasic(2737 mGy*cm) compared to a biphasic CT scan(2135 mGy*cm) was not significant(P = 0.135).CONCLUSION IMH is a common and difficult to detect entity of AAS. An additional unenhanced acquisition within an aortic CTA protocol facilitates the detection of IMH.

Acute Cholecystitis: Computed Tomography (CT) versus Ultrasound (US)

Acute cholecystitis is a common surgical emergency and ultrasound (US) is currently considered the first-line diagnostic imaging test. The relative accuracy of computed tomography (CT) in detecting acute cholecystitis has received little attention in the literature. We report a case series of 113 patients who underwent emergency laparoscopic cholecystectomy at a tertiary surgical centre in Australia, between 2014 and 2016, after undergoing both US and CT examination for acute right upper quadrant pain. Both US and CT had a relatively low sensitivity in detecting acute cholecystitis in the patients with histologically proven acute cholecystitis (47% and 45% respectively) but high specificity (84% and 79% respectively). As expected, US was much more sensitive in detecting cholelithiasis (92%) in comparison to CT (55%). With the added advantage of CT in excluding other alternative intra-abdominal pathology in patients presenting with acute right upper quadrant pain, and similar accuracy in detecting acute cholecystitis, the need for ultrasound may be negated in cases where acute cholecystitis has been confirmed on CT. However, it is noted that both US and CT had a significant false negative rate for acute cholecystitis, and if there remains a clinical suspicion despite initial normal imaging, repeat delayed imaging and/or surgical opinion may be warranted.