CT and MRI Features and Prognosis of Acute Necrotic Collectionsin Patients with Acute Pancreatitis
-
摘要: 目的:总结急性坏死性胰腺炎(ANP)患者局部并发症急性坏死性积聚(ANC)的影像特征,探讨影响ANC转归的因素。方法:回顾性分析31例ANP患者的临床及影像资料,在CT或MRI上观察ANC的影像特点,将其转归分为吸收组与包裹性坏死(WON)组,采用卡方检验比较两组间差异的统计学意义。结果:31例ANC平扫CT均呈斑片状不均匀低密度影,其内见小灶性类圆形等、低密度混杂影(23例)及脂肪低密度影(22例);19例ANC在平扫MRI均呈T1混杂低信号、T2混杂较高信号,其内FS T2WI可见低信号碎片影。3例(9.7%)合并局部感染,12例(38.7%)合并出血。增强扫描坏死组织无强化,其周边可有不同程度的斑片状或线样强化。对31例ANP患者随访(中位137天)显示,12例(38.7%)ANC完全吸收,19例(61.3%)形成WON,吸收组与WON组在坏死是否累及胰腺、累及胰腺部位、坏死体积、MCTSI评分的差异有统计学意义。结论:ANC在CT表现为不均匀液体密度,MRI呈不均匀信号影,增强扫描坏死组织无强化,但其周边组织可有不同程度强化改变。随访显示ANC可完全吸收或形成WON,并与多个影像因素相关。
-
关键词:
- 改良计算机体层摄影严重指数 /
- 胰腺炎 /
- 急性坏死性积聚
Abstract: Objective: To summarize the imaging features of acute necrotic collections (ANC), a local complication of acute necrotizing pancreatitis (ANP), and to explore the factors affecting the prognosis of patients with ANC. Methods: The clinical and imaging data of 31 patients with ANP were analyzed retrospectively. Characteristics of ANC on computed tomography (CT) and magnetic resonance imaging (MRI) were analyzed as well. Based on the follow-up outcomes, patients were divided into the absorption group and the walled-off necrosis (WON) group; a chi-square test was used to compare the two. Results: Plain CT revealed patchy, uneven, low-density shadows in 31 cases of ANC (focal, oval, and iso-density and low-density mixed shadows:23 cases; fatty low-density shadows: 22 cases). Plain MRI revealed mixed low-signal intensities on T1-weighted imaging and mixed high-signal intensities on T2-weighted imaging in 19 cases of ANC; low-signal fragments were seen on Fat suppressed T2-weighted imaging in some of these cases. ANC was complicated with local infection and hemorrhage in 3 (9.7%) and 12 (38.7%) cases, respectively. The necrotic tissues did not show any enhancement, but the surrounding tissues appeared patchy or linear-enhancing changes with varying degrees on enhanced scans. Follow-up examination (median: 137 days) revealed that ANC was completely absorbed in 12 cases (38.7%) and had developed into WON in 19 cases (61.3%). The absorption and WON groups differed significantly in terms of necrosis involving the pancreas, affected locations of the pancreas, necrotic volumes, and the modified CT severity index scores. Conclusion: On CT and MRI, ANC appears as uneven liquid densities and heterogeneous signal intensities, respectively. The necrotic tissue itself has no enhancement, but its surrounding tissue presents with different degrees of enhancing changes on enhanced scanning. Follow-up findings reveal that ANC can completely dissipate or progress to WON, which is related to several imaging factors. -
表 1 31例ANP患者ANC转归的影响因素
Table 1. Factors influencing the ANC outcome in 31 patients with ANP
项目 影响因素 WON组(n=19) 吸收组(n=12) P 坏死是否累及胰腺 累及胰腺及胰周 19 7 0.005 仅累及胰周组织 0 5 胰腺坏死部位 胰头 9 0 0.005 胰体 18 5 0.002 胰尾 14 5 0.060 两个部位及以上 17 2 0.000 坏死体积 <30% 5 10 0.003 ≥30% 14 2 是否合并感染 合并感染 1 2 0.543 未合并感染 18 10 是否伴有出血 有出血 9 3 0.274 无出血 10 9 MCTSI评分 ≤6分 2 9 0.000 >6分 17 3 病因 胆石症 10 7 1.000 酗酒 2 1 1.000 高脂血症 10 2 0.065 -
[1] HABTEZION A, GUKOVSKAYA A S, PANDOL S J. Acute pancreatitis: A Multifaceted set of organelle and cellular interactions[J]. Gastroenterology, 2019, 156(7): 1941−1950. DOI: 10.1053/j.gastro.2018.11.082. [2] BANKS P A, BOLLEN T L, DERVENIS C, et al. Classification of acute pancreatitis-2012: Revision of the Atlanta classification and definitions by international consensus[J]. Gut, 2013, 62(1): 102−111. DOI: 10.1136/gutjnl-2012-302779. [3] 蒋志琼, 张小明, 肖波. 急性胰腺炎国际结构化CT报告模板解读[J]. 中华放射学杂志, 2021,55(10): 1004−1007. doi: 10.3760/cma.j.cn112149-20201128-01263JIANG Z Q, ZHANG X M, XIAO B. Interpretation of international structured CT report template for acute pancreatitis[J]. Chinese Journal of Radiology, 2021, 55(10): 1004−1007. (in Chinese). doi: 10.3760/cma.j.cn112149-20201128-01263 [4] HEETER Z R, HAUPTMANN E, CRANE R, et al. Pancreaticocolonic fistulas secondary to severe acute pancreatitis treated by percutaneous drainage: Successful nonsurgical outcomes in a single-center case series[J]. Journal of Vascular and Interventional Radiology, 2013, 24(1): 122−129. DOI: 10.1016/j.jvir.2012.09.020. [5] DIMAIO C J. Management of complications of acute pancreatitis[J]. Current Opinion in Gastroenterology, 2018, 34(5): 336−342. DOI: 10.1097/MOG.0000000000000462. [6] RANA S S. An overview of walled-off pancreatic necrosis for clinicians[J]. Expert Review of Gastroenterology and Hepatology, 2019, 13(4): 331−343. DOI: 10.1080/17474124.2019.1574568. [7] 闫媛媛, 靳二虎, 张洁, 等. CT和MRI对急性胰腺炎局部并发症的诊断价值研究[J]. CT理论与应用研究, 2018,27(3): 393−400. DOI: 10.15953/j.1004-4140.2018.27.03.13.YAN Y Y, JIN E H, ZHANG J, et al. Diagnostic value of CT and MRI in local complications of acute pancreatitis[J]. CT Theory and Applications, 2018, 27(3): 393−400. DOI: 10.15953/j.1004-4140.2018.27.03.13. (in Chinese). [8] THOENI R F. The revised Atlanta classification of acute pancreatitis: Its importance for the radiologist and its effect on treatment[J]. Radiology, 2012, 262(3): 751−764. DOI: 10.1148/radiol.11110947. [9] FOSTER B R, JENSEN K K, BAKIS G, et al. Revised Atlanta classification for acute pancreatitis: A pictorial essay[J]. Radiographics, 2016, 36(3): 675−687. DOI: 10.1148/rg.2016150097. [10] BOLLEN T L. Acute pancreatitis: International classification and nomenclature[J]. Clinical Radiology, 2016, 71(2): 121−133. DOI: 10.1016/j.crad.2015.09.013. [11] BOXHOORN L, VOERMANS R P, BOUWENSE S A, et al. Acute pancreatitis[J]. Lancet, 2020, 396(10252): 726−734. DOI: 10.1016/S0140-6736(20)31310-6. [12] GRASSEDONIO E, TOIA P, la GRUTTA L, et al. Role of computed tomography and magnetic resonance imaging in local complications of acute pancreatitis[J]. Gland Surgery, 2019, 8(2): 123−132. DOI: 10.21037/gs.2018.12.07. [13] RANA S S, SHARMA R K, GUPTA P, et al. Natural course of asymptomatic walled off pancreatic necrosis[J]. Digestive and Liver Disease, 2019, 51(5): 730−734. DOI: 10.1016/j.dld.2018.10.010. [14] 肖波, 张小明, 徐海波. 急性胰腺炎的影像术语: 急性胰周液体积聚与急性坏死性积聚(一)[J]. 放射学实践, 2019,34(10): 1096−1101.XIAO B, ZHANG X M, XU H B. Imaging terms of acute pancreatitis: Acute peripancreatic fluid volume accumulation and acute necrotic accumulation (1)[J]. Radiology Practice, 2019, 34(10): 1096−1101. (in Chinese). [15] 肖波, 张小明, 徐海波. 急性胰腺炎的影像术语: 胰腺假性囊肿与胰腺包裹性坏死(二)[J]. 放射学实践, 2019,34(11): 1207−1211.XIAO B, ZHANG X M, XU H B. Imaging terminology of acute pancreatitis: Pancreatic pseudocyst and pancreatic encapsulated necrosis (2)[J]. Radiology Practice, 2019, 34(11): 1207−1211. (in Chinese). [16] BEZMAREVIC M, VANDIJK S M, VOERMANS R P, et al. Management of (Peri) pancreatic collections in acute pancreatitis[J]. Visceral Medicine, 2019, 35(2): 91−96. DOI: 10.1159/000499631. [17] HUANG J, QU H P, ZHENG Y F, et al. The revised Atlanta criteria 2012 altered the classification, severity assessment and management of acute pancreatitis[J]. Hepatobiliary & Pancreatic Diseases International, 2016, 15(3): 310−315. DOI: 10.1016/s1499-3872(15)60040-6. [18] 刘建, 李昂, 刘殿刚, 等. CT检查预测急性胰腺炎局部并发症转归的价值[J]. 中华普外科手术学杂志(电子版), 2017,11(4): 285−288.LIU J, LI A, LIU D G, et al. The value of CT examination in predicting the outcome of local complications of acute pancreatitis[J]. Chinese Journal of general surgery (Electronic Edition), 2017, 11(4): 285−288. (in Chinese). [19] ALBERTI P, PANDO E, MATA R, et al. Evaluation of the modified computed tomography severity index (MCTSI) and computed tomography severity index (CTSI) in predicting severity and clinical outcomes in acute pancreatitis[J]. Journal of Digestive Diseases, 2021, 22(1): 41−48. DOI: 10.1111/1751-2980.12961. [20] MANRAI M, KOCHHAR R, GUPTA V, et al. Outcome of acute pancreatic and peripancreatic collections occurring in patients with acute pancreatitis[J]. Annals of Surgery, 2018, 267(2): 357−363. DOI: 10.1097/SLA.0000000000002065. [21] SARATHI P P, DAS K, BHATTACHARYYA A, et al. Natural resolution or intervention for fluid collections in acute severe pancreatitis[J]. British Journal of Surgery, 2014, 101(13): 1721−1728. DOI: 10.1002/bjs.9666. [22] KOUTROUMPAKIS E, DASYAM A K, FURLAN A, et al. Isolated peripancreatic necrosis in acute pancreatitis is infrequent and leads to severe clinical course only when extensive: A prospective study from a us tertiary center[J]. Journal of Clinical Gastroenterology, 2016, 50(7): 589−595. DOI: 10.1097/MCG.0000000000000482. [23] HEISS P, BRUENNLER T, SALZBERGER B, et al. Severe acute pancreatitis requiring drainage therapy: Findings on computed tomography as predictor of patient outcome[J]. Pancreatology, 2010, 10(6): 726−733. DOI: 10.1159/000320710. -