Management of acute pancreatitis

While ultrasound is useful in demonstrating associated gallstones, biliary sludge and fluid collections, CT or MRI demonstrates the complications of acute pancreatitis with greater sensitivity and specificity.
Localized areas of necrotic pancreatic tissue can be demonstrated on contrast-enhanced CT, together with vascular complications, such as thrombosis.
MRCP or CT is used to demonstrate the main pancreatic duct and its point of insertion into the common bile duct. Anomalous insertions are asso-ciated with pancreatitis, due to the reflux of bile into the pancreatic duct. ERCP, which is more invasive and subject to potential complications, isgenerally reserved for circumstances which require the removal of stones, alleviating the need for surgery, and in the placement of stents in the case of strictures. Pancreatitis can be difficult to treat, and management consists of alleviating the symptoms and removing the cause where possible. Patients with gallstone pancreatitis do well after cholecystectomy,but if the gallbladder is not removed recurrent attacks of increasingly severe inflammation occur in up to a third of patients.

Pseudocysts which do not resolve spontaneously may be drained percutaneously under ultrasound or CT guidance, or, depending on the site of the collection, a drain may be positioned endoscopically from the cyst into the stomach. Pseudocyst formation may cause thrombosis of the splenic vein, spreading to the portal and mesenteric veins in some cases. Other vascular complications include splenic artery aneurysm, which may form as a result of damage to the artery
by the pseudocyst. Surgery to remove necrotized or haemorrhagic areas of pancreatic tissue may be undertaken in severe cases.

Ultrasound images Splenic and portal vein thrombosis is a complication of pancreatitis.
A dilated pancreatic duct (arrow) filled with blood in haemorrhagic pancreatitis.
ERCP: a patient with chronic pancreatitis has a dilated proximal pancreatic duct.
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