Imaging of inflammatory disease of the pancreas

Increasingly acute and chronic pancreatitis (AP and CP) are considered a continuum of a single entity. Nonetheless, if, after flare-up, the pancreas shows no residual inflammation, it is classified as AP. CP is characterised by a long cycle of worsening and waning glandular inflammation without the pancreas ever returning to its baseline structure or function. According to the International Consensus Guidelines on Early Chronic Pancreatitis, pancreatic inflammation must last at least 6 months before it can be labelled CP. The distinction is important because, unlike AP, CP can destroy endocrine and exocrine pancreatic function, emphasising the importance of early diagnosis. As typical AP can be diagnosed by clinical symptoms plus laboratory tests, imaging is usually reserved for those with recurrent, complicated or CP. Imaging typically starts with ultrasound and more frequently with contrast-enhanced computed tomography (CECT). MRI and/or MR cholangiopancreatography can be used as a problem-solving tool to confirm indirect signs of pancreatic mass, differentiate between solid and cystic lesions, and to exclude pancreatic duct anomalies, as may occur with recurrent AP, or to visualise early signs of CP. MR cholangiopancreatography has replaced diagnostic endoscopic retrograde cholangiopancreatography (ERCP). However, ERCP, and/or endoscopic ultrasound (EUS) remain necessary for transpapillary biliary or pancreatic duct stenting and transgastric cystic fluid drainage or pancreatic tissue sampling, respectively. Finally, positron emission tomography-MRI or positron emission tomography-CT are usually reserved for complicated cases and/or to search for extra pancreatic systemic manifestations. In this article, we discuss a broad spectrum of inflammatory pancreatic disorders and the utility of various modalities in diagnosing acute and chronic pancreatitis.

Sclerosing cholangitis in a patient treated with nivolumab

A 69-year-old retired miner with stage 4 non-small-cell lung cancer presented with a 2-month history of obstructive liver function tests following nivolumab immunotherapy. His case had not responded to high dose prednisolone or mycophenolate and he was admitted for investigation. MR cholangiopancreatography demonstrated areas of intrahepatic biliary tree beading and stricturing, in keeping with sclerosing cholangitis. Prednisolone and mycophenolate were stopped and ursodeoxycholic acid commenced with subsequent partial improvement of the patient’s liver function tests.

Migrated PEG balloon causing acute pancreatitis

Percutaneous endoscopic gastrostomy (PEG) is a common procedure for an unsafe swallow or inability to maintain oral nutrition. When a PEG tube needs replacement, a balloon gastrostomy tube is usually placed through the same, well formed and mature tract without endoscopy. We present a patient with a rare complication related to the balloon gastrostomy tube, to raise awareness and minimise the risk of this complication in the future. A 67-year-old female patient presented to the emergency department with severe abdominal pain and vomiting. Her gastrostomy feeding tube displaced inwards, up to the feeding-balloon ports complex. After investigations, she was diagnosed with acute pancreatitis. MR cholangiopancreatography (MRCP) confirmed features of this and, interestingly, an inflated gastrostomy balloon could be seen abutting the major and minor ampullae. The patient confirmed that the PEG tube had been changed to a balloon gastrostomy tube some time ago, but the external fixation plate (external bumper) had been loose lately, with the tube repeatedly moving inwards. She admitted that, 1 day before admission, the PEG tube had receded into the stomach and could not be pulled out with a gentle tug. After reviewing the MRCP images, the balloon was deflated, and the tube retracted. Once correctly placed, the balloon was reinflated, and her symptoms improved over the next 2 days.

A comparative study of Accuracy, Sensitivity, and Specificity of MR Cholangiopancreatography versus Ultrasonography for diagnosis of hepatobiliary and pancreatic pathologies

Background: The diagnosis of abdominal pathologies is a challenge and radiology is a very important tool in diagnosis. Various methods are often used for the diagnosis of such conditions. We in the present study tried to compare the efficacy of magnetic resonance cholangiopancreatography and ultrasonography in evaluating biliary duct diseases. Methods: The present study was conducted in the Department of Radiodiagnosis, Prathima Institute of Medical Sciences, Naganur, Karimnagar. All patients presenting with recurrent pancreatitis, hypochondriac pain, jaundice presenting to the radiology department are included in the present study. Patients with metallic implants, claustrophobia are excluded from the present study. Ultrasonography was performed using a Philips HD 15 and Philips affinity 70 machine. Both curvilinear and linear probes were used in the study. Images of the biliary tree were recorded for later review. MRI-MRCP was performed on Philips ACHIEVA 1.5 Tesla MRI Scanner. Results : In this study, n=13 subjects were clinically suspected to have cholelithiasis (n=7), choledocholithiasis (n=2), and both Cholelithiasis with choledocholithiasis (n=4). Ultrasonography was able to diagnose Cholelithiasis correctly in n=5 cases, choledocholithiasis in n=1 case, Cholelithiasis with choledocholithiasis in n=4 cases and rule out Cholelithiasis in n=2 cases, but failed to identify distal CBD calculus in n=1 case (choledocholithiasis) hence having a diagnostic accuracy of 92.31% for the cholelithiasis-choledocholithiasis group. Conclusion: MR Cholangiopancreatography is very accurate in demonstrating calculi at the distal end of CBD as an area of the signal void, also in demonstrating strictures as the cause of dilatation of biliary radicals. It showed the length of the stricture segment very well and differentiated stricture as malignant and benign.