Medical Image of the Week: Necrotizing Pancreatitis

Figure 1. Contrast-enhanced CT of the abdomen and pelvis demonstrates innumerable foci of gas adjacent to the pancreatic head/body junction (red arrow) with marked inflammation of the pancreatic head (blue arrow). These findings are consistent with necrotizing pancreatitis.

A 60-year-old man with a past medical history significant for coronary artery disease status post percutaneous coronary intervention was admitted to Banner University Medical Center for acute pancreatitis complicated by a pericardial effusion requiring pericardiocentesis. The following day, the patient developed severe shortness of breath requiring increasing amounts of supplemental oxygen. The patient was emergently transferred to ICU for noninvasive bilevel positive airway pressure ventilation, but he subsequently required intubation. Throughout his worsening condition, he denied any abdominal pain, only relaying ongoing substernal chest pain. His troponins, however, remained negative and echocardiography failed to show any reaccumulation of the pericardial effusion.

CT scan of the chest failed to show any pulmonary embolism. But, CT abdomen displayed acute pancreatitis complicated by peripancreatic gas consistent with necrotizing pancreatitis (Figure 1). Emergent laparotomy was completed. There were no signs of stomach or duodenal perforation. Purulent fluid was removed from the lesser sac and an irrigating stump was placed.

Hem Desai MD¹, Tammer Elani MD¹, Nour Alhoda Parsa MD¹ and Kareem Ahmad MD²

¹Department of Internal Medicine and ²Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

University of Arizona

Tucson, AZ

Reference

1. Thoeni RF. The revised Atlanta classification of acute pancreatitis: Its importance for the radiologist and its effect on treatment. Radiology. 2012;262(3):751-64. [CrossRef] [PubMed]

Reference as: Desai H, Elani T, Parsa NA, Ahmad K. Medical image of the week: necrotizing pancreatitis. Southwest J Pulm Crit Care. 2015;11(2):84-5. doi: http://dx.doi.org/10.13175/swjpcc080-15 PDF

Medical Image of the Week: Pancreatic Abscess

Figure 1. CT scan of the abdomen showing fluid collections (arrows).

Figure 2. Ultrasound of the abdomen showing a distended pancreatic duct, which communicates to an inferior fluid collection, likely a pseudo-cyst.

Figure 3. Coronal CT of the abdomen and pelvis showing pelvic abscess (arrow). 

A 55 year old woman, with a history of alcohol abuse and necrotizing pancreatitis, was readmitted for worsening abdominal pain and acute respiratory failure. A CT scan of the abdomen and pelvis showed an atrophic pancreas and multiple fluid collections. Along the inferior surface of the pancreas, there is a fluid collection with an evolving loculated rim, which is asymmetric, the larger component measure 2.9 cm x 4.7 cm (Figure 1, large arrow). Anterior to the body of the pancreas, there is an additional 2.2 cm x 2.4 cm with evolving loculated rim (Figure 1, short arrow), both compatible with a pseudocyst.  Ultrasound of the abdomen showed a distended pancreatic duct that communicates to the smaller fluid collection (Figure 2).  Coronal CT of the abdomen and pelvis showed a 12.4 cm pelvic abscess (Figure 3). CT guided drainage of the pelvic abscess was performed with positive culture of the fluid for E. coli. She developed secondary peritonitis and had a successful exploratory laparotomy.

Carmen Luraschi-Monjagatta MD, Mohammed Alzoubaidi MD, and Elizabeth Ulliman MD

Department of Pulmonary, Allergy, Sleep and Critical Care.

Internal Medicine, South Campus.

University of Arizona

Tucson, Arizona

Reference as: Lurachi-Monjagatta C, Alzoubaidi M, Ullman E. Medical image of the week: pancreatic abscess. Southwest J Pulm Crit Care. 2014;8(2):126-7. doi: http://dx.doi.org/10.13175/swjpcc017-14 PDF

Medical Image of the Week: Hypertriglyceridemia-induced Pancreatitis

Figure 1. Panel A. Abdominal CT scan showing pancreatitis with edema and indistinct pancreatic borders (arrows). Panel B. Patient’s milky serum sample from elevated triglycerides. 

A 38 year old man presented with diffuse abdominal pain and was found to have pancreatitis on abdominal CT image (Figure 1, Panel A). His triglyceride level was 4573 mg/dL and his serum red top tube was visibly lipemic (Figure 1, Panel B).  He underwent one cycle of plasmapheresis and his triglyceride level decreased to below 500mg/dL.

Nathaniel Reyes, MD and Gordon Carr, MD

Division of Pulmonary and Critical Care Medicine

Arizona Respiratory Center

University of Arizona

Tucson, AZ

Reference as: Reyes N, Carr G. Medical image of the week: hypertriglyceridemia-induced pancreatitis. Southwest J Pulm Crit Care 2013;6(1):22. PDF

Ground-Glass Opacities

Reference as: Gopal V, Robbins RA. Ground-glass opacities. Southwest J Pulm Crit Care 2011;2:67-70. (Click here for PDF version)

A 54-year-old male was admitted to the medical intensive care unit complaining of abdominal pain, nausea, and vomiting for 2 days. He had a past medical history of pancreatitis in 2009, treated as outpatient, and asthma treated with albuterol inhaler as needed. His medication list included gemfibrizol, gabapentin, and amitriptyline. He drank 6-8 beers per day and smoked 1 pack-per-day for the past 40 years.

On physical examination is the patient was afebrile, his lungs are clear to auscultation, but tenderness was present in both lower quadrants. The remainder of the physical examination was normal.

Laboratory examination revealed a normal complete blood count and normal basic metabolic panel. Abnormal laboratory values included an elevated total bilirubin of 2.7 mg/dL (normal 0.2-1 mg/dL); alkaline phophatase 169 U/L (normal 10-40 U/L);  alanine aminotransferase 286 U/L (normal 10-35 U/L); amylase 468 U/L (normal 25-125 U/L), and lipase 1580 U/L (normal 8-78 U/L). Arterial blood gasmeasurements showed PaO_{2 =} 91 mm Hg, PaCO₂ = 26 mm Hg, pH = 7.52, and oxygen saturation = 98% while breathing room air.

Chest radiography (Figure 1, Panel A) was interpreted as showing a “right upper lobe infiltrate which could represent an acute pneumonia”.  No distinct abnormalities were identified on abdominal radiographs (Figure 1, Panel B).

 Figure 1. Panel A. Frontal chest radiography.  Panel B. Abdominal radiography.

To further evaluate the possibility of a right upper lobe abnormality at chest radiography, thoracic CT was performed and as showing patchy ground-glass opacities throughout the lungs bilaterally (Figure 2).

Figure 2. Representative images from thoracic CT.

Question 1. What’s the most likely diagnosis?

1. Hypersensitivity pneumonitis
2. Acute inhalational injury secondary to “huffing”.
3. Drug-induced lung disease
4. Valley Fever
5. Ground-glass opacities associated with pancreatitis

Question 2. What would you do next?

1. Hypersensitivity panel
2. Bronchoscopy with bronchoalveolar lavage
3. Begin Diflucan
4. Broaden his antibiotic coverage
5. Repeat the thoracic CT scan in 3-4 days.

The thoracic CT was repeated four days later and the ground-glass opacities seen previously had largely resolved (Figure 3).

Figure 3.  Representative images from thoracic CT performed four days following the initial study Figure 2).

These ground-glass opacities likely represent subclinical non-cardiogenic pulmonary edema in the setting of acute pancreatitis. Ground-glass opacities are foci of increased lung attenuation that do not obscure underlying vessels or bronchial margins (1). Ground-glass opacities often represent parenchymal abnormalities below the spatial resolution of high-resolution CT of the lung. Although the differential diagnosis of ground-glass opacities at high-resolution CT is large, these etiologies may be broadly divided into acute or chronic causes. Table 1 lists some of the more common causes of ground-glass opacities at high-resolution CT.

Table 1: Common Etiologies for Ground-Glass Opacity at Thoracic CT

Acute	Chronic
Pulmonary edema (cardiogenic or non-cardiogenic)	Interstitial diseases (hypersensitivity pneumonitis, desquamative interstitial pneumonia, respiratory bronchiolitis-interstitial lung disease, nonspecific interstitial pneumonia, sarcoidosis, others)
Infectious pneumonitis (PJP, CMV, HSV, RSV, others)	Bronchoalveolar carcinoma
Noninfectious pneumonitis (hypersensitivity pneumonitis, acute inhalational exposures, drug-induced lung diseases)	Other causes (drug toxicity, pulmonary alveolar proteinosis, organizing pneumonia, chroic eosinophilic pneumonia, others)

Our patient had no apparent cause, other than subclinical non-cardiogenic pulmonary edema secondary to pancreatitis. Pulmonary edema is a well known complication of pancreatitis and can be severe (2). It seems likely that, as more sensitive methods for the detection of pulmonary abnormalities, such as thoracic CT, are increasingly applied to patients with pancreatitis, that subclinical pulmonary injury may be increasingly detected.

Venu Gopal, M.D.

Chief, Infectious Disease, Phoenix VA Medical Center

Richard A. Robbins, M.D.

Chief, Pulmonary and Critical Care, Phoenix VA Medical Center

Slide Set

References

1. Miller WT Jr, Shah RM.  Isolated diffuse ground-glass opacity in thoracic CT: causes and clinical presentations.  AJR Am J Roentgenol 2005;184:613-22.
2. Raghu MG, Wig JD, Kochhar R, Gupta D, Gupta R, Yadav TD, Agarwal R, Kudari AK, Doley RP, Javed A. Lung complications in acute pancreatitis. JOP. 2007;8:177-85.