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1. Banks PA, Freeman ML. Practice guidelines in acute pancreatitis. Am J Gastroenterol. 2006;101(10):2379-2400. Review/Other-Dx N/A Practice guideline for AP. N/A 4
2. Morgan DE. Imaging of acute pancreatitis and its complications. Clin Gastroenterol Hepatol. 2008;6(10):1077-1085. Review/Other-Dx N/A To describe the imaging evaluation of patients with AP by using the 1992 Atlanta Symposium classification and definitions to describe local complications depicted on contrast-enhanced CT. Correlation with the proposed revision of Atlanta Symposium definitions set forth by the Acute Pancreatitis Working Group is discussed. No results stated in abstract. 4
3. Singh VK, Bollen TL, Wu BU, et al. An assessment of the severity of interstitial pancreatitis. Clin Gastroenterol Hepatol. 2011;9(12):1098-1103. Observational-Dx 149 consecutive patients Primary aim of study was to examine the severity of interstitial pancreatitis among a cohort of nontransferred consecutive patients. The secondary aim was to compare severity between patients with interstitial pancreatitis and extrapancreatic necrosis. Among the patients with interstitial pancreatitis, the median Charlson comorbidity score was 1, the median APACHE II score was 7, and the median bedside index for severity of AP score was 1. In addition, the median length of hospital stay was only 4 days; only 1% had persistent organ failure and only 1% to 2% required intervention. The mortality rate of interstitial pancreatitis was 3%; it was associated significantly with comorbidity (the median Charlson comorbidity score scores of nonsurvivors and survivors was 4 and 1, respectively, P=.003). Patients with extrapancreatic necrosis had greater levels of disease severity, compared with patients with interstitial pancreatitis. 3
4. Acute Pancreatitis Classification Working Group. Revision of the Atlanta classification of acute pancreatitis (3rd revision). Accessed 7 September 2012. Review/Other-Dx N/A A revision of the Atlanta classification of AP is presented. N/A 4
5. Thoeni RF. The revised Atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment. Radiology. 2012;262(3):751-764. Review/Other-Dx N/A To review the importance of revised Atlanta classification of AP. N/A 4
6. Bollen TL. Imaging of acute pancreatitis: update of the revised Atlanta classification. Radiol Clin North Am. 2012;50(3):429-445. Review/Other-Dx N/A To review the cross-sectional imaging features of AP and present proposed definitions of the revised Atlanta classification. No results stated in abstract. 4
7. Uhl W, Warshaw A, Imrie C, et al. IAP Guidelines for the Surgical Management of Acute Pancreatitis. Pancreatology. 2002;2(6):565-573. Review/Other-Dx N/A International Association of Pancreatology guidelines for the surgical management of AP. 1) Mild AP is not an indication for pancreatic surgery. 2) The use of prophylactic broad-spectrum antibiotics reduces infection rates in CT-proven necrotizing pancreatitis but may not improve survival. 3) Fine-needle aspiration for bacteriology should be performed to differentiate between sterile and infected pancreatic necrosis in patients with sepsis syndrome. 4) Infected pancreatic necrosis in patients with clinical signs and symptoms of sepsis is an indication for intervention including surgery and radiological drainage. 5) Patients with sterile pancreatic necrosis (with negative fine-needle aspiration for bacteriology) should be managed conservatively and only undergo intervention in selected cases. 6) Early surgery within 14 days after onset of the disease is not recommended in patients with necrotizing pancreatitis unless there are specific indications. 7) Surgical and other forms of interventional management should favor an organ-preserving approach, which involves debridement or necrosectomy combined with a postoperative management concept that maximizes postoperative evacuation of retroperitoneal debris and exudate. 8) Cholecystectomy should be performed to avoid recurrence of gallstone-associated AP. 9) In mild gallstone-associated AP, cholecystectomy should be performed as soon as the patient has recovered and ideally during the same hospital admission. 10) In severe gallstone-associated AP, cholecystectomy should be delayed until there is sufficient resolution of the inflammatory response and clinical recovery. 11) Endoscopic sphincterotomy is an alternative to cholecystectomy in those who are not fit to undergo surgery in order to lower the risk of recurrence of gallstone-associated AP. 4
8. Singh VK, Wu BU, Bollen TL, et al. A prospective evaluation of the bedside index for severity in acute pancreatitis score in assessing mortality and intermediate markers of severity in acute pancreatitis. Am J Gastroenterol. 2009;104(4):966-971. Observational-Dx 397 consecutive cases of AP To prospectively evaluate the ability of the bedside index for severity of AP score to predict mortality as well as intermediate markers of severity in a tertiary center. Among 397 cases, there were 14 (3.5%) deaths. There was a statistically significant trend for increasing mortality (P<0.0001) with increasing bedside index for severity of AP score. The area under the ROC for mortality by bedside index for severity of AP score in the prospective cohort was 0.82 (95% CI: 0.70, 0.95), which was similar to that of the previously published validation cohort. A bedside index for severity of AP score =3 was associated with an increased risk of developing organ failure (OR =7.4, 95% CI: 2.8, 19.5), persistent organ failure (OR =12.7, 95% CI: 4.7, 33.9), and pancreatic necrosis (OR =3.8, 95% CI: 1.8, 8.5). 3
9. Wu BU, Conwell DL. Acute pancreatitis part I: approach to early management. Clin Gastroenterol Hepatol. 2010;8(5):410-416, quiz e456-418. Review/Other-Dx 1 patient Review diagnosis and management of AP. No results stated in abstract. 4
10. Arvanitakis M, Koustiani G, Gantzarou A, et al. Staging of severity and prognosis of acute pancreatitis by computed tomography and magnetic resonance imaging-a comparative study. Dig Liver Dis. 2007;39(5):473-482. Observational-Dx 35 patients studied; 22 had biliary AP Study aimed to examine: (1) the staging of AP by CT and MRI, (2) the correlation of CT and MR severity indices, and 3) the correlation of MRSI with CRP, Ranson score, duration of hospitalization and clinical outcome. 6/35 patients (17%) had necrotizing AP. 15/35 patients (43%) had severe AP according to Ranson criteria. A significant correlation was noted between MRSI and CRP (r = 0.419, P<0.005), Ranson score (r = 0.431, P<0.05), duration of hospitalization (r = 0.497, P<0.01) and clinical outcome (r = 0.420, P<0.05). Comparison of the imaging methods showed a significant correlation between MRSI and CTSI (r = 0.887, P<0.01). 3
11. Viremouneix L, Monneuse O, Gautier G, et al. Prospective evaluation of nonenhanced MR imaging in acute pancreatitis. J Magn Reson Imaging. 2007;26(2):331-338. Observational-Dx 90 patients To compare the value of nonenhanced-MRI with contrast-enhanced CT scan in assessing AP and in evaluating the severity index with clinical outcome. The coefficient correlation between CTSI and MRISI was good, with r = 0.6 (P<0.001). Considering contrast-enhanced CT scan as the gold standard, sensitivity , specificity , PPV, and NPV of nonenhanced-MRI for detecting severe AP based on imaging criteria were 100%, 82.6%, 100%, and 21%, respectively. Nonenhanced-MRI discriminates normal pancreatic parenchyma from edema and necrosis with a correlation between morbidity (P<0.008). 2
12. Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002;223(3):603-613. Review/Other-Dx N/A Advantages and limitations of the clinical, laboratory, and imaging prognostic indexes are analyzed and discussed. Contrast-enhanced CT is the imaging modality of choice to help stage the severity of inflammatory processes, detect pancreatic necrosis, and depict local complications. CT has been shown to yield an early overall detection rate of 90% with close to 100% sensitivity after 4 days for pancreatic gland necrosis. The CTSI has shown an excellent correlation with the development of local complications and the incidence of death in this population. 4
13. Chatzicostas C, Roussomoustakaki M, Vardas E, Romanos J, Kouroumalis EA. Balthazar computed tomography severity index is superior to Ranson criteria and APACHE II and III scoring systems in predicting acute pancreatitis outcome. J Clin Gastroenterol. 2003;36(3):253-260. Observational-Dx 78 patients To prospectively analyze the prognostic usefulness of four different scoring systems in separately assessing three variables; AP severity, development of organ failure and pancreatic necrosis. 44 patients were classified as mild and 34 as severe pancreatitis. When we compared likelihood ratios of positive test, only that for the Balthazar score (11.2157) was able to generate large and conclusive changes from pretest to post-test probability in AP severity prediction. Likelihood ratios of positive test were 2.4157 for Ranson, 4.0980 for APACHE II and 3.6670 for APACHE III score. The APACHE II and III scores and Ranson criteria performed slightly better than the Balthazar score in predicting organ failure (likelihood ratios of positive test: 4.0667, 3.2892, 3.0362 and 1.7941 respectively), while when predicting pancreatic necrosis the APACHE II and III performed slightly better than the Ranson score (likelihood ratios of positive test: 2.0769, 2.7500 and 1.7813 respectively). 3
14. Gurleyik G, Emir S, Kilicoglu G, Arman A, Saglam A. Computed tomography severity index, APACHE II score, and serum CRP concentration for predicting the severity of acute pancreatitis. JOP. 2005;6(6):562-567. Observational-Dx 55 consecutive patients To establish the value of the CTSI in predicting the severity of AP and to compare it with the accuracy of the APACHE II score and serum CRP concentrations. 13 patients had severe pancreatitis according to the Atlanta classification. The mean values of predictive markers in the mild and the severe pancreatitis groups were: CTSI 1.26 and 6.30 (P<0.001); APACHE II 4.14 and 8.61 (P<0.001); and CRP 96.0 mg/L and 192.4 mg/L (P<0.001), respectively. The sensitivity, specificity, PPV, NPV and accuracy were calculated for the CTSI (>3: 85%, 98%, 92%, 95%, and 95%), for APACHE II (=7: 62%, 86%, 57%, 88%, and 80%) and for CRP (=150 mg/L: 85%, 74%, 50%, 94%, and 76%). 3
15. Kaya E, Dervisoglu A, Polat C. Evaluation of diagnostic findings and scoring systems in outcome prediction in acute pancreatitis. World J Gastroenterol. 2007;13(22):3090-3094. Observational-Dx 199 consecutive patients To determine factors related to disease severity, mortality and morbidity in AP. Biliary pancreatitis was the most common form, followed by idiopathic pancreatitis (53% and 26%, respectively). 63 patients had severe pancreatitis and 136 had mild disease. Respiratory rate >20/min, pulse rate >90/min, increased CRP, LDH and aspartate aminotransferase levels, organ necrosis >30% on CT and leukocytosis were associated with severe disease. The rate of glucose intolerance, morbidity and mortality were 24.1%, 24.8% and 13.6%, respectively. CRP >142 mg/L, BUN >22 mg/dL, LDH >667 U/L, base excess >-5, CTSI >3 and APACHE score >8 were related to morbidity and mortality. 3
16. Kim YS, Lee BS, Kim SH, Seong JK, Jeong HY, Lee HY. Is there correlation between pancreatic enzyme and radiological severity in acute pancreatitis? World J Gastroenterol. 2008;14(15):2401-2405. Observational-Dx 119 patients To investigate the correlation between the changes of pancreatic enzyme, the biochemical markers and the clinical results according to the Balthazar CT grade. 83 patients (69.7%) were male, and the mean age of the patients was 57 +/- 15.7 years. The biliary pancreatitis patients had an older mean age. 49 patients (41.1%) had biliary pancreatitis and 46 (38.6%) had alcoholic pancreatitis. Group 3 patients had a longer duration of pain (2.51 +/- 1.16 vs 3.17 +/- 1.30 vs 6.56 +/- 6.13, P<0.001), a longer period of fasting (7.49 +/- 4.65 vs 10.65 +/- 5.54 vs 21.88 +/- 13.81, P<0.001) and a longer hospital stay (9.17 +/- 5.34 vs 14.63 +/- 8.65 vs 24.47 +/- 15.52, P<0.001) than the other groups. On the univariate analysis, the factors that affected the radiological grade were the leukocyte count at admission (P=0.048), the hemoglobin (P=0.016) and total bilirubin concentrations (P=0.023), serum lipase (P=0.009), the APACHE II scores at admission (P=0.017), the APACHE II scores after 24 h (P=0.031), the CRP titer (P=0.0001) and the follow-up CRP titer (P=0.003). But the CRP level (P=0.001) and follow up CRP titer (P=0.004) were only correlated with the radiological grade on multivariate analysis. According to the ROC curve, when we set the CRP cut off value at 83 mg/L, the likelihood ratio for a positive test was 3.84 and the likelihood ratio for a negative test was 0.26 in group 3. 3
17. Makela JT, Eila H, Kiviniemi H, Laurila J, Laitinen S. Computed tomography severity index and C-reactive protein values predicting mortality in emergency and intensive care units for patients with severe acute pancreatitis. Am J Surg. 2007;194(1):30-34. Observational-Dx 68 patients To examine the clinical and biochemical factors that may influence the risk of mortality on admission to emergency and ICUs. The mortality rate during the ICU stay was 18% (12/68) and that during the whole period of hospitalization 26% (18/68). A CRP value over 150 was the only independent predictor of mortality on admission into the emergency unit, whereas the CTSI and the elevated CRP value over 150 predicted significantly and independently mortality on admission into the ICU. Linear backward regression analysis showed that high CRP values and respiratory failure on ICU admission correlate with longer ICU stay. Men's ICU stays were longer than those of women. 3
18. Ocampo C, Zandalazini H, Kohan G, Silva W, Szelagowsky C, Oria A. Computed tomographic prognostic factors for predicting local complications in patients with pancreatic necrosis. Pancreas. 2009;38(2):137-142. Observational-Dx 138 patients To evaluate dynamic CT as a prognostic indicator of local complications in patients with pancreatic necrosis. Multivariate analysis identified the following prognostic factors for local complications: (1) extent of pancreatic necrosis (OR, 7.32; 95% CI, 1.32-23.76; P=0.015) and presence of peripancreatic necrosis (OR, 37.32; 95% CI, 3.77-369.38; P=0.002) were useful to predict the development of infected pancreatic necrosis; and (2) transparenchymal necrosis with upstream viable (enhancing) pancreas (OR, 36.22; 95% CI, 3.18-412.36; P=0.004) and no peripancreatic necrosis (OR, 0.016; 95% CI, 0.004-0.62; P<0.001) were associated with pseudocyst development. 3
19. Vriens PW, van de Linde P, Slotema ET, Warmerdam PE, Breslau PJ. Computed tomography severity index is an early prognostic tool for acute pancreatitis. J Am Coll Surg. 2005;201(4):497-502. Observational-Dx 79 patients To test the hypothesis that the CTSI, established within 48 hours after admission, is prognostic for morbidity and mortality and can predict the necessity for admission to an ICU. The overall complication rate was 57%; mortality was 9%. In patients with a CTSI of 0 to 3, these rates were 42% and 2%, respectively; in those with CTSI of 4 to 6, 81% and 19%, respectively; and in those with CTSI of 7 to 10, 100% and 33%, respectively. Outcomes of subsequent CT scans did not alter the initial prognosis. Early CTSI correlated well with the incidence of complications, sepsis, mortality, and necessity for ICU admission. 2
20. Casas JD, Diaz R, Valderas G, Mariscal A, Cuadras P. Prognostic value of CT in the early assessment of patients with acute pancreatitis. AJR. 2004;182(3):569-574. Observational-Dx 148 patients To investigate the prognostic value of early CT in AP, the role of pancreatic necrosis as an indicator of prognosis, and the need for the routine use of IV iodinated contrast material in early CT to assess prognosis in these patients. All complications (n=15) and deaths (n=4) occurred in patients with a CT grade of severe disease; differences as compared with mild grade were significant (P<0.001 and P<0.03, respectively). CT grade had a sensitivity and specificity of 100% and 61.6%, respectively, for predicting morbidity and 100% and 56.9% for predicting mortality. The 13 patients with necrosis were all in the severe group (P<0.001). Necrosis detection on early CT had a sensitivity and specificity of 53.3% and 90.2%, respectively, for predicting morbidity and 75% and 83.8% for mortality. 3
21. Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174(2):331-336. Observational-Dx 88 patients To analyze the prognostic value of the mitial CT examination as determined by the appearance of the pancreas during a bolus study. Of the 88 patients in the study, 66 (75%) recovered with medical treatment alone and were discharged, while 22 (25%) required surgical interventions. Surgical drainage of infected fluid collections (abscesses) was performed in 19 patients (22%), and internal drainage of pancreatic pseudocysts was performed in 3 patients (3%). 5 patients with abscesses died in the hospital (6%) after one or several surgical interventions. 3
22. Mortele KJ, Wiesner W, Intriere L, et al. A modified CT severity index for evaluating acute pancreatitis: improved correlation with patient outcome. AJR. 2004;183(5):1261-1265. Observational-Dx 266 consecutive patients To assess the correlation with patient outcome and interobserver variability of a modified CTSI in the evaluation of patients with AP compared with the currently accepted CTSI. When applying the modified index, the severity of pancreatitis and the following parameters correlated more closely than when the currently accepted index was applied: the length of the hospital stay (0-34 days) (modified index [P=0.0054-0.0714] vs current index [P=0.0052-0.3008]); the need for surgical or percutaneous procedures (10/66 patients) (modified index [P=0.0112] vs current index [P=0.0324]); and the occurrence of infection (21/66 patients) (modified index [P<1e(-10)] vs current index [P<1e(-04)]). Significant correlation between the severity of pancreatitis and the development of organ failure (9/66 patients) was seen only using the modified index (P=0.0024), not the current index (P=0.0513). The interobserver agreement was similar with the modified (kappa range, 0.71-0.85) and the current (kappa range, 0.63-0.86) indexes. 2
23. Bollen TL, Singh VK, Maurer R, et al. Comparative evaluation of the modified CT severity index and CT severity index in assessing severity of acute pancreatitis. AJR. 2011;197(2):386-392. Observational-Dx 196 patients To compare the modified CTSI with the CTSI regarding assessment of severity parameters in AP. Both CT indexes were also compared with the APACHE II index. Although for both CT indexes a significant relationship was observed between the score and each severity parameter (P<0.0001), no significant differences were seen between the CT indexes. Compared with the APACHE II index, both CT indexes more accurately correlated with the need for intervention (CTSI, P=0.006; modified CTSI, P=0.01) and pancreatic infection (CTSI, P=0.04; modified CTSI, P=0.06) and more accurately diagnosed clinically severe disease (area under the curve, 0.87; 95% CI, 0.82–0.92). Interobserver agreement was excellent for both indexes: for CTSI, 0.85 (95% CI, 0.80–0.90) and for modified CTSI, 0.90 (95% CI, 0.85–0.95). 2
24. Foitzik T, Bassi DG, Fernandez-del Castillo C, Warshaw AL, Rattner DW. Intravenous contrast medium impairs oxygenation of the pancreas in acute necrotizing pancreatitis in the rat. Arch Surg. 1994;129(7):706-711. Review/Other-Dx Animals To investigate the mechanism by which acute necrotizing pancreatitis is mediated. Oxygen saturation of hemoglobin was increased in animals with mild AP (mean [±SEM], 58.7%±1.2% vs 55.2%±1.5% in control animals; P<.05) and was decreased in animals with acute necrotizing pancreatitis (51.2%±1.2% vs 55.2%±1.5% P<.05). 15 minutes after the infusion of contrast medium, oxygen saturation of hemoglobin significantly decreased further in animals with acute necrotizing pancreatitis (51.4%±1.8% before infusion of contrast medium vs 46.1%±1.7% at 15 minutes; P<.05) and remained significantly below the comparable group receiving intravenous saline for the entire 60-minute test. 4
25. Kaiser AM, Grady T, Gerdes D, Saluja M, Steer ML. Intravenous contrast medium does not increase the severity of acute necrotizing pancreatitis in the opossum. Dig Dis Sci. 1995;40(7):1547-1553. Review/Other-Dx Animals To evaluate whether contrast medium may worsen the severity of AP. Administration of contrast agent during early stages of necrotizing pancreatitis in the opossum does not worsen the disease severity. The concept that administration of contrast medium during early stages of pancreatitis is dangerous and should not be accepted until additional experimental and clinical studies support its validity. 4
26. Saifuddin A, Ward J, Ridgway J, Chalmers AG. Comparison of MR and CT scanning in severe acute pancreatitis: initial experiences. Clin Radiol. 1993;48(2):111-116. Review/Other-Dx 7 patients To assess the value of MRI in patients with severe AP and compare with CT. Postgadolinium MRI was equivalent to contrast-enhanced CT in differentiating viable pancreatic parenchyma from areas of pancreatic necrosis. MRI identified the presence of gas in a case of pancreatic abscess but failed to identify small foci of pancreatic calcification demonstrated in one case by CT. MRI was also equivalent to CT in assessing the location and extent of peripancreatic inflammatory changes and fluid collections. However, MRI, particularly the T2-weighted spin echo, was superior to CT in characterizing the complex nature of such inflammatory changes in one case. 4
27. Vitellas KM, Paulson EK, Enns RA, Keogan MT, Pappas TN. Pancreatitis complicated by gland necrosis: evolution of findings on contrast-enhanced CT. J Comput Assist Tomogr. 1999;23(6):898-905. Review/Other-Dx 32 patients To investigate the natural history of pancreatic necrosis on contrast-enhanced CT in patients managed nonoperatively. The 32 patients had a mean Ranson clinical grade of 5.8 (range 3-8). 18/32 patients were managed nonoperatively and 14 patients required a necrosectomy after initial nonoperative management. In the 32 patients, the location of necrosis was in the head (3), body (6), tail (2), head/body (2), head/body/tail (9), body/tail (9), and head/tail (1). Extent of necrosis was 0%-25% (9), 26%-50% (6), 51%-75% (6), and 76%-100% (11). The extent of necrosis remained stable during follow-up in 22 (69%) patients and increased during follow-up in 10 (31%). Necrosectomy was performed in 6 (60%) patients in whom there was an increase in necrosis and 8 (36%) patients in whom necrosis was stable. No patient had restoration of normal enhancement in an area that was previously necrotic. There were 5 patients who were managed nonoperatively (mean follow-up 318 days) in whom the necrosis eventually resorbed, forming a focal parenchymal cleft reminiscent of a scar. 5/32 patients died. 4
28. Bollen TL, Singh VK, Maurer R, et al. A comparative evaluation of radiologic and clinical scoring systems in the early prediction of severity in acute pancreatitis. Am J Gastroenterol. 2012;107(4):612-619. Observational-Dx 150 patients To compare the accuracy of CT and clinical scoring systems for predicting the severity of AP on admission. Of 346 consecutive episodes of AP, there were 159 (46%) episodes in 150 patients (84 men, 66 women; mean age, 54 years; age range, 21-91 years) who were evaluated with a contrast-enhanced CT scan (n=131 episodes) or an unenhanced CT scan (n=28 episodes) on the first day of admission. Clinically severe AP was diagnosed in 29/159 (18%) episodes; 9 (6%) patients died. Overall, the Balthazar grading system (any CT technique) and CTSI (contrast-enhanced CT only) demonstrated the highest accuracy among the CT scoring systems for predicting severity, but this was not statistically significant. There were no statistically significant differences between the predictive accuracies of CT and clinical scoring systems. 3
29. Morgan DE, Ragheb CM, Lockhart ME, Cary B, Fineberg NS, Berland LL. Acute pancreatitis: computed tomography utilization and radiation exposure are related to severity but not patient age. Clin Gastroenterol Hepatol. 2010;8(3):303-308; quiz e333. Observational-Dx 869 patients To evaluate abdominal CT use among patients hospitalized for AP at a tertiary care hospital and compare estimated radiation doses with disease severity and patient age. The mean number of abdominopelvic CTs per patient, per hospitalization, was 1.9 (range, 1–12); the mean number was 3.0 over the 5-year period (range, 1–19). During hospitalization, each patient was exposed to a mean estimated radiation dose of 31.03± 26.4 mSv (range, 14.7–176.9 mSv). Patients with pancreatitis grades D or E (n=233) compared with grades A through C (n=333) had longer periods of hospitalization (mean, 23.3 vs 10.8 days; P<.001), more days as an inpatient (mean, 2.54 vs 1.45 d; P<.001), more total CT scans (mean, 4.02 vs 2.37; P<.001), and higher total effective radiation doses (mean, 53.5 vs 35 mSv; P<.0001). Linear regression revealed a relationship between dose and disease grade, but not patient age. 4
30. Mortele KJ, Ip IK, Wu BU, Conwell DL, Banks PA, Khorasani R. Acute pancreatitis: imaging utilization practices in an urban teaching hospital--analysis of trends with assessment of independent predictors in correlation with patient outcomes. Radiology. 258(1):174-81, 2011 Jan. Observational-Dx 252 patients To evaluate imaging utilization trends in patients with AP and to assess independent predictors of radiology usage in relation to patient outcomes. Mean utilization was 9.9 radiologic studies per patient (95% CI: 7.5, 12.3), with relative value unit of 7.8 (95% CI: 6.3, 9.4). Utilization was highest on day 0, declining rapidly by day 4; 53% of imaging occurred during initial hospitalization. Chest radiography (38%) and abdominal CT (17%) were the most commonly performed studies. Patients with longer hospital stay (P=.001), higher APACHE II score (P=.0012), higher pain levels (P=.003), drug-induced AP (P=.002), and prior episodes of AP (P<.001) underwent significantly more radiologic studies. After adjustment for confounders, a 2.5-fold increase in the use of high-cost (CT and MRI) examinations and a 1.4-fold increase in relative value units per case-mix-adjusted admissions (P<.05) were observed during the 2.5-year study period. This increased use was not associated with improvement in patient outcomes. 3
31. Ball CG, Correa-Gallego C, Howard TJ, et al. Radiation dose from computed tomography in patients with necrotizing pancreatitis: how much is too much? J Gastrointest Surg. 2010;14(10):1529-1535 Observational-Dx 238 patients To identify the frequency and effective radiation dose of CT imaging for patients with necrotizing pancreatitis. Necrosis was identified in 18% (238/1,290) of patients with AP (mean age = 53 years; hospital/ICU length of stay = 23/7 days; mortality = 9%). A median of 5 CTs/patient [interquartile range = 4] were performed during a median 2.6-month interval. The average effective dose was 40 mSv per patient (equivalent to 2,000 chest X-rays; 13.2 years of background radiation; one out of 250 increased risk of fatal cancer). The actual effective dose was 63 mSv considering various scanner technologies. CTs were infrequently (20%) followed by direct intervention (199 interventional radiology, 118 operative, 12 endoscopic) (median = 1; interquartile range = 2). MRI did not have a CT-sparing effect. Mean direct hospital costs increased linearly with CT number (R = 0.7). 4
32. Anderson SW, Lucey BC, Varghese JC, Soto JA. Accuracy of MDCT in the diagnosis of choledocholithiasis. AJR. 2006; 187(1):174-180. Observational-Dx 72 patients To evaluate the diagnostic performance of contrast-enhanced and unenhanced MDCT performed for various indications, in detecting choledocholithiasis. Unenhanced and contrast-enhanced MDCT images, interpreted in PACS workstations with axial images, are moderately sensitive and specific for showing choledocholithiasis. 2
33. Anderson SW, Rho E, Soto JA. Detection of biliary duct narrowing and choledocholithiasis: accuracy of portal venous phase multidetector CT. Radiology. 2008;247(2):418-427. Observational-Dx 94 patients 94 patients To retrospectively evaluate the sensitivity and specificity of 64-detector CT in the portal venous phase by using transverse images and both multiplanar and minimum intensity reformations for the detection of biliary duct narrowing and choledocholithiasis, with MRCP or ERCP as the reference standard. 2
34. Golea A, Badea R, Socaciu M, Diaconu B, Iacob D. Quantitative analysis of tissue perfusion using contrast-enhanced transabdominal ultrasound (CEUS) in the evaluation of the severity of acute pancreatitis. Med Ultrason. 2010;12(3):198-204. Observational-Dx 25 patients 25 patients To assess the role of contrast enhanced US in appreciating the severity of AP by quantitative analysis of the degree of vascularization and the areas of pancreatic parenchymal necrosis. 3
35. Ripolles T, Martinez MJ, Lopez E, Castello I, Delgado F. Contrast-enhanced ultrasound in the staging of acute pancreatitis. Eur Radiol. 2010;20(10):2518-2523. Observational-Dx 50 consecutive patients To determine the diagnostic value of contrast-enhanced US in the assessment of AP, with CT as the reference standard. A significant correlation between CT and contrast-enhanced US was found for the CTSI (r = 0.926), extent of necrosis (r = 0.893) and Balthazar grade (r = 0.884). The sensitivity, specificity, PPV and NPV for detecting severe AP based on CT findings (severity index >3 and/or presence of necrosis) were respectively 91%, 100%, 100% and 83%. A significant correlation between contrast-enhanced US severity index and clinical variables was found: Ranson score (r = 0.442), CRP levels 48 h after admission (r = 0.385) and length of hospital stay (r = 0.362). 2
36. Arvanitakis M, Delhaye M, De Maertelaere V, et al. Computed tomography and magnetic resonance imaging in the assessment of acute pancreatitis. Gastroenterology. 2004;126(3):715-723. Observational-Dx 39 patients To compare the accuracy of MRI with CT in assessing AP and to explore the correlation between MRI findings and clinical outcome. A strong correlation was demonstrated between CTSI and MRSI on admission and 7 days later. MRSI on admission correlated with the following: the Ranson score, CRP levels 48 hours after admission, duration of hospitalization, and clinical outcome regarding morbidity, including local and systemic complications. Considering the Ranson score as the gold standard, MRI detected severe AP with 83% (58–96, 95% CI) sensitivity, 91% (68–98) specificity vs 78% (52–93) and 86% (63–96) for CT. MRCP after IV secretin injection showed pancreatic duct leakage in 3 patients (8%). 1
37. Kim YK, Kim CS, Han YM. Role of fat-suppressed t1-weighted magnetic resonance imaging in predicting severity and prognosis of acute pancreatitis: an intraindividual comparison with multidetector computed tomography. J Comput Assist Tomogr. 2009;33(5):651-656. Observational-Dx 31 patients To determine the diagnostic value of MR grading focusing on elevated signal on T1-weighted images in the prediction of severity and prognosis of AP as compared with the Balthazar CT grading. There was a significant correlation between CT and MR gradings for pancreatic or peripancreatic inflammation (r = 0.688, P<0.01). However, for all of the outcome parameters and outcome grading, a stronger correlation was seen with the MR grading than with the CT grading. No significant correlation was found between CT grading and infected necrosis (r = 0.316, P=0.083). 3
38. Tang W, Zhang XM, Xiao B, et al. Magnetic resonance imaging versus Acute Physiology And Chronic Healthy Evaluation II score in predicting the severity of acute pancreatitis. Eur J Radiol. 2011;80(3):637-642. Observational-Dx 94 patients To study the correlation between established MRI criteria of disease severity in AP and the APACHE II score, and to assess the utility of each prognostic indicators in AP. In patients with pancreatitis, no significant correlation can be found between the APACHE II score and the MRSI score (P=0.196). The MRSI score correlated well with morbidity (P=0.006) but not with mortality (P=0.137). The APACHE II score correlated well with mortality (P=0.002) but not with the morbidity (P=0.112). The MRSI score was superior to the APACHE II score as a predictor of the length of hospitalization (r=0.52 vs r=0.35). A high MRSI and APACHE II score correlated with the need for being in the ICU (P=0.000 and P=0.000, respectively). 2
39. Mofidi R, Lee AC, Madhavan KK, Garden OJ, Parks RW. The selective use of magnetic resonance cholangiopancreatography in the imaging of the axial biliary tree in patients with acute gallstone pancreatitis. Pancreatology. 2008;8(1):55-60. Observational-Dx 249 patients To assess the impact following the introduction of MRCP in the management of acute gallstone pancreatitis in a tertiary referral unit. There was no significant difference in serum bilirubin levels [ERCP 43 mmol/l (18-204) vs MRCP 39 mmol/l (24-180), P=NS] or the proportion of patients with CBD stones [ERCP 10 (17.5%) vs MRCP 7 (14.2%), P=NS] between the two groups. Patients who underwent MRCP had a shorter median hospital stay [MRCP 5 days (range: 3-14) vs ERCP 9 days (range: 4-20), P<0.01] and higher rate of cholecystectomy during the index admission (MRCP 83.3% vs ERCP 67.2%, P<0.05). There was a high degree of correlation between preoperative MRCP results and findings of subsequent intraoperative cholangiogram or therapeutic ERCP (area under ROC curve: 0.94). 3
40. Macari M, Finn ME, Bennett GL, et al. Differentiating pancreatic cystic neoplasms from pancreatic pseudocysts at MR imaging: value of perceived internal debris. Radiology. 2009;251(1):77-84. Observational-Dx 22 patients; 2 readers To retrospectively evaluate the sensitivity and specificity of several morphologic findings that may be seen with cystic pancreatic lesions, in the diagnosis of pseudocyst at MRI. The readers' assessments of the presence or absence of cystic debris were concordant for 40 (95%) of the 42 patients, with a kappa coefficient of 0.889, which indicated nearly perfect agreement. 13 (93%) of 14 lesions found to have debris by either or both readers were pseudocysts, and only one (4%) of the 22 cystic neoplasms had debris. Both readers were more likely to identify septa within cystic neoplasms than within pseudocysts; however, the difference was not significant for either reader. The readers were more likely to observe microlobulated morphology in cystic neoplasms than in pseudocysts, with the difference between these lesion types, in terms of prevalence of microlobulated morphology, exhibiting a trend toward-but not reaching-statistical significance (P=.0627). 2
41. Mark DH, Lefevre F, Flamm CR, Aronson N. Evidence-based assessment of ERCP in the treatment of pancreatitis. Gastrointest Endosc. 2002;56(6 Suppl):S249-254. Review/Other-Dx N/A Article reports the results of an evidence based assessment of ERCP for the treatment of pancreatitis. Available evidence suggests that early ERCP reduces complications in patient populations with AP and signs and symptoms suggesting biliary obstruction. 4
42. Napoleon B, Dumortier J, Keriven-Souquet O, Pujol B, Ponchon T, Souquet JC. Do normal findings at biliary endoscopic ultrasonography obviate the need for endoscopic retrograde cholangiography in patients with suspicion of common bile duct stone? A prospective follow-up study of 238 patients. Endoscopy. 2003;35(5):411-415. Observational-Dx 238 patients To determine whether normal findings at initial EUS obviated the need for ERC. During follow-up, 59 (25 %) patients underwent cholecystectomy, with (n=31) or without (n=28) cholangiography, and 30 patients underwent ERC (13 %). CBD stone was found in 14 (6 %) patients. Of these 30 patients, ERC was done in 15 cases in the first week after EUS, because of persistent suspicion of a CBD stone which was found in 10 patients. The 15 late ERC procedures (carried out more than 1 week after EUS) revealed only one CBD stone. The NPV of EUS for the diagnosis of CBD stones was 95.4 %. 3
43. Adler DG, Baron TH, Davila RE, et al. ASGE guideline: the role of ERCP in diseases of the biliary tract and the pancreas. Gastrointest Endosc. 2005;62(1):1-8. Review/Other-Dx N/A Guideline on the role of ERCP in diseases of the biliary tract and the pancreas. N/A 4
44. Harrison ME, Anderson MA, Appalaneni V, et al. The role of endoscopy in the management of patients with known and suspected colonic obstruction and pseudo-obstruction. Gastrointest Endosc. 2010;71(4):669-679. Review/Other-Dx N/A Guideline on the role of endoscopy in patients with suspected choledocholithiasis. N/A 4