Necrotizing pancreatitis

Case contributed by Dr Mohamed Mahmoud Elthokapy


Known diabetic patient presented with severe abdominal pain and vomiting not relieved by medications for 8 days as well as abdominal swelling.

Patient Data

Age: 60 years
Gender: Male

The pancreas is seen enlarged in size, showing irregular contour, heterogeneously mixed textures with mainly its body is the seat of intra-pancreatic and peripancreatic walled off heterogeneous collections, and are seen distending the lesser sac. Another loculated heterogeneous collection is seen related to the gastro-hepatic ligament and porta-hepatis region. This is associated with marked smudging and haziness of fat planes with peripancreatic phlegmon/ collection causing significant stretching of the stomach anteriorly and pyloro-duodenal segment to the right side. No obvious intra-parenchymal gases foci were detected.

Slightly prominent regional lymph nodes are also noted.

Patent celiac and mesenteric arteries with obliterated peri-vascular fat planes.  

Fairly opacified portal vein, branches, and divisions, apart from a mildly attenuated confluence of SMV with the splenic vein. 

Moderate amount of free intra-peritoneal collection is also seen filling peritoneal recesses extending to para-renal spaces, para-colic gutters as well as caudally extending to pelvic recess. Additionally, retro-crural fluid extension with bilateral pleural effusion is additionally seen.  Another localized walled-off collection is noted at the left subphrenic region.

Thickened gastric and intestinal walls more at the upper abdomen with edematous submucosal lining and blurred mesenteric fat planes.  Heterogeneously smudged peritoneal and mesenteric fat diffusely with misty mesentery.   Thickened bilateral renal fascias and blurred perinephric fat planes.

The liver appears mildly enlarged in size with non-homogeneous texture, yet no definite focal lesion or intra-hepatic biliary radicles dilatation. A right renal small stone is incidentally noted.

Catheterized urinary bladder. NG tube is noted. Edematous abdominal wall muscles with subcutaneous diffuse edematous changes. 

The rest of the abdominal and pelvic organs are within normal limits

The patient underwent surgical laparotomy with drainage of heterogeneous collections and debridement of necrotic tissues.

6 months later


Significant improvement and resolution of the previous findings.

Case Discussion

The first CT findings are of necrotizing pancreatitis associated with peri-pancreatic collection and phlegmon as well as free intraperitoneal collections and bilateral pleural effusions. 

Modified CT severity index (Modified Balthazar grading) = 8 (maximum score = 10).

The findings of the post-operative follow-up study revealed significant improvement.

Key teaching points:

  1. Hypoenhancing (necrotic) areas of the pancreas have increased conspicuity on narrow (liver) windows.
  2. When there is necrotizing pancreatitis, the collections about the pancreas are referred to as "acute necrotic collections" until around week 4 when they are organized, and then are referred to as "walled-off necrosis".

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