Dharani Subramaniam,MBBS Gillian Leiberman,MD COMPUTED TOMOGRAPHIC COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITIS ANALYSIS OF PANCREATITIS NOVEMBER,2004 DHARANI SUBRAMANIAM,MBBS HARVARD MEDICAL INTERNATIONAL SRI RAMACHANDRA MEDICAL COLLEGE & RESEARCH INSTITUTE GILLIAN LEIBERMAN,MD
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Dharani Subramaniam,MBBS
Gillian Leiberman,MD
COMPUTED TOMOGRAPHIC COMPUTED TOMOGRAPHIC ANALYSIS OF PANCREATITISANALYSIS OF PANCREATITIS
NOVEMBER,2004
DHARANI SUBRAMANIAM,MBBS
HARVARD MEDICAL INTERNATIONAL
SRI RAMACHANDRA MEDICAL COLLEGE & RESEARCH INSTITUTE
GILLIAN LEIBERMAN,MD
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Dharani Subramaniam,MBBS
Gillian Leiberman,MD
PANCREATIC EMBRYOLOGYPANCREATIC EMBRYOLOGY
5TH WEEK 6TH WEEK
Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000.
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1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
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Dharani Subramaniam,MBBS
Gillian Leiberman,MD
Normal anatomy of pancreasNormal anatomy of pancreas
Management of patient 1Management of patient 1NPONPOTPNTPNAntibioticsAntibioticsAnalgesicsAnalgesicsRespiratory supportRespiratory supportFollowFollow--upup
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Resolved pancreatitis in Patient 1Resolved pancreatitis in Patient 1Normal attenuating
pancreas in patient 1 after conservative management
NonenhancedNonenhancedtransverse CT image transverse CT image shows findings of shows findings of pancreatitispancreatitis with with direct extension of direct extension of the inflammatory the inflammatory process into the process into the phrenicocolicphrenicocolicligament (arrow), ligament (arrow), which results in which results in narrowing at the narrowing at the splenicsplenic flexure. Note flexure. Note also the extension of also the extension of exudateexudate into the into the anterior anterior pararenalpararenalspace (arrowheads). space (arrowheads).
Is this a mass lesion?Is this a mass lesion?Frontal radiograph from solidFrontal radiograph from solid-- column barium enema column barium enema examination in a 37examination in a 37--yearyear--old old man with man with pancreatitispancreatitis shows shows marked, eccentric luminal marked, eccentric luminal narrowing and mucosal narrowing and mucosal irregularity at the irregularity at the splenicsplenic flexure (arrows) where the flexure (arrows) where the colon returns to the colon returns to the retroperitoneumretroperitoneum. Although the . Although the appearance suggests appearance suggests malignancy, only benign malignancy, only benign inflammation extending into inflammation extending into the the phrenicocolicphrenicocolic ligament ligament from the pancreas was found from the pancreas was found at surgery and at surgery and histopathologichistopathologic examination. examination.
ROLE OF ULTRASOUND IN ACUTE ROLE OF ULTRASOUND IN ACUTE PANCREATITISPANCREATITIS
WHEN CT FAILS TO SHOW GALLSTONES OR IMPACTED WHEN CT FAILS TO SHOW GALLSTONES OR IMPACTED COMMON BILE DUCTCOMMON BILE DUCTMONITOR A RESOLVING PSEUDOCYSTMONITOR A RESOLVING PSEUDOCYST
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MAJOR LIMITATIONS OF ULTRASOUNDMAJOR LIMITATIONS OF ULTRASOUNDBOWEL GAS BOWEL GAS INABILITY TO DEFINE THE COMPLEX SPREAD OF INFECTION INABILITY TO DEFINE THE COMPLEX SPREAD OF INFECTION
ALONG FASCIAL PLANESALONG FASCIAL PLANESCANNOT REVEAL AREAS OF PANCREATIC NECROSIS IN PATIENTS CANNOT REVEAL AREAS OF PANCREATIC NECROSIS IN PATIENTS
WITH SEVERE PANCREATITISWITH SEVERE PANCREATITISCANNOT REVEAL MANY VASCULAR AND GASTROINTESTINAL CANNOT REVEAL MANY VASCULAR AND GASTROINTESTINAL
COMPLICATIONSCOMPLICATIONSIMAGINE A PROBE ON A PATIENT WITH AN ACUTE ABDOMINAL IMAGINE A PROBE ON A PATIENT WITH AN ACUTE ABDOMINAL
PRESENTATIONPRESENTATION
ULTRASOUND TRANSDUCER
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COMPUTED TOMOGRAPHY IS CONSIDERED THECOMPUTED TOMOGRAPHY IS CONSIDERED THE GOLD STANDARDGOLD STANDARD
IN IMAGING PANCREATITISIN IMAGING PANCREATITIS
SENSITIVITY IN ACUTE PANCREATITIS- 77%-92%
SPECIFICITY IN ACUTE PANCREATITIS- 100%
REMEMBER CT MAY APPEAR NORMAL IN 14-28% OF MILD PANCREATITIS
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INDICATIONS OF CTINDICATIONS OF CTTO CONFIRM THE DIAGNOSIS TO CONFIRM THE DIAGNOSIS
IN SEVERE PANCREATITIS TO RULE OUT COMPLICATIONS AND IN SEVERE PANCREATITIS TO RULE OUT COMPLICATIONS AND STAGE THE DISEASESTAGE THE DISEASE
CLINICAL EVIDENCE OF SUDDEN DETERIORATION OR CLINICAL EVIDENCE OF SUDDEN DETERIORATION OR COMPLICATIONSCOMPLICATIONS
UNRESPONSIVE TO 72 HOURS OF CONSERVATIVE THERAPYUNRESPONSIVE TO 72 HOURS OF CONSERVATIVE THERAPY
Gallstone-induced pancreatitis in a 27-year-old woman.Transverse CT scan obtained with intravenous and oral contrast material reveals a large, edematous, homogeneously attenuating (73-HU) pancreas (1) and peripancreatic inflammatory changes (white arrows). Although the attenuation values are low, there is no pancreatic necrosis.Calcified gallstones are seen in gallbladder (black arrow).2 = liver (140 HU).
EMIL J.BALTHAZAR,MD ACUTE PANCREATITIS:ASSESMENT OF SEVERITY WITH CLINICAL AND CT EVALUATION;RADIOLOGY2002;223:603-613
Axial, enhanced Axial, enhanced CT scans of the CT scans of the upper abdomen upper abdomen show extensive show extensive
gas in the region gas in the region of the body andof the body and
tail of the tail of the pancreas with pancreas with
infiltration of the infiltration of the peripancreaticperipancreatic fatfat
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Chronic pancreatitisChronic pancreatitis
Arrows show multiple calcifications within the pancreatic duct which is dilated.
Medline medical encyclopedia
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WHAT DO I LOOK FOR NEXT?WHAT DO I LOOK FOR NEXT?LOOK FOR COMPLICATIONS OF LOOK FOR COMPLICATIONS OF PANCREATITIS PANCREATITIS PSEUDOCYSTSPSEUDOCYSTSABSCESSABSCESSNECROSISNECROSISVENOUS THROMBOSISVENOUS THROMBOSISPSEUDOANEURYSMPSEUDOANEURYSMHAEMORRHAGEHAEMORRHAGEPANCREATIC PLEURAL EFFUSIONPANCREATIC PLEURAL EFFUSIONPANCREATIC ASCITESPANCREATIC ASCITES
Pseudocyst
Haemorrhage
Obstruction
Thrombosis
Rupture
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Pancreatic Pancreatic PseudocystPseudocyst
Pseudocyst of pancreas
Bidmc,pacs
Bidmc,pacs
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PseudocystPseudocyst in in saggitalsaggital planeplane
Ileus Secondary to Pancreatic Pseudocyst : A Case Report
Süleyman Büyükberber, MD et al;TURGUT OZAL TIP MERKEZI DERGISI 1996:3(2):124-126
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HAEMORHAGE INTO A HAEMORHAGE INTO A PSEUDOCYSTPSEUDOCYST
Hemorrhagic pancreatic pseudocyst
in a 57-year-old man who presented with acute abdominal pain. Axial CT scan obtained with intravenous contrast demonstrates calcifications from chronic pancreatitis in the head of the pancreas. A high-attenuation focus of blood (arrow) is seen within the low-attenuation pseudocyst, a finding that is consistent with hemorrhage.
Portal venous thrombosisPortal venous thrombosisPortal venous thrombus not
occluding the vein completely
Pseudocyst with extension into the pararenal spaces
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BIDMC PACSBIDMC PACS
EXTENSION OF PSEUDOCYST IN THE PARA RENAL SPACE, REMEMBER THAT EXTENSION POSTERIORLY INTO THE PARARENAL SPACE IS RARE,IT ACTUALLY
TRACKS IN A SPACE BETWEEN GREOTA’S FASCIA AND THE LATEROCONAL FASCIA RESEMBLING AN INVOLVEMENT OF POSTERIOR PARARENAL SPACE
VassiliosVassilios raptopoulos,MD.Paulraptopoulos,MD.Paul K K Kleinman,MD.SandryKleinman,MD.Sandry Marks,jr.,DDS,PhD.MarjorieMarks,jr.,DDS,PhD.Marjorie Snyder,BS.paulSnyder,BS.paul M silverman,MD(1986)Renal M silverman,MD(1986)Renal fascialfascial pathway:Posteriorpathway:Posterior extension extension of pancreatic effusions within the anterior of pancreatic effusions within the anterior pararenalpararenal space.Radiology.158:367space.Radiology.158:367--374374
Pancreatic abscess in a 40 year-old man with acute pancreatitis. Axial CT scan obtained with rapid bolus administration of intravenous contrast material shows an air-fluid level (A) in the lesser sac anterior to the underlying pancreas (arrow), whose enhancement implies viability.
Bidmc,pacs
AA
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PANCREATIC NECROSIS PANCREATIC NECROSIS AREA OF FOCAL NON
ENHANCEMENT
EVIDENCE OF NECROSIS
The current case demonstrates findings of both acute and necrotizing pancreatitis.
Following a bolus injection, there is enhancement of the parenchyma in the body and tail but persistent low attenuating areas are identified in
the pancreatic head
Uhrad.com radiology teaching files
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Pancreatic necrosisPancreatic necrosisIf necrosis occurs, it tends to occur early in course of If necrosis occurs, it tends to occur early in course of disease disease Diagnosis depends upon clinical presentation and Diagnosis depends upon clinical presentation and presence of gas in presence of gas in retroperitoneumretroperitoneum
Diagnosis of necrosis on CTDiagnosis of necrosis on CTFocal or diffuse Focal or diffuse WellWell--marginatedmarginatedArea of Area of parenchymalparenchymal nonnon--enhancement enhancement >3cm >3cm Infected pancreatic necrosis recognized at helical CT asInfected pancreatic necrosis recognized at helical CT as
Bubbles of gas within areas of pancreas Bubbles of gas within areas of pancreas Or, collection of gas and tissue within the Or, collection of gas and tissue within the
retroperitoneumretroperitoneum
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Pancreatic necrosisPancreatic necrosis
E. Coli can infect necrotic pancreas E. Coli can infect necrotic pancreas Produces gas in body of pancreas and Produces gas in body of pancreas and retroperitoneumretroperitoneum
Emphysematous pancreatitis warrants Emphysematous pancreatitis warrants Early use of antibiotics Early use of antibiotics PercutaneousPercutaneous drainage of fluid collections drainage of fluid collections If no response If no response
Surgical resection of infected necrotic tissue Surgical resection of infected necrotic tissue
Carries grave prognosis Carries grave prognosis
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PANCREATIC NECROSISPANCREATIC NECROSIS
FOCAL NONENHACING REGION OF THE
PANCREAS INVOLVING MORE
THAN 3 CM OF THE BODY OF THE
PANCREAS IN THE POST CONTRAST
CT
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IS THERE ANYTHING ELSE?IS THERE ANYTHING ELSE?LOOK FOR OTHER CAUSES OF ACUTE LOOK FOR OTHER CAUSES OF ACUTE ABDOMEN/ ABDOMINAL PAINABDOMEN/ ABDOMINAL PAIN
Balthazar’s CT staging of pancreatitisBalthazar’s CT staging of pancreatitis
GRADEGRADE CT FINDINGCT FINDINGAA NORMAL PANCREAS NORMAL PANCREAS
BB PANCREATIC ENLARGEMENTPANCREATIC ENLARGEMENT
CC PANCREATIC INFLAMMATION PANCREATIC INFLAMMATION AND/OR PERIPANCREATIC FATAND/OR PERIPANCREATIC FAT
DD SINGLE PERIPANCREATIC FLUID SINGLE PERIPANCREATIC FLUID COLLECTIONCOLLECTION
EE TWO OR MORE FLUID TWO OR MORE FLUID COLLECTIONS AND/ OR COLLECTIONS AND/ OR RETROPERITONEAL AIRRETROPERITONEAL AIR
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CT severity indexCT severity index
Additional points are added depending on the degree of necrosis
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Clinical relevance of CT in grading of Clinical relevance of CT in grading of acute pancreatitis acute pancreatitis
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grad
e A
/B/C
(no
fluid
colle
ctio
ns)
grad
e D
/E(fl
uid
colle
ctio
ns)
mortalitymorbidity
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LIMITATIONS OF CTLIMITATIONS OF CTIV CONTRAST ALLERGYIV CONTRAST ALLERGY
RENAL INSUFFICIENCYRENAL INSUFFICIENCY
LESS SENSITIVE FOR GALLSTONES LESS SENSITIVE FOR GALLSTONES THAN ULTRASOUNDTHAN ULTRASOUND
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ROLE OF MRIROLE OF MRI
FOR THE ABOVE SAID LIMITATIONS MRI CAN BE USEDFOR THE ABOVE SAID LIMITATIONS MRI CAN BE USED
GADOLINIUM MRI IS AS GOOD ASCONTRAST ENHANCED CT GADOLINIUM MRI IS AS GOOD ASCONTRAST ENHANCED CT ESPECIALLY IN EVALUATING PANCREATIC NECROSISESPECIALLY IN EVALUATING PANCREATIC NECROSIS
PANCREATIC DUCTAL RUPTURE AND GALL STONES CAN BE PICKED PANCREATIC DUCTAL RUPTURE AND GALL STONES CAN BE PICKED UP EASILYUP EASILY
IN PANCREATIC NECROSIS MRI HAS BEEN PROVEN TO BE A BETTER IN PANCREATIC NECROSIS MRI HAS BEEN PROVEN TO BE A BETTER IMAGING MODALITY AS IT DOES NOT INCREASE THE ISCHEMIC IMAGING MODALITY AS IT DOES NOT INCREASE THE ISCHEMIC PENUMBRA AS IV CONTRAST USED IN CONTRAST ENHANCED PENUMBRA AS IV CONTRAST USED IN CONTRAST ENHANCED COMPUTED TOMOGRAPHY MAY DO.COMPUTED TOMOGRAPHY MAY DO.
DISADVANTAGESDISADVANTAGES--TIME CONSUMING AND COSTLYTIME CONSUMING AND COSTLY
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DIFFERENTIAL DIAGNOSIS OF DIFFERENTIAL DIAGNOSIS OF PANCREATIC CYSTIC LESIONSPANCREATIC CYSTIC LESIONS
Focal pancreatic mass on CT scanFocal pancreatic mass on CT scan
Focal pancreatic mass on CT scan
Liver metastases Adenopathy
Peripancreatic invasionNo other abnormalities
Fluid in lesser sacPseudocystcalcifications
Carcinoma Pancreatitis
Characterise byMRI
MRCPERCP
FOCAL PANCREATITIS VS MASS LESION
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Patient 2Patient 2HISTORY OF PRESENTING ILLNESSHISTORY OF PRESENTING ILLNESSTRANSFERRED FROM ANOTHER TRANSFERRED FROM ANOTHER HOSPITALHOSPITALKNOWN CASE OF ACUTE KNOWN CASE OF ACUTE PANCREATITISPANCREATITISHISTORY OF ALCOHOL ABUSE +HISTORY OF ALCOHOL ABUSE +
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ON ARRIVALON ARRIVALCONSCIOUS AND IN PAINCONSCIOUS AND IN PAINDIFFUSE ADDOMINAL PAIN GUARDING DIFFUSE ADDOMINAL PAIN GUARDING POSITIVEPOSITIVEHEART RATE 99/MINHEART RATE 99/MINRESPIRATORY RATERESPIRATORY RATE--2222OXYGEN SATURATION OXYGEN SATURATION –– NORMALNORMAL
FLUID COLLECTIONS OF MODERATE FLUID COLLECTIONS OF MODERATE AMOUNTAMOUNTNEAR THE TAIL OF THE PANCREASNEAR THE TAIL OF THE PANCREASNEAR THE HEAD OF THE PANCREASNEAR THE HEAD OF THE PANCREAS2 LARGE PERIRENAL COLLECTIONS 2 LARGE PERIRENAL COLLECTIONS
PATIENT WAS DISCHARGED WITH 2 PATIENT WAS DISCHARGED WITH 2 DRAINS TO A REHABILITATION CENTRE DRAINS TO A REHABILITATION CENTRE ONCE HIS CLINICAL CONDITION WAS ONCE HIS CLINICAL CONDITION WAS STABLESTABLE
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REFERENCESREFERENCES1.Balthazar EJ, 1.Balthazar EJ, FreenyFreeny PC, PC, vanSonnenbergvanSonnenberg E. Imaging and intervention in acute pancreatitis. E. Imaging and intervention in acute pancreatitis. Radiology 1994;193(2):297Radiology 1994;193(2):297--300. 300. 2. Balthazar EJ, Robinson DL, 2. Balthazar EJ, Robinson DL, MegibowMegibow AJ, AJ, RansonRanson JH. Acute pancreatitis: value of CT in JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology 1990;174(2):331.establishing prognosis. Radiology 1990;174(2):331.3. 3. BegerBeger HG, Rau B, Mayer J, HG, Rau B, Mayer J, PrallePralle U. Natural course of acute pancreatitis. World J U. Natural course of acute pancreatitis. World J SurgSurg1997;21(2):130.1997;21(2):130.4. Block S, Maier W, Bittner R, et al. Identification of pancrea4. Block S, Maier W, Bittner R, et al. Identification of pancreas necrosis in severe acute s necrosis in severe acute pancreatitis: imaging procedures versus clinical staging. Gut 19pancreatitis: imaging procedures versus clinical staging. Gut 1996;27(9):103596;27(9):1035--42.42.5. 5. BoudgheneBoudghene F, L F, L HermineHermine C, Bigot JM. Arterial complications of pancreatitis: diagnosticC, Bigot JM. Arterial complications of pancreatitis: diagnostic and and therapeutic aspects in 104 cases. J therapeutic aspects in 104 cases. J VascVasc IntervInterv RadiolRadiol 1993;4(4):5511993;4(4):551--8. 8. 6. Bradley EL. A clinically based classification system for acut6. Bradley EL. A clinically based classification system for acute pancreatitis. Summary of the e pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, SeptembeInternational Symposium on Acute Pancreatitis, Atlanta, September 1992. Arch r 1992. Arch SurgSurg 1993 1993 May; 128(5): 586May; 128(5): 586--90. 90. 7. 7. ClavienClavien PA, Hauser H, Meyer P, PA, Hauser H, Meyer P, RohnerRohner A. Value of contrastA. Value of contrast--enhanced computerized enhanced computerized tomography in the early diagnosis and prognosis of acute pancreatomography in the early diagnosis and prognosis of acute pancreatitis. A prospective study of titis. A prospective study of 202 patients. Am J 202 patients. Am J SurgSurg 2000;155(3):4572000;155(3):457--66. 66. 8. Dalzell DP, 8. Dalzell DP, ScharlingScharling ES, ES, OttOtt DJ, DJ, WolfmanWolfman NT. Acute pancreatitis: the role of diagnostic NT. Acute pancreatitis: the role of diagnostic imaging. imaging. CritCrit Rev Rev DiagnDiagn Imaging 1998; 39(5): 339Imaging 1998; 39(5): 339--63. 63. 9.Emil J 9.Emil J Balthazar,MDBalthazar,MD Radiology 2002;223:603Radiology 2002;223:603--61361310. 10. FreenyFreeny PC. Incremental dynamic bolus computed tomography of acute pancPC. Incremental dynamic bolus computed tomography of acute pancreatitis. reatitis. IntInt J J PancreatolPancreatol 1993;13(3):1471993;13(3):147--58. 58. 11. Fried AM. 11. Fried AM. RetroperitoneumRetroperitoneum, pancreas, spleen, and lymph nodes. In: , pancreas, spleen, and lymph nodes. In: McGahanMcGahan JP, JP, Goldberg BB, eds. Diagnostic Ultrasound: A Logical Approach. LipGoldberg BB, eds. Diagnostic Ultrasound: A Logical Approach. Lippincottpincott--Raven; 1998: Raven; 1998: p.761p.761--85. 85. 12.Gambiez LP, Ernst OJ, 12.Gambiez LP, Ernst OJ, MerlierMerlier OA. Arterial OA. Arterial embolizationembolization for bleeding for bleeding pseudocystspseudocystscomplicating chronic pancreatitis. Arch complicating chronic pancreatitis. Arch SurgSurg 1997; 132(9):10161997; 132(9):1016--21. 21. 13.Go VLW. Etiology of pancreatitis in the United States, In: Ac13.Go VLW. Etiology of pancreatitis in the United States, In: Acute Pancreatitis: Diagnosis ute Pancreatitis: Diagnosis and Therapy, New York, Raven, 1994: p. 235and Therapy, New York, Raven, 1994: p. 235--9.9.
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REFERENCESREFERENCES14.Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & 14.Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & FebigerFebiger, 1918; , 1918; Bartleby.comBartleby.com, 2000, 200015.Kempainen 15.Kempainen E,SainioE,Sainio V,HaaipianenV,Haaipianen R,KivisaariR,Kivisaari AL,KivilaksoAL,Kivilakso E,PualakainenE,Pualakainen P.EarlyP.Early localisatinlocalisatin of necrosis by of necrosis by
contrast enhanced CT can predict outcome in severe contrast enhanced CT can predict outcome in severe pancreatitis.Brpancreatitis.Br J J SurgSurg 1996;83:9241996;83:924--929.929.16.Kim T ,Murakami 16.Kim T ,Murakami T,TakahashiT,Takahashi S,,etS,,et al.al.--Pancreatic CT Pancreatic CT imaging:Effectsimaging:Effects of different injection rates and doses of of different injection rates and doses of
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space.Raptopoulosspace.Raptopoulos V, V, KleinmanKleinman PK, Marks S PK, Marks S JrJr, Snyder M, Paul Silverman PM.367, Snyder M, Paul Silverman PM.367--74 Radiology. 1986 74 Radiology. 1986 Feb;158(2): Feb;158(2):
20. 20. SSüüleymanleyman BBüüyyüükberberkberber MD et MD et al,Ileusal,Ileus Secondary to Pancreatic Secondary to Pancreatic PseudocystPseudocyst : A Case Report : A Case Report SSüüleymanleyman BBüüyyüükberberkberber, MD et , MD et al;TURGUTal;TURGUT OZAL TIP MERKEZI DERGISI 1996:3(2):124OZAL TIP MERKEZI DERGISI 1996:3(2):124--126126
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24.Yeo 24.Yeo CJ,BastidasCJ,Bastidas JA,LynchJA,Lynch NyhanNyhan A,etA,et al .Natural history of pancreatic al .Natural history of pancreatic pseudocystspseudocysts documented by Computed documented by Computed tomography.Surgtomography.Surg GynecGynec ObstetObstet 1990;170;4111990;170;411--417417