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The Revised Atlanta Classification of Acute Pancreatitis

Its Importance for the Radiologist and its effect on Treatment
by

Jeff Hodge

on 1 February 2013

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Transcript of The Revised Atlanta Classification of Acute Pancreatitis

Its importance for the radiologist
and its effect on treatment

Jeff Hodge Pgy4
Combined GI/Rad rounds
Feb 1, 2013 Revised Atlanta Classification
of Pancreatitis Imaging-based Morphologic Classification CECT primary tool for assessment
Not all patients with acute pancreatitis need to undergo CECT
not indicated in patients with no clinical signs of severe pancreatitis and who show rapid clinical improvement In patients over 40
with NO IDENTIFIABLE CAUSE CECT should be used to exclude a possible neoplasm Learning Objectives: Define acute pancreatitis in its early phase and later phase, and the persistent organ failure that can accompany its occurrence

List the various fluid collections encountered in acute pancreatitis as defined by the revised Atlanta classification

Identify the two phases of acute pancreatitis, the parameters that determine care, and the treatment for an infected walled-off necrosis Outline Introduction

Clinical Definition, Course, and Severity of Disease
Imaging-based Morphologic Classification

Treatment Options

Conclusions Introduction In 1992, Atlanta classification for acute pancreatitis
was introduced
Acute pancreatitis: acute inflammatory process
+/- involvement of local tissues and remote organs Mild minimal organ dysfunction
-> uneventful recovery Severe associated with organ failure
+/- local complications including pseudocyst,
pancreatic necrosis or abscess Why was a revision necessary? Advancing knowledge of the disease process,
improved imaging and changing treatment
options Necrotizing pancreatitis Included sterile and infected necrosis

No distinction between pancreatic and
peripancreatic necrosis. Did not include exact
radiological criteria for local complications 2008, ACUTE PANCREATITIS CLASSIFICATION WORKING GROUP Devised to improve clinical assessment and management of acute pancreatitis and to clarify appropriate terms for peripancreatic fluid collections, pancreatic and/or peripancreatic necrosis and changes over time

Recognized the morphologic characteristics and clinical severity might not directly correlate. GOAL: facilitate more objective communication between physicians and institutions through a precise standardized classification system that allows better treatment planning *applies only to adults (>18 years of age) ACUTE PANCREATITIS: according to the revised Atlanta classification Clinically defined by at least the first two of three features:
abdominal pain suggestive of pancreatitis (often radiating to the back)
serum amylase and lipase THREE or more time normal
imaging to be used if the elevated values are <3 times normal
characteristic findings on CT, MR or US If acute pancreatitis is diagnosed on the basis of the first two criteria with no systemic sign of severe systemic inflammatory response syndrome (SIRS) or persistent organ failure,
CT with contrast MAY NOT BE NECESSARY for determining patient care Introduces 2 distinct phases First (early) phase: occurs within the 1st week
involves early inflammation with variable degrees of pancreatic edema and ischemia
leads to resolution or to permanent necrosis and liquefaction
severity is entirely based on clinical parameters Late phase: begins after the first week, can extend to weeks-months
characterized by increasing necrosis, infection and persistent multi-organ failure (MOF)
Imaging becomes more important for detecting local complications and directing treatment CT should be performed in patients who develop or are likely to develop severe acute pancreatitis or complications
Ideal time for assessing complications is after 72 hours from symptom onset
CT to be repeated if clinical picture changes
fever, decreased hematocrit or sepsis CT useful for guiding drainage therapy and for follow-up of these procedures Important findings for radiologist to mention whether pancreatic necrosis is present
characterize pancreatic parenchymal and extrapancreatic fluid collections
presence of ascites and extrapancreatic findings
gallstones
biliary dilatation
venous thrombosis
aneurysms
contiguous inflammatory involvment of the GI tract MR imaging Reserved for detection of choledocholithiasis not visualized on CECT
Characterize collections for non-liquefied material Also useful when CECT is contraindicated Ultrasound Helpful with GB stones
less accurate than CECT or MR for distal bile duct stones
Operator dependent MORPHOLOGIC STAGES OF ACUTE PANCREATITIS 1992 ATLANTA REVISED Interstitial edematous pancreatitis Acute necrotizing pancreatitis Interstitial edematous pancreatitis Acute necrotizing pancreatitis parenchymal necrosis alone
peripancreatic necrosis alone
combined type Sterile or Infected Interstitial Edematous Pancreatitis IEP Localized or diffuse enlargement of the pancreas
Normal homogeneous or slightly heterogeneous enhancement
Mild inflammatory changes in the peripancreatic soft tissue ie. stranding Pancreatic parenchymal necrosis alone Seen in fewer than 5% of patients
lack of enhancement on CT
often divided into 3 categories <30% 30-50% >50% Peripancreatic necrosis alone approximately 20% of patients
located in retroperitoneum and lesser sac
better prognosis than do patients with parenchymal necrosis, although higher morbitity than IEP only Pancreatic parenchymal necrosis with peripancreatic necrosis most common type, 75-80% with ANP
combination of the above two findings Pancreatic and Peripancreatic Collections In the revised Atlanta classification=> important distinction between fluid and non-liquefied collections Acute peripancreatic
fluid collection APFC Acute necrotic collection ANC APFC peripancreatic fluid collections without any non-liquefied components
arises in patients with IEP during first 4 weeks
caused by pancreatic and peripancreatic inflammation or by rupture of small peripheral side duct branches
no discernable wall Most APFCs reabsorbed spontaneously within the first few weeks and do not become infected Intervention to be avoided at this stage ~4 weeks Pseudocyst occurs in 10-20% of cases
well circumscribed, round/oval homogeneousperipancreatic fluid collections
surrounded by well-defined enhancing wall/capsule Contain NO non-liquefied components Pseudocysts contain amylase and lipase
due to communication with the pancreatic ductal system
many cysts seal off such a communication and vanish spontaneously Helpful if you can see communicating duct with CECT or MRCP Pseudocysts can rarely become infected look for gas ANCs in first 4 weeks
persistent collection with fluid AND necrotic material
liquefaction of the necrotic tissue occurs gradually (2-6 weeks) ANCs and APFCs can look alike in the early stages:
look for necrotic debris ~4 weeks Walled-off necrosis thickened wall forms
can involve pancreatic or peripancreatic tissue or both
sterile or infected Contains necrotic pancreatic parenchyma vs pseudocysts do not Complications of Acute Pancreatitis all four types of pancreatic fluid collections can be sterile or infected
non-liquefied collections (ANCs/WOC) more likely to become infected Distinction between sterile and infected collection is important for treatment and prognosis look for gas bubbles in the collection to suggest infection Spontaneous and therapeutic drainage can lead to erroneous diagnosis of infection If there is high clinical suspicion, FNA can be performed (false negatives 10%) Patients with INFECTED NECROSIS usually need percutaneous, laparascopic, endoscopic or surgical intervention Patients with STERILE NECROSIS usually do not require any intervention unless they have persistent pain, anorexia/vomiting or unable tolerate oral feeding TREATMENT OPTIONS The Revised Atlanta classification is designed to aid patients treatment through appropriate triage to intervention or conservative medical care Severity or stage of acute pancreatitis dictates the type of treatment that the patient needs Treatment of IEP IEP usually self-limited with supportive measures alone APFCs resolve spontaneously or mature into pseudocysts majority of pseudocysts disappear spontaneously
~25% become symptomatic or infected and require drainage Various routes, include transgastric Treatment of Necrotizing Pancreatitis requires close monitoring and may require minimally invasive interventions or surgery depending on the clinical status of the patient (sepsis, acute hemorrhage) trend away from early surgical debridement to supportive therapy during first 2 weeks
several studies (Mier et all, 1997, Rodrigues et all 2008) found mortality rate of 58% in patients who underwent surgery after 48-72 hours, vs 27% in patients >12 days Image-guided drainage procedures can be performed to bridge seriously ill patients before surgery Treatment of Sterile Pancreatic Necrosis close monitoring with CT every 7-10 days to rule out infection and to monitor necrosis, and look for complications (hemorrhage, etc)
Patients with clinical, but not radiological signs of infection should be considered for FNA Sterile collections can be percutaneously drained in patients who do not improve spontaneously
*controversial due to risk of becoming infected* Treatment of Infected Pancreatic Necrosis infected of necrotic pancreatic tissue is common and associated with high morbidity and mortality
usually treated with surgical debridement and antibiotics Necrotic tissue usually blocks percutaneous catheters, although this can be attempted to bridge unwell patients (step-up approach) Related treatment Pseudoaneurysms or active bleeding can be treated with coil embolization/covered stent Placement of NJ or pecutaneous-jejunal feeding tubes CONCLUSIONS Thanks to Dr. Zalev for articles and cases References:
Questions? Revised Atlanta classification used to precisely describe acute pancreatitis, standardize terminology and help in treatment planning defines acute pancreatitis as IEP or necrotizing pancreatitis
distinguishes early and late phases In acute IEP, collections that do not have capsule are called APFCs; after development of a capsule referred to as pseudocysts In necrotizing pancreatitis, there is ANC without an enhancing capsule, and WON with an enhancing capsule collections can be sterile or infected
difference between collections in IEP and necrotizing pancreatitis: presence of nonliquefied material in necrotizing pancreatitis look for signs of infection
treatment planning bases on severity and complications Theoni, R. The Revised Atlanta Classification of Acute Pancreatitis. Radiology, V. 262, March 2012

Freeny, P and Morgan D. Acute Pancreatitis: Update 2012. University of Alabama at Birmingham, 2012

Bradley EL. A Clinically based classification system for acute pancreatitis. Atlanta, Ga, September 1992. Arch Surg 1993; 128(5)

Bollen T et al. Toward an update of the Atlanta classification on acute pancreatitis: review of new and abandoned terms. Pancreas 2007; 35(2);107-113

Malangoni MA, Martin AS. Outcome of severe acute pancreatitis. Am J Surg 2005; 189(3); 273-277
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