Echo-Enhanced Ultrasonography

Emilio Brocchi, Fabio Piscaglia, Miriam Bonora, Natascia Celli, Annamaria Venturi,
Lorenzo Fantini, Paola Tomassetti, Roberto Corinaldesi, Raffaele Pezzilli
Department of Internal Medicine and Gastroenterology, Sant’Orsola-Malpighi Hospital,
Alma Mater Studiorum, University of Bologna. Bologna, Italy
Summary
We report the imaging of a patient in whom
the diagnosis of acute pancreatitis and the
assessment of disease severity was carried out
using echo-enhanced ultrasonography.
Contrast-enhanced computed tomography
confirmed the echo-enhanced ultrasonography
picture. Echo-enhanced ultrasonography may
become the imaging technique of choice in
assessing the severity of acute pancreatitis
since it is easy to perform, safe and lends
itself to emergency situations. Most
importantly, this technique should be also
useful for following-up patients and it may be
also an alternative to MRI in those patients in
whom
contrast-enhanced
computed
tomography cannot be carried out.
Introduction
At present, contrast-enhanced computed
tomography (CECT) is the technique of
choice to confirm the diagnosis of acute
pancreatitis; furthermore the computed
tomography severity index [1] is at present
largely applied to classify the severity of the
illness. Echo-enhanced ultrasonography
(EEUS) has recently been proposed as a
reliable method for staging the severity of
acute pancreatitis [2]. We report the imaging
of a patient with acute pancreatitis in whom
the severity assessment was made by EEUS
and confirmed by CECT.
Case Report
An 81-year-old female, was admitted to the
our Emergency Room because of persistent
epigastric pain of 6-hour duration radiating to
the back.
Two months previously, during a check-up
examination, a diagnosis of gallstones had
been made using ultrasonography. She had
been treated with ACE-inhibitors for arterial
hypertension and with proton pump inhibitors
for non-erosive gastroesophageal reflux
disease. She had never smoked, and did not
drink coffee or alcohol.
On admission, abdominal examination
showed a tenderness of the epigastrium;
cardiopulmonary
and
neurological
examinations were normal. Her blood
pressure was 130/80 mmHg and the
electrocardiogram showed no alterations. The
results of a routine blood analysis are reported
in Table 1. In particular, increased activity of
serum pancreatic enzymes were found. A
chest X-ray did not reveal any alterations and
plain abdominal X-ray showed an ileus. A
microlithiasis of the gallbladder and an
enlarged pancreatic gland were found at
ultrasonography. The diagnosis of acute
pancreatitis was made and the patient was
treated medically.

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JOP. Journal of the Pancreas – http://www.joplink.net – Vol. 6, No. 5 – September 2005. [ISSN 1590-8577]
465
Two days later, due to the persistence of pain
and an increased plasma concentration of C-
reactive protein (16.4 mg/dL, reference range:
0-0.8 mg/dL), but without any physical signs
of deterioration, an EEUS was carried out.
(Image 1 and Videoclip of Movie 1). Twelve
hours later, we also performed a CECT
(Image 2).
The pain progressively disappeared over a
three day period, and the patient was
discharged from the hospital 15 days later.
Another EEUS examination was carried out
and the patient was cholecystectomized. At
present, the patient is still alive; she is in good
health, and she has had no relapses of acute
pancreatitis.
Imaging Comments
The EEUS showed a hypoechogenic mass of
the pancreas of about 45 mm, compatible with
necrosis of the pancreatic parenchyma (Image
Table 1. Biochemical findings of the patient on admission.
Value
Reference range
Leucocytes
13.590 x103/µL
4.8-8.5 x103/µL
Hemoglobin
14.0 g/dL
13.0-16.0 g/dL
Hematocrit
40.8%
40-54%
Total bilirubin
2.9 mg/dL
0-1.2 mg/dL
Amylase
2,464 U/L
0-220 U/L
Lipase
9,204 U/L
0-270 U/L
Glucose
1.01 g/L
0.60-1.10 g/L
Albumin
3.5 g/dL
Greater than 3.2 g/dL
PaO2
95 mmHg
Greater than 90 mmHg
Calcium
8.5 mg/dL
8.0-11.5 mg/dL
Alkaline phosphatase
265 U/L
98-280 U/L
Gamma-glutamyl transpeptidase (GGT)
34 U/L
0-50 U/L
Creatinine
0.8 mg/dL
0.50-1.2 mg/dL
AST
36 U/L
0-37 U/L
ALT
71 U/L
0-40 U/L
CA 19-9
6 mL-1
0-37 mL-1
C-reactive protein (after 48 hours)
16.4 mg/dL
0-0.8 mg/dL
Videoclip of Movie 1
Image 1
Image 2

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JOP. J Pancreas (Online) 2005; 6(5):464-466.
JOP. Journal of the Pancreas – http://www.joplink.net – Vol. 6, No. 5 – September 2005. [ISSN 1590-8577]
466
1 and Videoclip of Movie 1), the Wirsung
duct with a diameter of 2.5 mm, an
inflammatory lymph node at the hepatic hilus,
and complete obstruction of the splenic vein.
The CECT (Image 2) performed after 12
hours confirmed the findings seen at EEUS
showing an enlarged head of the pancreas
with edema of the peripancreatic fat and
necrosis of the pancreatic parenchyma.
Conclusions
EEUS may become the imaging technique of
choice in assessing the severity of acute
pancreatitis since it is easy to perform, safe
and lends itself to emergency situations. Most
importantly, this technique should be also
useful for following-up patients and it may be
also an alternative to MRI in those patients in
whom CECT cannot be carried out.
Received August 5
th
, 2005 – Accepted August
24
th
, 2005
Keywords Image Enhancement; Pancreatitis,
Acute Necrotizing; Tomography, Spiral
Computer; Ultrasonography
Abbreviations CECT: contrast-enhanced
computed tomography; EEUS: echo-enhanced
ultrasonography
Correspondence
Raffaele Pezzilli
Department of Internal Medicine
Sant’Orsola-Malpighi Hospital
Via Massarenti, 9
40138 Bologna
Italy
Phone: +39-051.636.4148
Fax: +39-051.549.653
E-mail: pezzilli@aosp.bo.it
References
1. Balthazar EJ, Robinson DL, Megibow AJ, Ranson
JH. Acute pancreatitis: value of CT in establishing
prognosis. Radiology 1990; 174:331-6. [PMID
2296641
2. Rickes S, Uhle C, Kahl S, Kolfenbach S,
Moenkemueller K, Effenberger O, Malfertheiner P.
Echo-enhanced ultrasound: a new valid initial imaging
approach for severe acute pancreatitis. Gut 2005; July
20. [PMID 16033880

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