Treatment of patients with acute pancreatitis is based on the initial assessment of disease severity. Severe pancreatitis occurs in 20%-30% of all patients with acute pancreatitis and is characterized by a protracted clinical course, multiorgan failure, and pancreatic necrosis. Early staging is based on the presence and degree of systemic failure (cardiovascular, pulmonary, renal) and on the presence and extent of pancreatic necrosis. Individual laboratory indexes (markers of pancreatic injury, markers of inflammatory response), while promising, have not yet gained clinical acceptance. Numeric grading systems with sensitivities of about 70% are commonly used today as indicators of organ failure and disease severity. Contrast material-enhanced computed tomography is used in addition to help evaluate local pancreatic morphology and the presence and extent of pancreatic necrosis. Advantages and limitations of the clinical, laboratory, and imaging prognostic indexes are analyzed and discussed.

In 83 patients with acute pancreatitis, the initial computed tomographic (CT) examinations were classified by degree of disease severity (grades A-E) and were correlated with the clinical follow-up, objective prognostic signs, and complications and death. The length of hospitalization correlated well with the severity of the initial CT findings. Abscesses occurred in 21.6% of the entire group, compared with 60.0% of grade E patients. Pleural effusions were also more common in grade E patients. Grades A and B patients did not have abscesses, and none died, regardless of the number of prognostic signs. Abscesses were seen in 80.0% of patients with six to eight prognostic signs, compared with 12.5% of those with zero to two. The use of prognostic signs with initial CT findings results in improved prognostic accuracy. Early CT examination of patients with acute pancreatitis is a useful prognostic indicator of morbidity and mortality.

An International Symposium was held in Atlanta in 1992 to present the state of the art of diagnostic evaluation and management of acute pancreatitis and to agree on an acceptable series of clinical definitions for classifying the disease and its complications. The symposium was composed of 40 internationally recognized experts in pancreatic disease from 15 countries representing six disciplines (anatomy, gastroenterology, internal medicine, pathology, radiology, and surgery). The purpose of this article is to present the radiologically relevant aspects of the symposium; to define the state of the art of imaging and intervention in acute pancreatitis, particularly how and when to use computed tomography and how and when to perform percutaneous therapy versus surgery; and to encourage radiologists to use precise and proper nomenclature when describing the morphologic manifestations of acute pancreatitis as depicted by various imaging modalities.

This review shows how a systematic pattern approach can be used to narrow the differential diagnosis when an abnormal small-bowel loop is detected on MDCT.