Acute Pancreatitis

Variant: 1 Suspected acute pancreatitis. First time presentation. Epigastric pain and increased amylase and lipase. Less than 48 to 72 hours after symptom onset. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US abdomen	Usually Appropriate	O
US duplex Doppler abdomen	May Be Appropriate	O
MRI abdomen without and with IV contrast with MRCP	May Be Appropriate	O
MRI abdomen without IV contrast with MRCP	May Be Appropriate	O
CT abdomen and pelvis with IV contrast	May Be Appropriate	☢☢☢
US abdomen with IV contrast	Usually Not Appropriate	O
CT abdomen and pelvis without IV contrast	Usually Not Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 2 Suspected acute pancreatitis. Initial presentation with atypical signs and symptoms; including equivocal amylase and lipase values (possibly confounded by acute kidney injury or chronic kidney disease) and when diagnoses other than pancreatitis may be possible (bowel perforation, bowel ischemia, etc.). Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI abdomen without and with IV contrast with MRCP	Usually Appropriate	O
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
US abdomen	May Be Appropriate	O
US duplex Doppler abdomen	May Be Appropriate	O
MRI abdomen without IV contrast with MRCP	May Be Appropriate	O
CT abdomen and pelvis without IV contrast	May Be Appropriate	☢☢☢
US abdomen with IV contrast	Usually Not Appropriate	O
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 3 Acute pancreatitis. Critically ill, systemic inflammatory response syndrome (SIRS), severe clinical scores (eg, Acute Physiology, Age, and Chronic Health Evaluation [APACHE]-II, Bedside Index for Severity in AP [BISAP], or Marshall). Greater than 48 to 72 hours after onset of symptoms.

Procedure	Appropriateness Category	Relative Radiation Level
MRI abdomen without and with IV contrast with MRCP	Usually Appropriate	O
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
US duplex Doppler abdomen	May Be Appropriate	O
MRI abdomen without IV contrast with MRCP	May Be Appropriate	O
CT abdomen and pelvis without IV contrast	May Be Appropriate	☢☢☢
US abdomen	Usually Not Appropriate	O
US abdomen with IV contrast	Usually Not Appropriate	O
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 4 Acute pancreatitis. Continued SIRS, severe clinical scores, leukocytosis, and fever. Greater than 7 to 21 days after onset of symptoms.

Procedure	Appropriateness Category	Relative Radiation Level
MRI abdomen without and with IV contrast with MRCP	Usually Appropriate	O
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
US abdomen	May Be Appropriate	O
US duplex Doppler abdomen	May Be Appropriate	O
MRI abdomen without IV contrast with MRCP	May Be Appropriate	O
CT abdomen and pelvis without IV contrast	May Be Appropriate	☢☢☢
US abdomen with IV contrast	Usually Not Appropriate	O
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 5 Known necrotizing pancreatitis. Significant deterioration in clinical status, including abrupt decrease in hemoglobin or hematocrit, hypotension, tachycardia, tachypnea, abrupt change in fever curve, or increase in white blood cells.

Procedure	Appropriateness Category	Relative Radiation Level
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
US abdomen	May Be Appropriate	O
US duplex Doppler abdomen	May Be Appropriate	O
MRI abdomen without and with IV contrast with MRCP	May Be Appropriate	O
MRI abdomen without IV contrast with MRCP	May Be Appropriate	O
CT abdomen and pelvis without IV contrast	May Be Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	May Be Appropriate	☢☢☢☢
US abdomen with IV contrast	Usually Not Appropriate	O

Variant: 6 Acute pancreatitis. Known pancreatic or peripancreatic fluid collections with continued abdominal pain, early satiety, nausea, vomiting, or signs of infection. Greater than 4 weeks after symptom onset.

Procedure	Appropriateness Category	Relative Radiation Level
MRI abdomen without and with IV contrast with MRCP	Usually Appropriate	O
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
US abdomen	May Be Appropriate	O
US duplex Doppler abdomen	May Be Appropriate	O
MRI abdomen without IV contrast with MRCP	May Be Appropriate	O
CT abdomen and pelvis without IV contrast	May Be Appropriate	☢☢☢
US abdomen with IV contrast	Usually Not Appropriate	O
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Panel Members

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Discussion of Procedures by Variant

Variant 1: Suspected acute pancreatitis. First time presentation. Epigastric pain and increased amylase and lipase. Less than 48 to 72 hours after symptom onset. Initial imaging.

Variant 1: Suspected acute pancreatitis. First time presentation. Epigastric pain and increased amylase and lipase. Less than 48 to 72 hours after symptom onset. Initial imaging.
A. CT Abdomen and Pelvis

Variant 2: Suspected acute pancreatitis. Initial presentation with atypical signs and symptoms; including equivocal amylase and lipase values (possibly confounded by acute kidney injury or chronic kidney disease) and when diagnoses other than pancreatitis may be possible (bowel perforation, bowel ischemia, etc.). Initial imaging.

Variant 3: Acute pancreatitis. Critically ill, systemic inflammatory response syndrome (SIRS), severe clinical scores (eg, Acute Physiology, Age, and Chronic Health Evaluation [APACHE]-II, Bedside Index for Severity in AP [BISAP], or Marshall). Greater than 48 to 72 hours after onset of symptoms.

Variant 4: Acute pancreatitis. Continued SIRS, severe clinical scores, leukocytosis, and fever. Greater than 7 to 21 days after onset of symptoms.

Variant 4: Acute pancreatitis. Continued SIRS, severe clinical scores, leukocytosis, and fever. Greater than 7 to 21 days after onset of symptoms.
A. CT Abdomen and Pelvis

Variant 4: Acute pancreatitis. Continued SIRS, severe clinical scores, leukocytosis, and fever. Greater than 7 to 21 days after onset of symptoms.
B. MRI Abdomen

Variant 4: Acute pancreatitis. Continued SIRS, severe clinical scores, leukocytosis, and fever. Greater than 7 to 21 days after onset of symptoms.
C. US Abdomen

Variant 4: Acute pancreatitis. Continued SIRS, severe clinical scores, leukocytosis, and fever. Greater than 7 to 21 days after onset of symptoms.
D. US Abdomen with IV Contrast

Variant 4: Acute pancreatitis. Continued SIRS, severe clinical scores, leukocytosis, and fever. Greater than 7 to 21 days after onset of symptoms.
E. US Duplex Doppler Abdomen

Variant 5: Known necrotizing pancreatitis. Significant deterioration in clinical status, including abrupt decrease in hemoglobin or hematocrit, hypotension, tachycardia, tachypnea, abrupt change in fever curve, or increase in white blood cells.

Variant 6: Acute pancreatitis. Known pancreatic or peripancreatic fluid collections with continued abdominal pain, early satiety, nausea, vomiting, or signs of infection. Greater than 4 weeks after symptom onset.

Summary of Recommendations

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

References

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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination