Some Roentgen Aspects of Pancreatic Necrosis

Abstract

The clinical diagnosis of acute pancreatitis is made rather infrequently; yet the diagnosis following surgical exploration is not uncommon. This wide discrepancy attests our lack of acumen in establishing a correct evaluation of those cases studied. Hence, any means that will provide a clearer understanding must command attention. A large group of cases has been studied roentgenographically over a period of years, and various signs indicative of acute or subacute pancreatitis have been enumerated. These point predominantly to the changes induced in the gastro-intestinal tract, especially the stomach and duodenum. Case (1) in his excellent treatise on the subject reviews the changes that may be manifest, but it is evident that no one of these or any combination is diagnostic, nor will we, in this discussion, contribute any definitive set of criteria by which a positive roentgen diagnosis can be achieved. The case under discussion was, however, characterized by such striking roentgenographic findings that we feel they should be recorded. One of the most significant reasons for the many incorrect diagnoses is the failure to think of the pancreas as the basis of abdominal complaints. A greater awareness of the organ as the exciting factor of abdominal symptoms will undoubtedly lead to closer scrutiny prior to exploratory laparotomy and contribute to more accurate diagnosis. Bronner (2) suggests upper intestinal studies in any suspicious case, so that changes in the position, contour, and physiology of the stomach and duodenum may be demonstrated. Frostberg (3) attached considerable significance to the “inverted figure 3 sign” in changes within the head of the pancreas. We have encountered this particular sign infrequently, even though a number of cases of carcinoma of the pancreas were studied very carefully. We did, however, find it present in one instance, and on the strength of it, plus spasm of the duodenum, we proffered the diagnosis of pancreatitis. This was verified at operation. In the case to be recorded here the signs and symptoms pointed so strongly to disease of the large intestine that no opaque material was given by mouth. Instead, a barium enema was considered the most logical procedure, after a film of the abdomen had been made. Unfortunately, the film failed to include the lung bases, so that we were deprived of the value of one finding that has been stressed—the basal exudates that often occur. The latter are mentioned by de Takáts and Mackenzie (4) and by Case (1) as an important part of the roentgen pattern in pancreatitis. Case Report with Necropsy Findings W. E. S., a 42-year-old white married male, a cotton-mill worker, was admitted to the medical service for the first time on June 7, 1943, complaining of abdominal pain and distention of ten days' duration.