The roentgen manifestations of relapsing pancreatitis.

Abstract

Relapsing pancreatitis is a disease of recurring exacerbations separated by varying intervals of seemingly relative clinical quiescence. At any given time it represents the summation of all previous episodes. In recent years, the pathologists have increasingly emphasized the continuing, chronic, relapsing, and progressive nature of this disease as well as its varied manifestations and associated conditions. The clinicians, also, now clearly recognize relapsing pancreatitis as a distinct entity, even though it is a complex syndrome with many aspects. Its presence may be difficult to detect, or even suspect, since the clinical picture may vary in the history of any one patient. Especially is this true in the subclinical phases. Facts relating to etiology, pathogenesis, sex, age, the role of obesity, alcohol, trauma, common channel, infection, etc., have been well covered by Doubilet and Mulholland (5 and 6) and need no further elaboration. The roentgen manifestations of relapsing pancreatitis can be divided into two groups: (1) those indicating an acute or a subacute exacerbation and (2) those indicating chronic pancreatitis. 1. Roentgen Manifestations of an Acute or Subacute Exacerbation Roentgen Manifestations Which Involve the Duodenum: Inasmuch as relapsing pancreatitis is a continuing and progressive disease, it is important to detect new episodes as early as possible. The papillary sign (8) is the earliest roentgen indication of a sudden subacute or acute exacerbation.2 Laboratory data have been overemphasized (3) and the usual roentgen signs appear too late. Anatomic studies (8) have provided basic information concerning the size, shape, and position of the vaterian papilla in health and disease. In the course of relapsing pancreatitis it was noted, during a gastrointestinal series, that very early in the relapse the papilla became enlarged as the result of edema, even before pancreatic swelling could be detected. If the inflammatory condition was severe, the edema spread from the papilla as a center and involved the contiguous duodenal mucosa in all directions. The papillary enlargement, however, at the center, was always the greatest. This papillary edema reflected the underlying inflammatory condition, increasing and decreasing almost daily with the degree of inflammation. Its recognition in a case of known chronic pancreatitis is pathognomonic of a relapse. In other instances, it at least indicates a regional inflammatory condition. The next roentgen manifestation may be a functional disturbance in the duodenum. This may take the form of a change in motility (usually an increase), altered peristalsis, the presence of retroperistalsis, localized evanescent areas of spasm, intolerance to barium, and modification of the usual pattern of barium distribution. The valvulae conniventes, which normally have a continuous uniform appearance, may show skipped areas free of barium.