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Fig. 4. CT severity index related to the degree of necrosis of the pancreatic parenchyma (according to Balthazar). Grad A = 0, B = 1, C = 2, D = 3, E = 4; no necrosis = 0, 30% of necrosis = 2, < 50% = 4, > 50% = 6 (data from [29])

appearance, in general without septations. Since large cysts are prone to complications (such as rupture, infection, hemorrhage, biliary obstruction or fistulization to the GI tract), cysts greater than 5-7 cm should be treated by percutaneous drainage or operative mar-supilization.

In a septic patient, fluid collections that are not waterlike, and rim enhancement in contrast enhanced CT or MRI studies, imply the presence of abscesses until proven otherwise. Gas is detected as a characteristic sign of an infected fluid collection in only 20% of cases with pancreatic abscesses. Percutaneous aspiration or drain-placement is the proper treatment.

In contrast to abscess formations, superinfected necrotic areas of the pancreas are much more difficult to handle. Percutaneous drainage therapy is mostly frustrating due to the more solid consistency of the infected necrosis, however, a biopsy is often needed to prove the diagnosis. In most cases, a percutaneous, endoscopy-guided necrosectomy or a surgical intervention has to be considered.

Pseudoaneurysm formation and hemorrhage may result from the extravasated pancreatic enzymes that cause vascular injury, and are typically late complications that occur after several episodes of severe AP. While pseudoa-neurysms are generally easily detected by any kind of imaging modality, retroperitoneal hemorrhage is best depicted by contrast-enhanced CT or unenhanced MRI. Angiography with arterial embolization is the treatment of choice and is generally superior to the surgical therapy.

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