Male (40 years) with sudden onset of abdominal pain, most prominent in the left upper quadrant accompanied by nausea and vomiting of non-specific content. The evening before he consumed >2.5 L of beer and pizza. Ten months before he was diagnosed with AP including >30% of necrosis (body and tail).
Non-contrast and contrast-enhanced abdominal CT within 48 hours from the onset of clinical symptoms revealed left pleural effusion, necrosis of almost entire pancreas (>30%). Acute necrotic collection (7x10 cm) involving pancreatic body and tail with apparent haemorrhage within the collection. Enlarged spleen without contrast enhancement. Partial splenic artery occlusion due to compression from the acute necrotic collection and partial splenic vein thrombosis. Pneumatosis of the postero-lateral wall of the stomach without contrast enhancement which is apparent in other gastric segments. There is a prominent difference between greater curvature without contrast enhancement and lesser curvature with intensive enhancement. A small amount of peritoneal effusion. Prominent contrast enhancement of both suprarenal glands, without enlargement or mass.
Approximately 15 to 25 per cent of all patients with acute pancreatitis (AP) develop severe AP. Mortality rates remain high in subgroups of patients with severe disease. A young male patient (40 yo) with recurrent severe acute pancreatitis was admitted at the department of gastroenterology 5 hours after alcohol and food abuse with severe abdominal pain, rebound tenderness and guarding. The patient had a history of alcoholism and drug addiction. Within 48 hours from admission clinical deterioration with abdominal distension, absence of peristalsis and increase of inflammatory parameters were perceived. Emergency CT of the abdomen was performed using dedicated protocol (non-contrast and late arterial contrast phase scan). According to the revised Atlanta classification  it was classified as severe necrotizing acute pancreatitis, which is characterized by inflammation associated with pancreatic parenchymal necrosis and/or peripancreatic necrosis. Modified CT severity index has been developed based upon the degree of necrosis, inflammation, and presence of extrapancreatic complications [2,3]. Our patient had >80% of necrotic pancreatic parenchyma (modified CTSI – 10) which resulted in organ failure. Early and persistent organ failure is a reliable indicator of a prolonged hospital stay and increased mortality. A CT scan is not required on the first day unless complications or other diagnoses are being considered. It takes time for pancreatic necrosis to develop and thus CT may be normal in the first 48 to 72 hours. Clinical deterioration may be triggered by different vascular, inflammatory or systemic complications. Due to significant clinical deterioration in our patient, urgent CT exam was requested. Explorative laparotomy based on CT findings demonstrated hematinized ascites and prominent visceral fat. Omentectomy with acute necrotic collection lavage and drainage was performed. Hollow viscera were vital, transient ischemia of the stomach was noticed. The abdominal cavity was left open due to the planned second look exploration. After third exploration abdomen was closed. The next day hemodynamic instability appeared. After preparation of the greater curvature of the stomach necrosis of the posterior gastric wall (fundus and corpus, length 15 cm) was found. Sleeve resection and feeding jejunostomy were done. The patient was stable and recovered after 3 weeks.
Despite clear radiological report surgeons did not found gastric wall necrosis? Was the ischemic lesion reversible or accurate exploration was not possible due to extensive pancreatic collection? CT finding indicated irreversible gastric necrosis in the first place.
 Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62:102.
 Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002;223 (3): 603-13. doi:10.1148/radiol.2233010680
 Mortele KJ, Wiesner W, Intriere L, et al. A modified CT severity index for evaluating acute pancreatitis: improved correlation with patient outcome. AJR Am J Roentgenol. 2004;183 (5): 1261-5. doi:10.2214/ajr.183.5.1831261