Clinical-CT mismatch in acute pancreatitis: a new concept and report of two cases
Case Report

Clinical-CT mismatch in acute pancreatitis: a new concept and report of two cases

Yingjie Wu1,2#, Xiaolei Yi3#, Maoyong Xu4, Hao Liang1,2 ORCID logo

1Institute of TCM Diagnostics, Hunan University of Chinese Medicine, Changsha, China; 2Provincial Key Laboratory of TCM Diagnostics, Hunan University of Chinese Medicine, Changsha, China; 3Department of Hepatobiliary Surgery, Changsha Hospital of Traditional Chinese Medicine (Changsha Eighth Hospital), Changsha, China; 4Department of Radiology, Changsha Hospital of Traditional Chinese Medicine (Changsha Eighth Hospital), Changsha, China

Contributions: (I) Conception and design: Y Wu, H Liang; (II) Administrative support: X Yi; (III) Provision of study materials or patients: X Yi, M Xu; (IV) Collection and assembly of data: Y Wu; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

#These authors contributed equally to this work as co-first authors.

Correspondence to: Hao Liang, MD. Institute of TCM Diagnostics, Hunan University of Chinese Medicine, 300 Xueshi Rd, Science-Education Industrial Park, Yuelu Region, Changsha 410208, China; Provincial Key Laboratory of TCM Diagnostics, Hunan University of Chinese Medicine, Changsha 410208, China. Email: lianghao@hnucm.edu.cn.

Background: Acute pancreatitis (AP) is a condition with varying severity, ranging from mild to severe, each presenting different prognostic outcomes. Accurate and early assessment of AP severity is crucial for determining appropriate treatment and management. Traditionally, the severity of AP has been evaluated using clinical criteria or imaging, but discrepancies between these assessments can complicate clinical decision-making.

Case Description: This case report presents two patients with AP, where a mismatch was observed between clinical and imaging severity assessments. In the first case, laboratory tests suggested mild AP, while computed tomography (CT) imaging indicated severe pathology. In contrast, the second case showed severe AP according to the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, but the CT imaging only revealed mild findings. This clinical-CT mismatch highlights the need for a comprehensive approach to evaluating AP severity, rather than relying on a single assessment method.

Conclusions: The report introduces the concept of clinical-CT mismatch in the assessment of AP. It emphasizes the importance of integrating clinical scores, such as APACHE II, with imaging findings to provide a more accurate and reliable evaluation of severity. By doing so, clinicians can enhance decision-making and improve management strategies for AP.

Keywords: Acute pancreatitis (AP); mismatch; case report; severity assessment

Received: 08 January 2025; Accepted: 16 April 2025; Published online: 08 July 2025.

doi: 10.21037/acr-25-12

Highlight box

Key findings

• This study reports two clinical cases of acute pancreatitis (AP) exhibiting discordance between clinical severity [as measured by the Acute Physiology and Chronic Health Evaluation II (APACHE II) score] and imaging severity [as measured by the Modified Computed Tomography Severity Index (MCTSI)]. The observed “clinical-CT mismatch” underscores the limitations of relying solely on either clinical or imaging assessments for accurately evaluating AP severity.

What is known and what is new?

• It is well established that AP severity can be stratified using clinical scoring systems (e.g., APACHE II) or imaging-based metrics (e.g., MCTSI). However, these methods can yield conflicting severity classifications.

• The novelty of this report lies in formally defining and illustrating “clinical-CT mismatch”, demonstrating the gap between systemic clinical indicators and localized imaging findings.

What is the implication, and what should change now?

• These findings highlight the need for a more integrative approach that combines clinical, laboratory, and imaging data to form a comprehensive view of AP severity. Clinicians should be aware of potential incongruences and consider additional diagnostic methods when standard evaluations yield conflicting results. A multi-dimensional assessment strategy may improve patient management and optimize therapeutic decision-making.

Introduction

Acute pancreatitis (AP) is a common cause of acute abdominal pain related to the digestive system. In AP, these enzymes (such as trypsin) become prematurely activated inside the pancreas. Once activated, they start to digest the pancreatic tissue itself, leading to inflammation, swelling, and damage to the pancreas and surrounding tissues. The global incidence of AP currently averages 34 cases per 100,000 annually and exhibits a consistent year-on-year increase (1,2). Evaluating the severity of AP is crucial for guiding management decisions and predicting outcomes. Several scoring systems and clinical criteria are used to assess the severity of AP. While the Revised Atlanta Classification (RAC) outlines a three-tier severity system by the primary complications of AP (3), it is crucial to recognize additional factors that contribute to morbidity and mortality associated with AP. The imaging-based classification such as the Balthazar Computed Tomography Severity Index (CTSI) and the Modified Computed Tomography Severity Index (MCTSI) (4,5), as well as clinical indicator-based scoring systems such as the Ranson score (6), the Bedside Index for Severity in Acute Pancreatitis (BISAP) (7), the Acute Physiology and Chronic Health Evaluation II (APACHE II) (8), have been established for stratifying the severity of AP. However, inconsistencies in the scoring system of indicators and imaging are not rare in AP. These discrepancies may arise due to the inherent limitation of assessing the disease at a single time point, whereas the pathophysiology of AP is dynamic and continuously evolving. This temporal variability can lead to significant divergences between clinical severity assessments and radiological findings. This study presents two clinical cases with inconsistencies of APACHE II score and the MCTSI to raise the concept of clinical-CT mismatch in AP. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-25-12/rc).

Case presentation

Case 1

A 38-year-old male presented with a one-day history of persistent, distending abdominal pain with intermittent exacerbations, localized to the epigastric region without radiation. Associated symptoms included nausea and vomiting of gastric contents, without fever, chills, or diarrhea. Abdominal examination revealed distension, significant tenderness in the epigastric and subxiphoid regions, and absence of visible peristaltic waves. Murphy’s sign was negative. Contrast-enhanced computed tomography (CT) performed within 48 hours demonstrated findings consistent with AP (Figure 1), including peripancreatic exudation, fluid collection in the omental bursa, and reduced, heterogeneous enhancement of the pancreatic parenchyma. Additional imaging findings included bilateral pleural effusions, thickening of the anterior renal fascia, and fluid accumulation around the liver and spleen. Initial laboratory testing revealed a serum amylase (AMY) level of 1,937 U/L (reference range: 35–135 U/L), exceeding the upper normal limit by more than threefold. Characteristic abdominal pain and CT findings were consistent with AP, meeting the diagnostic criteria (9).

Figure 1 Axial CT findings in a representative patient. (A,B) A large volume of homogeneous, non-enhancing fluid density is observed in the omental bursa and peripancreatic regions (arrows), consistent with acute peripancreatic fluid collection. (C) Imaging reveals diffuse pancreatic enlargement with poorly defined peripancreatic fat planes. The heterogeneous density of the pancreatic parenchyma, along with the presence of small fat droplets (arrow), is indicative of necrotizing pancreatitis. CT, computed tomography.

An APACHE II score of ≥8 indicates severe acute pancreatitis (SAP) (10-12). The patient’s APACHE II score was 1 (Table 1), well below this threshold, indicating a low risk of critical complications and a mild disease course. In contrast, the patient’s MCTSI score was 8, classifying the case as SAP according to the MCTSI scoring criteria (4,12-14). This discrepancy, where clinical scoring indicates a mild condition but imaging findings suggest a severe form, highlights the phenomenon of “clinical-CT mismatch” in AP.

Table 1

APACHE II scoring results for the case 1 patient with AP

Parameter Patient value Reference range APACHE II score
Age, years 38 ≤44 0
Glasgow coma score 14 15 1
Temperature, ℃ 36.3 36–38.4 0
Mean arterial pressure, mmHg 108 70–109 0
Heart rate, bpm 90 70–109 0
Respiratory rate, bpm 20 12–24 0
PaO2 (FiO2 <50%), mmHg 73 >70 0
Arterial pH 7.38 7.33–7.49 0
Sodium, mEq/L 138.40 130–149 0
Potassium, mEq/L 4.23 3.5–5.4 0
Creatinine, mg/dL 0.90 0.6–1.4 0
Hematocrit, % 37.9 30–45.9 0
White blood cell count, ×109/L 14.71 3–14.9 0
Severe organ system insufficiency or is immunocompromised None 0
Total 1

AP, acute pancreatitis; APACHE II, Acute Physiology and Chronic Health Evaluation II; PaO2, partial pressure of oxygen; FiO2, fraction of inspired oxygen.

Final disposition: the patient received treatment primarily consisting of intravenous fluid resuscitation and symptomatic support, including the use of anti-infective agents, gastric acid inhibitors, pancreatic enzyme inhibitors, antispasmodics, and analgesics. In addition, therapy was complemented by traditional Chinese medicine (TCM) modalities administered under the guidance of a TCM physician, based on syndrome differentiation. Although the patient’s clinical course was initially protracted, gradual improvement was achieved with intensive management, and he was eventually discharged in stable condition without major complications.

Case 2

A 66-year-old female presented with a 5-hour history of persistent upper abdominal pain and discomfort that began spontaneously at home without identifiable precipitating factors. The pain was described as distending, with intermittent exacerbations, and localized to the upper abdomen without radiation. Associated symptoms included nausea without vomiting. The medical history included AP, cholecystitis with gallstones, hepatitis C, cirrhosis, and hypertension. Abdominal examination revealed a flat abdomen with no visible gastric or intestinal distension or peristaltic waves, but significant tenderness in the subxiphoid and left upper abdominal regions. Contrast-enhanced CT with three-dimensional reconstruction performed at admission demonstrated findings consistent with AP (Figure 2), including pancreatic enlargement. Additional imaging findings included cirrhosis, splenomegaly, an enhancing nodule in the right hepatic lobe, cholelithiasis, right kidney and ureteral hydronephrosis, and ascites. Initial laboratory testing revealed an AMY level of 2,561.10 U/L (reference range: 35–135 U/L), exceeding the upper normal limit by more than threefold. Characteristic abdominal pain, markedly elevated AMY levels, and CT findings confirmed the diagnosis of AP.

Figure 2 Axial CT images of the pancreas. (A,B) Pancreatic enlargement with peripancreatic exudative changes is observed (arrows), indicating acute pancreatitis. CT, computed tomography.

Clinical and laboratory data yielded an APACHE II score of 13 (Table 2), consistent with SAP. However, the CT-based MCTSI score was 4, corresponding to moderately severe acute pancreatitis (MSAP). This discrepancy between the APACHE II and MCTSI scores highlights a clinical-CT mismatch. While the APACHE II score, based on clinical and laboratory data, indicated a severe disease course, the MCTSI score derived from imaging suggested a relatively milder condition. This discordance illustrates the divergence between laboratory indicators of severity and imaging findings, where clinical and laboratory data suggest a more advanced condition, while imaging findings appear less severe.

Table 2

APACHE II scoring results for the case 2 patient with AP

Parameter Patient value Reference range APACHE II score
Age, years 66 ≤44 5
Glasgow coma score 15 15 0
Temperature, ℃ 38.5 36–38.4 1
Mean arterial pressure, mmHg 111.67 70–109 2
Heart rate, bpm 76 70–109 0
Respiratory rate, bpm 20 12–24 0
PaO2 (FiO2 <50%), mmHg 78 >70 0
Arterial pH 7.35 7.33–7.49 0
Sodium, mEq/L 138.30 130–149 0
Potassium, mEq/L 3.35 3.5–5.4 1
Creatinine, mg/dL 0.62 0.6–1.4 0
Hematocrit, % 27.2 30–45.9 2
White blood cell count, ×109/L 3.42 3–14.9 0
Severe organ system insufficiency or is immunocompromised Elective postoperative 2
Total 13

AP, acute pancreatitis; APACHE II, Acute Physiology and Chronic Health Evaluation II; PaO2, partial pressure of oxygen; FiO2, fraction of inspired oxygen.

Final disposition: treatment focused on aggressive intravenous fluid replacement combined with supportive care, including anti-infective, anti-inflammatory, analgesic, and choleretic medications. She responded well to conservative management, with complete resolution of inflammation and no development of additional local or systemic complications, and was discharged in stable condition after an uneventful hospital stay.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patients for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

The RAC categorizes AP severity into mild (MAP), moderately severe (MSAP), and severe (SAP). While MAP is typically self-limiting with a favorable prognosis, MSAP involve local complications or transient organ failure, and SAP is associated with rapid progression, persistent organ failure, and high mortality rates (15). Approximately 15–20% of AP cases progress to MSAP or SAP (16), often resulting in complications, such as pancreatic hemorrhage, necrosis, systemic inflammatory response syndrome (SIRS), and multiple organ dysfunction syndrome (MODS) (17,18), which increase mortality rates to as high as 15–30% (19,20). Early and accurate severity assessment is critical for improving clinical management and reducing mortality.

The mismatch between stroke severity and lesions detected by imaging has been explored for many years, and clinical-CT mismatch also appears in AP. Scoring systems like APACHE II and MCTSI have notable limitations in the early assessment of AP. APACHE II evaluates systemic physiological responses, providing a comprehensive overview of patient status and predicting systemic inflammation and multiorgan dysfunction risks. However, it lacks sensitivity to local pancreatic damage, relies on 14 physiological parameters, and requires a 24-hour observation period, increasing clinical workload and limiting its utility in differentiating AP types or assessing localized injury (21). In contrast, MCTSI focuses on local pathology, assessing features like fluid collections and necrosis via imaging. However, its early-phase utility is limited due to CT imaging’s low sensitivity during the initial 24–48 hours, with significant morphological changes often detectable only after 72–96 hours (21). Optimal MCTSI imaging is typically performed 6–10 days post-onset (22), when pathological changes are more pronounced, constraining its timely assessment effectiveness in AP.

These factors underscore a key challenge: the dynamic and evolving nature of AP, which may produce discordant results between clinical and radiological evaluations. Initial mild imaging features may progress rapidly, while clinically severe presentations might improve before significant morphological changes become evident. Thus, single-point evaluations are often insufficient, and serial assessments should be considered. Moreover, the existence of a multitude of proposed severity markers for AP, none of which has demonstrated an accuracy exceeding approximately 60%. This highlights the variability and limited predictive value of current tools when used in isolation, necessitating a multimodal assessment strategy. The two cases presented in this report clearly illustrate this issue. In Case 1, an APACHE II score of 1 suggested mild disease, but imaging revealed extensive pancreatic and peripancreatic involvement, resulting in an MCTSI score of 8, consistent with SAP. Conversely, Case 2 exhibited severe systemic indicators with an APACHE II score of 13 but minimal imaging abnormalities, yielding an MCTSI score of 4, below the threshold for severe disease. These cases underscore the inability of clinical or imaging assessments alone to fully capture AP severity. The limitations of both APACHE II and MCTSI highlight the need for integrated strategies that combine clinical, laboratory, and imaging data. Additionally, the temporal evolution of AP suggests that serial reassessments are necessary to capture shifts in disease activity and guide appropriate therapeutic interventions. It is also worth emphasizing that no specific pharmacological therapy currently exists for AP beyond supportive care and aggressive fluid resuscitation, which remain the cornerstone of treatment. This situation underscores an “admission dilemma”—clinicians are tasked with managing potentially life-threatening disease using limited therapeutic tools. Advancing our understanding of AP pathophysiology is crucial for the development of targeted therapies in the future.

Conclusions

This report introduces the concept of clinical-CT mismatch in AP, emphasizing discrepancies between clinical severity scores and imaging findings. The presented cases illustrate how reliance on single-modality evaluations can result in inconsistent severity classification. Given the dynamic progression of AP, single-time assessments may either underestimate or overestimate the true severity of the condition. Thus, the implementation of an integrated, multimodal diagnostic approach—incorporating clinical parameters, laboratory biomarkers, and serial imaging—is strongly recommended. Furthermore, future research should prioritize the development of hybrid diagnostic models, potentially combining artificial intelligence algorithms with traditional scoring systems, to enhance the timeliness and accuracy of AP severity prediction. Such innovations hold promise for improving individualized patient management, facilitating earlier interventions, and ultimately improving outcomes in AP.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-25-12/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-25-12/prf

Funding: This study was supported by the Natural Science Foundation of Hunan Province (No. 2024JJ9528), the Leading Research Program of Hunan University of Chinese Medicine (No. 2022XJJB002), and the Science and Technology Innovation Program of Hunan Province (No. 2022RC1021).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-25-12/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patients for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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doi: 10.21037/acr-25-12
Cite this article as: Wu Y, Yi X, Xu M, Liang H. Clinical-CT mismatch in acute pancreatitis: a new concept and report of two cases. AME Case Rep 2025;9:100.

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