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Severe acute pancreatitis can cause vascular complications in about 25% of patients with pancreatitis. The most common complication is venous thrombosis, of which splenic vein thrombosis is most prevalent, seen in 10–40% of cases [16,17]. Thrombosis can be seen on noncontrast images, as blood clots are hyperintense compared with blood. Post‐contrast images have even greater diagnostic accuracy as they show nonenhancing filling defects in vessels.

Pseudoaneurysm develops from vessel wall erosion caused by severe inflammation and pancreatic enzymes. The most common arteries involved are the splenic (40%), pancreaticoduodenal (20%), and rarely gastric and hepatic arteries [18,19]. In the setting of severe acute pancreatitis, reviewing radiologists should vigilantly inspect arteries for possible pseudoaneurysm or bleeding. Post‐contrast dynamic sequences depict pseudoaneurysm as a bulging structure arising from a vessel wall. Hemorrhage will be depicted as high‐density areas on T1‐weighted pre‐contrast images and active bleeding can be seen on post‐contrast images as extravasation of contrast from a vessel.

Figure 6.2 A 61‐year‐old male referred from an off‐site institution due to abdominal pain for a month. His CT examination suggested acute pancreatitis and portal vein thrombosis. (a) Axial T2‐weighted image demonstrates an organized complex collection with fistulization to the portal vein. (b) Coronal MRCP image demonstrates fistulization of the collections and entire portal system filled with pancreatic fluid. (c) Post‐contrast T1‐weighted image demonstrates the walled‐off necrosis that replaced the pancreatic parenchyma.

Sources: (a, c) courtesy of J.E. Domínguez‐Muñoz; (b) Morgan [14]. Reproduced with permission of Elsevier.