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The RSNA radiology reporting initiative is improving reporting practices by creating a library of clear and consistent report templates.

Supported in part by the National Institute of Biomedical Imaging and Bioengineering (NIBIB).

CT Pancreatitis

 

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This page demonstrates the templates as a synoptic and hierarchical report, with the initial view showing only the template title and the major section headers of the report. By clicking on the section headers it is possible to drill into the content of the template.

Report
Procedure
//Institution specific, with verbiage regarding post-processing per institution protocol as necessary for billing and coding purposes.
Intravenous contrast
None [ ______ ]
[ ______ ]
Specify agent and amount.
[ ______ ]
Clinical information
Acute pancreatitis [ ______ ]
Onset
"< 1 week ago"
"1 to 4 weeks ago"
"> 4 weeks ago"
[ ______ ]
Abdominal pain [ ______ ]
Amylase [ ______ ]
Lipase [ ______ ]
[ ______ ]
Comparison
None [ ______ ]
[ ______ ]
Findings
Pancreas
Normal
"No CT evidence of pancreatitis or its complications."
[ ______ ]
Pancreatitis [ ______ ]
Enlargement
Diffuse [ ______ ]
Focal
Uncinate process [ ______ ]
Head [ ______ ]
Neck [ ______ ]
Body [ ______ ]
Tail [ ______ ]
[ ______ ]
Parenchymal enhancement
Homogeneous [ ______ ]
Heterogeneous [ ______ ]
[ ______ ]
Necrosis
Absent [ ______ ]
Present
Percent involvement
positiveInteger
"%"
"< 30%"
"30% - 50%"
"> 50%"
Site
Uncinate process [ ______ ]
Head [ ______ ]
Neck [ ______ ]
Body [ ______ ]
Tail [ ______ ]
[ ______ ]
Indeterminate [ ______ ]
[ ______ ]
Intrapancreatic fluid collection
None [ ______ ]
Size
Measurement [{decimal} ]
Measurement [{decimal} ]
Measurement [{decimal} ]
Location [ ______ ]
Fluid characteristics [ ______ ] //Comment on the attenuation, fat, soft tissue, fluid, etc.
Homogeneous [ ______ ]
Heterogeneous [ ______ ]
Wall [ ______ ] //Describe thickness, completeness, septations, etc.
Well-defined [ ______ ]
Poorly-defined [ ______ ]
Extraluminal fluid or gas
Absent [ ______ ]
Present [ ______ ] //Presence of gas implies infected collection, may be necessary to confirm with FNA, for Gram stain/culture.
[ ______ ]
Extrapancreatic fluid collection
None [ ______ ]
Size
Measurement [{decimal} ]
Measurement [{decimal} ]
Measurement [{decimal} ]
Location [ ______ ]
Fluid characteristics [ ______ ] //Comment on the attenuation, fat, soft tissue, fluid, etc.
Homogeneous [ ______ ]
Heterogeneous [ ______ ]
Wall [ ______ ] //Describe thickness, completeness, septations, etc.
Well-defined [ ______ ]
Poorly-defined [ ______ ]
Extraluminal fluid or gas
Absent [ ______ ]
Present [ ______ ] //Presence of gas implies infected collection, may be necessary to confirm with FNA, for Gram stain/culture.
[ ______ ]
[ ______ ]
Gallbladder
Normal
"The gallbladder is normal, with no evidence of gallstones, wall thickening, or pericholecystic fluid."
[ ______ ]
Gallstones
None [ ______ ]
[ ______ ]
[ ______ ]
Extrahepatic bile ducts
Normal [ ______ ]
Abnormal [ ______ ]
[ ______ ]
Venous thrombosis
None [ ______ ]
Portal vein [ ______ ]
Superior mesenteric vein [ ______ ]
Splenic vein [ ______ ]
[ ______ ]
Varices
Absent [ ______ ] //Default
Present [ ______ ]
[ ______ ]
Arterial aneurysm
Absent [ ______ ] //Default
Present [ ______ ]
[ ______ ]
Pleural effusion
None [ ______ ]
Right
None [ ______ ]
Mild [ ______ ]
Moderate [ ______ ]
Severe [ ______ ]
[ ______ ]
Left
None [ ______ ]
Mild [ ______ ]
Moderate [ ______ ]
Severe [ ______ ]
[ ______ ]
[ ______ ]
Ascites
None [ ______ ]
Mild [ ______ ]
Moderate [ ______ ]
Severe [ ______ ]
[ ______ ]
Inflammatory involvement of other organs
None [ ______ ]
[ ______ ]
[ ______ ]
Impression
Pancreas
Normal
"No CT evidence of pancreatitis or its complications."
[ ______ ]
Interstitial edematous pancreatitis [ ______ ]
Necrotizing pancreatitis [ ______ ]
Pancreatic necrosis [ ______ ]
Peripancreatic necrosis [ ______ ]
[ ______ ]
Fluid collections
None [ ______ ]
Gas
Absent [ ______ ] //Default
Present [ ______ ]
[ ______ ]
Acute necrotic collection [ ______ ] //< 4 weeks after onset of pancreatitis
Acute peripancreatic fluid collection [ ______ ] //< 4 weeks after onset of pancreatitis
Panceatic pseudocyst [ ______ ] //> 4 weeks after onset of pancreatitis
Walled-off necrosis [ ______ ] //> 4 weeks after onset of pancreatitis
[ ______ ]
[ ______ ]