selection or data extraction. Although we did an extensive search of the literature, in view of the heterogeneity in criteria used for defining the structural and func- tional tests across different studies, we opted not to label this article as a system- atic review. Sonmoon Mohapatra, MD Department of Internal Medicine Rutgers Robert Wood Johnson Medical School Saint Peters, University Hospital New Brunswick, NJ Shounak Majumder, MD Suresh T. Chari, MD Division of Gastroenterology and Hepatology Department of Medicine Mayo Clinic Rochester, MN chari.suresh@mayo.edu The authors declare no conflict of interest. REFERENCES 1. Mohapatra S, Majumder S, Smyrk TC, et al. Diabetes mellitus is associated with an exocrine pancreatopathy: conclusions from a review of literature. Pancreas. 2016;45:1104–1110. 2. Bilgin M, Balci NC, Momtahen AJ, et al. MRI and MRCP findings of the pancreas in patients with diabetes mellitus: compared analysis with pancreatic exocrine function determined by fecal elastase 1. J Clin Gastroenterol. 2009;43:165–170. 3. Macauley M, Percival K, Thelwall PE, et al. Altered volume, morphology and composition of the pancreas in type 2 diabetes. PLoS One. 2015; 10:e0126825. 4. Saisho Y, Butler AE, Meier JJ, et al. Pancreas volumes in humans from birth to age one hundred taking into account sex, obesity, and presence of type-2 diabetes. Clin Anat. 2007;20: 933–942. The Role of Abdominal Computed Tomography Scan in Acute Pancreatitis To the Editor: A cute pancreatitis (AP) is one of the most common causes for frequent ad- missions in the United States causing huge financial health care burden. 1,2 Some of these resources were unwarranted such as abdominal computed tomography (CT) scan especially in mild to moderate AP. There have been few studies assessing the clinical role of abdominal CT scan. Hence, our objective was to explore the role of ab- dominal CT scan in patients with AP and whether clinical outcome differs. Retro- spective analysis of 1044 patients with AP who were admitted to our hospital in New York from 2010 to 2014 was performed. Acute pancreatitis etiologies include 40% gallstones, 35% due to alcohol, 15% hypertriglyceridemia, 2% post–endoscopic retrograde cholangiopancreatography, and 8% idiopathic. Among the 1044 patients, 656 patients with AP (63%) had an abdominal CT scan assessment, whereas 388 patients with AP (37%) did not have an abdominal CT scan imaging. Of the 656 patients, 518 patients (79%) had no evidence of fe- ver or leukocytosis, whereas 34 patients (5.2%) did have fever and/or leukocytosis as part of their initial presentation, in which 10 patients developed systemic organ failure. Only 10 patients (1.9%) of the 518 patients without fever or leukocytosis have diagno- sis of pancreatic necrosis on abdominal CT scan, whereas 48 patients (9.3%) of the same 518 patients have evidence of pan- creatic pseudocyst. Of the remaining 460 patients (88.8%), 305 patients (58%) showed evidence of AP without complica- tions, and 155 patients (29%) showed no evidence of AP. Local complications of AP were noted in 68 patients (6.5%); most were pancreatic pseudocyst of approximately 5% and pancreatic necrosis of approxi- mately 1.5%. Further analysis showed that mortality and 30-day readmission rates for AP showed no difference in comparison be- tween patients with AP who had no abdom- inal CT scan on presentation (388 patients, 37%) versus patients with AP who had a CT scan imaging (656 patients, 63%), with P values of 0.5 and 0.1, respectively. The use of abdominal CT scan made no clinical difference in the mortality outcome and 30-day readmission rate in patients with AP (Fig. 1). Acute pancreatitis is the one of the most common causes of inpatient hospital- ization and the principal common gastroin- testinal diagnosis on 2009 in the United States. This led to hospitalization cost of approximately 2.9 billion dollars annually, with mean cost of AP hospitalization of approximately $10,000 to $13,000 per day in the United States. 1,2 Part of these massive expenses is the abdominal imag- ing, specifically abdominal CT scan, and the average cost of abdominal CT scan is approximately $600 to $900 million annually based on Medicare fee reimbursement. 2 Cost burden is not the only dilemma; obtaining abdominal CT scan is becoming part of the routine clinical workup in the emergency department. In fact, there is an increase in the ordering of CT scans by pro- viders with an average of 14% (from 81 to 181 examinations) annually. 3 Acute pancreatitis can be divided into mild, moderate, or severe according to the revised Atlanta classification (2012). Mild AP is determined as AP with an absence of organ failure, as well as an absence of local complications, whereas severe AP is identi- fied as AP with persistent organ failure of more than 48 hours. Moderate AP is identi- fied with local complications and/or tran- sient organ failure (of <48 hours). 4 Current guidelines from the American Col- lege of Gastroenterology (2013) and the American College of Radiology (2013) rec- ommended to limit the use of abdominal CT scan imaging for patients with mild AP. 4,5 Contrast-enhanced abdominal CT scan imaging was recommended for pa- tients with an evidence of systemic inflam- matory response feature and for patients with deterioration in their clinical status more than 48 to 72 hours after onset of symptoms because these are signs of possi- ble potential AP complications. 1–6 This brings up some very important questions: are we able to predict mortality and out- come by detecting localized pancreatic com- plications on abdominal CT scan, and does management approach differ? There have been few studies published looking at the use of abdominal CT scan to predict mortal- ity, but none were conclusive. 7–9 Balthazar et al 7 and Simchuk et al 9 support the use of abdominal CT scan imaging to predict outcome in patients with AP; their findings suggest the use of scoring for patients with AP by implementing a scoring radiological system called CT scan severity index, which supports the use of CT scan in assessing and predicting outcomes. Bollen et al 8 did a comparative analysis between the existing radiological scoring versus clinical scoring systems. They found that there is no value of assessing AP severity by the use of ab- dominal CT scan solely. Severe AP can occur in (10%–25%) in mild AP. 1 Most of the severe AP can develop pancreatic complications, whether systemic or localized. Complications from severe AP include multiorgan failure, which accounts for 75% to 85% versus localized pancreatic complications, which accounts for 5% to 15%. The major cause of death from AP seems to be related to systemic complications causing multiorgan failure (adult respiratory distress syndrome, toxic metabolic encepha- lopathy, gastrointestinal hemorrhage, and re- nal failure) rather than pancreatic fluid collection or local pancreatic complications, which can be divided into walled-off pancre- atic necrosis and pseudocyst. 10 Pancreatic necrosis usually will be managed conserva- tively with intravenous fluids and pain management. Most are sterile pancreatic necrosis, and only 30% will develop infec- tion in which fine needle aspiration under CT scan imaging will be necessary to ob- tain pancreatic or peripancreatic fluid for culture and antibiotics therapy. 4,6 This Letters to the Editor Pancreas • Volume 46, Number 6, July 2017 e52 www.pancreasjournal.com © 2017 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.