Discordance between CECT and angiographic findings in severe acute pancreatitis-related hemorrhage: implications for interventional management.

Background: Hemorrhagic complications in severe acute pancreatitis (SAP) carry high mortality and demand timely intervention. Contrast-enhanced computed tomography (CECT) is routinely performed before digital subtraction angiography (DSA) to guide management decisions, yet its predictive accuracy for angiographic findings and interventional success remains poorly defined. Materials and methods: We conducted a retrospective analysis of 69 bleeding episodes in 56 SAP patients with clinical suspicion of active hemorrhage who underwent both CECT and subsequent DSA. Imaging findings were graded on a 3-point scale (Grade 0: negative; Grade 1: suspicious; Grade 2: definite bleeding). Intermodality concordance was evaluated using weighted kappa statistics, with DSA serving as the reference standard. Clinical outcomes including embolization success, rebleeding, and need for surgical rescue were recorded. Results: The intermodality agreement between CECT and DSA was fair (weighted κ = 0.29). Among 26 episodes with negative CECT findings (Grade 0), 69.2% (18/26) required and successfully underwent therapeutic embolization followed by clinical stabilization. Although CECT Grade 2 findings showed a high positive predictive value (94.1%), they were also associated with all instances of rebleeding and procedural abandonment. Nine episodes eventually required surgical rescue after DSA. Conclusion: In this selected high-risk cohort of SAP patients undergoing both CECT and DSA for clinically suspected hemorrhagic complications, CECT demonstrated only limited concordance with angiographic findings. Negative or non-definitive CT findings should be interpreted cautiously when clinical suspicion for ongoing hemorrhage persists, and angiographic evaluation should be considered as part of an integrated, clinically driven diagnostic and therapeutic pathway in this high-risk population.