American Pancreatic Association practice guidelines for chronic pancreatitis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2]
American Pancreatic Association Practice Guidelines in Chronic Pancreatitis:[1]
Epidemiology and Risk Factors:
| Recommendation | Evidence Level | Strength of Recommendation |
|---|---|---|
| Data on population-based estimates of chronic pancreatitis (CP) are emerging. | Low | Conditional |
| A small fraction of patients progress from AP to CP. | Moderate | Conditional |
| Alcohol and smoking are independent risk factors for CP. Both are associated with disease progression, and their risks are likely multiplicative. | High | Strong |
| The spectrum of risk factors for CP has broadened. | Low | Conditional |
| Genetic discoveries are rapidly uncovering new susceptibility factors. Knowledge of gene and gene-environment interactions may translate into new diagnostic and treatment paradigms. | Moderate | Strong |
Pathologic Definitions:
The usual level of evidence statements are generally not used in anatomic pathology.
| Recommendation |
|---|
| Chronic pancreatitis is characterized by atrophy and fibrosis of the exocrine tissue with or without chronic inflammation. |
| Scarring of the parenchyma may be focal, patchy, or diffuse. |
| Progressive fibrosis and atrophy may lead to exocrine insufficiency (steatorrhea) followed by endocrine insufficiency (diabetes). |
| Autoimmune pancreatitis can mimic pancreatic carcinoma. |
Role of Ultrasound and Computed Tomography:
| Recommendation | Evidence Level | Strength of Recommendation |
|---|---|---|
| Ultrasound and CT are best for the late findings of CP but are limited in the diagnosis of early or mild pancreatitis. | Moderate | Conditional |
| Intraductal pancreatic calcifications are the most specific and reliable sonographic and CT signs of CP. | Moderate | Strong |
| Computed tomography is helpful for the diagnosis of complications of CP. | Moderate | Strong |
| Computed tomography is helpful for the diagnosis of other conditions that can mimic CP. | Low | Conditional |
Role of MRI Imaging:
| Recommendation | Evidence Level | Strength of Recommendation |
|---|---|---|
| Compared with ultrasound and CT, MRI is a more sensitive imaging tool for the diagnosis of CP. | Moderate | Conditional |
| Ductal abnormalities are very specific and reliable MRI signs of CP. | Low | Conditional |
| Signal intensity changes in the pancreas, seen on MRI, may precede ductal abnormalities and suggest early CP. | Low | Conditional |
| Stimulation of the pancreas using intravenous (IV) secretin may improve the diagnostic accuracy in the detection of ductal and parenchymal abnormalities seen in CP. | Low | Conditional |
Role of Endoscopic Ultrasound:
| Recommendation | Evidence Level | Strength of Recommendation |
|---|---|---|
| The ideal threshold number of EUS criteria necessary to diagnose CP has not been firmly established, but the presence of 5 or more and 2 or less strongly suggests or refutes the diagnosis of CP. | Low | Strong |
| The EUS features of CP are not necessarily pathologic and may occur as a normal aging, as a normal variant, or due to nonpathologic asymptomatic fibrosis in the absence of endocrine or exocrine dysfunction. | Low | Strong |
| The relatively poor interobserver agreement (IOA) for EUS CP features limits the diagnostic accuracy and overall utility of EUS for diagnosing CP. | Moderate | Strong |
Role of Endoscopic Retrograde Cholangiopancreatography:
| Recommendation | Evidence Level | Strength of Recommendation |
|---|---|---|
| Endoscopic retrograde pancreatogram (ERP) is rarely used for diagnostic purposes. | Moderate | Strong |
| The correlation between the Cambridge criteria and histology is highest in advanced CP. | Moderate | Strong |
| Multiple confounders limit the interpretation of ductal changes by Cambridge criteria. | Low | Strong |
Role of Indirect Pancreatic Function Testing:
| Recommendation | Evidence Level | Strength of Recommendation |
|---|---|---|
| Indirect PFTs generally are sensitive for steatorrhea and useful in quantifying the degree of exocrine insufficiency. | Low | Conditional |
| Indirect PFTs are moderately sensitive and specific for diagnosing advanced CP but are less so for diagnosing early CP. | Strong | Conditional |
| The fecal elastase assay, the polyclonal assay more than the monoclonal, can be limited in specificity, especially if the stool sample is watery and/or in the presence of small bowel disease. | Low | Conditional |
| Fecal chymotrypsin may be useful in detecting compliance with exogenous pancreatic enzyme supplementation. | Low | Conditional |
| Fecal fat assays are sensitive for steatorrhea but are of limited utility due to the cumbersome nature of patient collection and laboratory handling of samples. In addition, strict adherence to dietary recommendations for several days is required. | Moderate | Conditional |
Role of Direct Pancreatic Function Tests:
| Recommendation | Evidence Level | Strength of Recommendation |
|---|---|---|
| Direct PFTs have high sensitivity for detecting late CP but lower sensitivity (70%–75%) for early CP. | Low | Strong |
| The traditional secretin and cholecystokinin (CCK) PFTs performed with the oroduodenal tube pancreas fluid collection are highly accurate but require fluoroscopy for confirmation of tube placement and are not widely utilized. | Moderate | Strong |
| The endoscopic PFT (ePFT) has good correlation with the traditional Dreiling PFT. | Moderate | Strong |
Correlation of Imaging and Function With Histology
| Recommendation | Evidence Level | Strength of Recommendation |
|---|---|---|
| As structural severity worsens in CP, exocrine function declines. | Moderate | Strong |
| Both EUS and PFT results correlate with fibrosis in CP. | Low | Conditional |
| A combined approach (eg, EUS/ePFT) could improve detection of minimal change CP (MCCP). | Low | Conditional |
References
- ↑ Conwell DL, Lee LS, Yadav D, Longnecker DS, Miller FH, Mortele KJ, Levy MJ, Kwon R, Lieb JG, Stevens T, Toskes PP, Gardner TB, Gelrud A, Wu BU, Forsmark CE, Vege SS (2014). "American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: evidence-based report on diagnostic guidelines". Pancreas. 43 (8): 1143–62. doi:10.1097/MPA.0000000000000237. PMC 5434978. PMID 25333398.