American Pancreatic Association practice guidelines for chronic pancreatitis: Difference between revisions

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{{Chronic pancreatitis}}
{{Chronic pancreatitis}}
{{CMG}} {{AE}} {{IQ}}
{{CMG}} {{AE}} {{IQ}}
== American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: Evidence-Based Report on Diagnostic Guidelines<ref name="pmid25333398">{{cite journal |vauthors=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 |title=American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: evidence-based report on diagnostic guidelines |journal=Pancreas |volume=43 |issue=8 |pages=1143–62 |year=2014 |pmid=25333398 |pmc=5434978 |doi=10.1097/MPA.0000000000000237 |url=}}</ref> ==
== American Pancreatic Association Practice Guidelines in Chronic Pancreatitis:<ref name="pmid25333398">{{cite journal |vauthors=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 |title=American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: evidence-based report on diagnostic guidelines |journal=Pancreas |volume=43 |issue=8 |pages=1143–62 |year=2014 |pmid=25333398 |pmc=5434978 |doi=10.1097/MPA.0000000000000237 |url=}}</ref> ==


=== Epidemiology and Risk Factors: ===
=== Epidemiology and Risk Factors: ===
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!Strength of Recommendation
!Strength of Recommendation
|-
|-
|Data on population-based estimates of CP are emerging.
|Data on population-based estimates of chronic pancreatitis (CP) are emerging.
|[[ACG guidelines classification scheme|Low]]
|[[ACG guidelines classification scheme|Low]]
|[[ACG guidelines classification scheme|Conditional]]
|[[ACG guidelines classification scheme|Conditional]]
Line 18: Line 18:
|[[ACG guidelines classification scheme|Conditional]]
|[[ACG guidelines classification scheme|Conditional]]
|-
|-
|Alcohol and smoking are independent risk factors for CP. Both are associated with disease progression, and their risks are likely multiplicative.
|[[Alcohol]] and [[smoking]] are independent risk factors for CP. Both are associated with disease progression, and their risks are likely multiplicative.
|[[ACG guidelines classification scheme|High]]
|[[ACG guidelines classification scheme|High]]
|[[ACG guidelines classification scheme|Strong]]
|[[ACG guidelines classification scheme|Strong]]
Line 37: Line 37:
!Recommendation
!Recommendation
|-
|-
|Chronic pancreatitis is characterized by atrophy and fibrosis of the exocrine tissue with or without chronic inflammation.
|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.
|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).
|Progressive [[fibrosis]] and atrophy may lead to exocrine insufficiency ([[steatorrhea]]) followed by endocrine insufficiency ([[diabetes]]).
|-
|-
| Autoimmune pancreatitis can mimic pancreas carcinoma.
| Autoimmune pancreatitis can mimic [[Pancreatic cancer|pancreatic carcinoma]].
|}
|}


=== Ultrasound and Computed Tomography: ===
=== Role of Ultrasound and Computed Tomography: ===
{| class="wikitable"
{| class="wikitable"
!Recommendation
!Recommendation
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!Strength of Recommendation
!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.
|[[Ultrasound]] and [[CT]] are best for the late findings of CP but are limited in the diagnosis of early or mild pancreatitis.
|[[ACG guidelines classification scheme|Moderate]]
|[[ACG guidelines classification scheme|Moderate]]
|[[ACG guidelines classification scheme|Conditional]]
|[[ACG guidelines classification scheme|Conditional]]
|-
|-
|Intraductal pancreatic calcifications are the most specific and reliable sonographic and CT signs of CP.
|Intraductal pancreatic [[Calcification|calcifications]] are the most specific and reliable sonographic and CT signs of CP.
|[[ACG guidelines classification scheme|Moderate]]
|[[ACG guidelines classification scheme|Moderate]]
|[[ACG guidelines classification scheme|Strong]]
|[[ACG guidelines classification scheme|Strong]]
|-
|-
|Computed tomography is helpful for the diagnosis of complications of CP.
|[[Computed tomography]] is helpful for the diagnosis of complications of CP.
|[[ACG guidelines classification scheme|Moderate]]
|[[ACG guidelines classification scheme|Moderate]]
|[[ACG guidelines classification scheme|Strong]]
|[[ACG guidelines classification scheme|Strong]]
|-
|-
|Computed tomography is helpful for diagnosis of other conditions that can mimic CP.
|[[Computed tomography]] is helpful for the diagnosis of other conditions that can mimic CP.
|[[ACG guidelines classification scheme|Low]]
|[[ACG guidelines classification scheme|Conditional]]
|}
 
=== Role of MRI Imaging: ===
{| class="wikitable"
!Recommendation
!Evidence Level
!Strength of Recommendation
|-
|Compared with [[ultrasound]] and CT, [[MRI]] is a more sensitive imaging tool for the diagnosis of CP.
|[[ACG guidelines classification scheme|Moderate]]
|[[ACG guidelines classification scheme|Conditional]]
|-
|Ductal abnormalities are very specific and reliable [[MRI]] signs of CP.
|[[ACG guidelines classification scheme|Low]]
|[[ACG guidelines classification scheme|Conditional]]
|-
|Signal intensity changes in the pancreas, seen on [[Magnetic resonance imaging|MRI]], may precede ductal abnormalities and suggest early CP.
|[[ACG guidelines classification scheme|Low]]
|[[ACG guidelines classification scheme|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.
|[[ACG guidelines classification scheme|Low]]
|[[ACG guidelines classification scheme|Conditional]]
|}
 
=== Role of Endoscopic Ultrasound: ===
{| class="wikitable"
!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.
|[[ACG guidelines classification scheme|Low]]
|[[ACG guidelines classification scheme|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.
|[[ACG guidelines classification scheme|Low]]
|[[ACG guidelines classification scheme|Strong]]
|-
|The relatively poor interobserver agreement (IOA) for EUS CP features limits the diagnostic accuracy and overall utility of EUS for diagnosing CP.
|[[ACG guidelines classification scheme|Moderate]]
|[[ACG guidelines classification scheme|Strong]]
|}
 
=== Role of Endoscopic Retrograde Cholangiopancreatography: ===
{| class="wikitable"
!Recommendation
!Evidence Level
!Strength of Recommendation
|-
|Endoscopic retrograde pancreatogram (ERP) is rarely used for diagnostic purposes.
|[[ACG guidelines classification scheme|Moderate]]
|[[ACG guidelines classification scheme|Strong]]
|-
|The correlation between the Cambridge criteria and histology is highest in advanced CP.
|[[ACG guidelines classification scheme|Moderate]]
|[[ACG guidelines classification scheme|Strong]]
|-
|Multiple confounders limit the interpretation of ductal changes by Cambridge criteria.
|[[ACG guidelines classification scheme|Low]]
|[[ACG guidelines classification scheme|Strong]]
|}
 
=== Role of Indirect Pancreatic Function Testing: ===
{| class="wikitable"
!Recommendation
!Evidence Level
!Strength of Recommendation
|-
|Indirect PFTs generally are sensitive for steatorrhea and useful in quantifying the degree of exocrine insufficiency.
|[[ACG guidelines classification scheme|Low]]
|[[ACG guidelines classification scheme|Conditional]]
|-
|Indirect PFTs are moderately sensitive and specific for diagnosing advanced CP but are less so for diagnosing early CP.
|[[ACG guidelines classification scheme|Strong]]
|[[ACG guidelines classification scheme|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.
|[[ACG guidelines classification scheme|Low]]
|[[ACG guidelines classification scheme|Conditional]]
|-
|Fecal chymotrypsin may be useful in detecting compliance with exogenous pancreatic enzyme supplementation.
|[[ACG guidelines classification scheme|Low]]
|[[ACG guidelines classification scheme|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.
|[[ACG guidelines classification scheme|Moderate]]
|[[ACG guidelines classification scheme|Conditional]]
|}
 
=== Role of Direct Pancreatic Function Tests: ===
{| class="wikitable"
!Recommendation
!Evidence Level
!Strength of Recommendation
|-
|Direct PFTs have high sensitivity for detecting late CP but lower sensitivity (70%–75%) for early CP.
|[[ACG guidelines classification scheme|Low]]
|[[ACG guidelines classification scheme|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.
|[[ACG guidelines classification scheme|Moderate]]
|[[ACG guidelines classification scheme|Strong]]
|-
|The endoscopic PFT (ePFT) has good correlation with the traditional Dreiling PFT.
|[[ACG guidelines classification scheme|Moderate]]
|[[ACG guidelines classification scheme|Strong]]
|}
 
=== Correlation of Imaging and Function With Histology ===
{| class="wikitable"
!Recommendation
!Evidence Level
!Strength of Recommendation
|-
|As structural severity worsens in CP, exocrine function declines.
|[[ACG guidelines classification scheme|Moderate]]
|[[ACG guidelines classification scheme|Strong]]
|-
|Both EUS and PFT results correlate with fibrosis in CP.
|[[ACG guidelines classification scheme|Low]]
|[[ACG guidelines classification scheme|Conditional]]
|-
|A combined approach (eg, EUS/ePFT) could improve detection of minimal change CP (MCCP).
|[[ACG guidelines classification scheme|Low]]
|[[ACG guidelines classification scheme|Low]]
|[[ACG guidelines classification scheme|Conditional]]
|[[ACG guidelines classification scheme|Conditional]]

Latest revision as of 22:01, 27 December 2017

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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

  1. ↑ 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.

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