Chronic pancreatitis other imaging findings: Difference between revisions

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==Other imaging findings==
Other imaging findings may include [[MRCP]], [[ERCP]], and [[endoscopic]] [[ultrasonography]]. [[Magnetic resonance cholangiopancreatography|MRCP]] is the diagnostic study of choice. [[Magnetic resonance cholangiopancreatography|MRCP]] findings suggestive of chronic pancreatitis may include calcifications and [[pancreatic duct]] obstruction. [[Endoscopic retrograde cholangiopancreatography|ERCP]] findings diagnostic of chronic pancreatitis may include beaded appearance of the main [[pancreatic duct]] and ectatic side branches from the main [[pancreatic duct]]. Presence of stones is the most predictive finding seen on [[endoscopic]] [[ultrasonography]]. Other findings suggestive of chronic pancreatitis may include visible side branches, [[cysts]], lobularity, an irregular main [[pancreatic duct]], hyperechoic foci, dilation of the main [[pancreatic duct]] and hyperechoic margins of the main [[pancreatic duct]]. Pancreatic function tests may include direct tests such as secretin stimulation tests and indirect tests.
 
==Other Imaging Findings==
Other imaging findings may include:
*[[MRCP]]
*[[ERCP]]
*Endoscopic ultrasonography
 
==== MRCP: ====
* The diagnostic study of choice.
* Secretin-enhanced MRCP use has been increased recently for the early diagnosis of chronic pancreatitis.
* Findings suggestive of chronic pancreatitis may include:
** Calcifications
** Pancreatic duct obstruction
* It involves no radiation risk.
[[Image: Chronic-pancreatitis-chain-of-lakes-1.png|300 px|center|left|frame|Case courtesy of Dr Praveen Jha, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/16287">rID: 16287</a>]]
 
==== Endoscopic retrograde cholangiopancreatography (ERCP): ====
* ERCP is usually done when there is no evidence of
** Calcifications on imaging
** Steatorrhea
 
*Findings diagnostic of chronic pancreatitis may include:
**Beaded appearance of the main pancreatic duct
**Ectatic side branches from the main pancreatic duct
 
*According to Cambridge classification, patients are divided into 3 categories on the basis of ductal changes seen on ERCP<ref name="pmid7523260">{{cite journal |vauthors=Bozkurt T, Braun U, Leferink S, Gilly G, Lux G |title=Comparison of pancreatic morphology and exocrine functional impairment in patients with chronic pancreatitis |journal=Gut |volume=35 |issue=8 |pages=1132–6 |year=1994 |pmid=7523260 |pmc=1375069 |doi= |url=}}</ref><ref name="pmid6479687">{{cite journal |vauthors=Axon AT, Classen M, Cotton PB, Cremer M, Freeny PC, Lees WR |title=Pancreatography in chronic pancreatitis: international definitions |journal=Gut |volume=25 |issue=10 |pages=1107–12 |year=1984 |pmid=6479687 |pmc=1432537 |doi= |url=}}</ref>
{| class="wikitable"
!Cambridge classification
!Ductal changes seen on ERCP
|-
|Cambridge I
|Equivocal changes
|-
|Cambridge II
|Mild to moderate changes
|-
|Cambridge III
|Considerable changes 
|}
 
==== Endoscopic ultrasonography (EUS): ====
*EUS is equally sensitive to ERCP and pancreatic function testing but the procedure requires high skill and usually performed by a skilled gastroenterologist.<ref name="pmid1633779">{{cite journal |vauthors=Zuccaro G, Sivak MV |title=Endoscopic ultrasonography in the diagnosis of chronic pancreatitis |journal=Endoscopy |volume=24 Suppl 1 |issue= |pages=347–9 |year=1992 |pmid=1633779 |doi= |url=}}</ref><ref name="pmid9684658">{{cite journal |vauthors=Catalano MF, Lahoti S, Geenen JE, Hogan WJ |title=Prospective evaluation of endoscopic ultrasonography, endoscopic retrograde pancreatography, and secretin test in the diagnosis of chronic pancreatitis |journal=Gastrointest. Endosc. |volume=48 |issue=1 |pages=11–7 |year=1998 |pmid=9684658 |doi= |url=}}</ref><ref name="pmid11231386">{{cite journal |vauthors=Wallace MB, Hawes RH, Durkalski V, Chak A, Mallery S, Catalano MF, Wiersema MJ, Bhutani MS, Ciaccia D, Kochman ML, Gress FG, Van Velse A, Hoffman BJ |title=The reliability of EUS for the diagnosis of chronic pancreatitis: interobserver agreement among experienced endosonographers |journal=Gastrointest. Endosc. |volume=53 |issue=3 |pages=294–9 |year=2001 |pmid=11231386 |doi= |url=}}</ref><ref name="pmid11923762">{{cite journal |vauthors=Kahl S, Glasbrenner B, Leodolter A, Pross M, Schulz HU, Malfertheiner P |title=EUS in the diagnosis of early chronic pancreatitis: a prospective follow-up study |journal=Gastrointest. Endosc. |volume=55 |issue=4 |pages=507–11 |year=2002 |pmid=11923762 |doi= |url=}}</ref>
*Presence of stones is the most predictive finding seen on EUS.
*Other findings suggestive of chronic pancreatitis may include:<ref name="pmid11231386">{{cite journal |vauthors=Wallace MB, Hawes RH, Durkalski V, Chak A, Mallery S, Catalano MF, Wiersema MJ, Bhutani MS, Ciaccia D, Kochman ML, Gress FG, Van Velse A, Hoffman BJ |title=The reliability of EUS for the diagnosis of chronic pancreatitis: interobserver agreement among experienced endosonographers |journal=Gastrointest. Endosc. |volume=53 |issue=3 |pages=294–9 |year=2001 |pmid=11231386 |doi= |url=}}</ref>
**Visible side branches
**Cysts
**Lobularity
**An irregular main pancreatic duct
**Hyperechoic foci and strands
**Dilation of the main pancreatic duct
**Hyperechoic margins of the main pancreatic duct
 
=== Pancreatic function tests: ===
 
===== (a) Direct/ Invasive tests: =====
* Direct tests are used to assess pancreatic insufficiency in the early course of disease when patient has clinical symptoms but no radiology findings.
* Direct tests involve pancreatic stimulation via meal or hormonal secretagogues and assessment of pancreatic secretions in the duodenal fluid.
* Direct tests along with radiographic findings (pancreatic calcifications) are stll considered to be the gold standard for the diagnosis of chronic pancreatitis.<ref name="pmid11276375">{{cite journal |vauthors=Boeck WG, Adler G, Gress TM |title=Pancreatic function tests: when to choose, what to use |journal=Curr Gastroenterol Rep |volume=3 |issue=2 |pages=95–100 |year=2001 |pmid=11276375 |doi= |url=}}</ref><ref name="pmid12641496">{{cite journal |vauthors=Chowdhury RS, Forsmark CE |title=Review article: Pancreatic function testing |journal=Aliment. Pharmacol. Ther. |volume=17 |issue=6 |pages=733–50 |year=2003 |pmid=12641496 |doi= |url=}}</ref><ref name="pmid15508057">{{cite journal |vauthors=Siegmund E, Löhr JM, Schuff-Werner P |title=[The diagnostic validity of non-invasive pancreatic function tests--a meta-analysis] |language=German |journal=Z Gastroenterol |volume=42 |issue=10 |pages=1117–28 |year=2004 |pmid=15508057 |doi=10.1055/s-2004-813604 |url=}}</ref><ref name="pmid16633964">{{cite journal |vauthors=Ammann RW |title=Diagnosis and management of chronic pancreatitis: current knowledge |journal=Swiss Med Wkly |volume=136 |issue=11-12 |pages=166–74 |year=2006 |pmid=16633964 |doi=2006/11/smw-11182 |url=}}</ref>
* The limitation of direct tests is that they are costly and cumbersome.<ref name="pmid11276375">{{cite journal |vauthors=Boeck WG, Adler G, Gress TM |title=Pancreatic function tests: when to choose, what to use |journal=Curr Gastroenterol Rep |volume=3 |issue=2 |pages=95–100 |year=2001 |pmid=11276375 |doi= |url=}}</ref><ref name="pmid12641496">{{cite journal |vauthors=Chowdhury RS, Forsmark CE |title=Review article: Pancreatic function testing |journal=Aliment. Pharmacol. Ther. |volume=17 |issue=6 |pages=733–50 |year=2003 |pmid=12641496 |doi= |url=}}</ref><ref name="pmid15508057">{{cite journal |vauthors=Siegmund E, Löhr JM, Schuff-Werner P |title=[The diagnostic validity of non-invasive pancreatic function tests--a meta-analysis] |language=German |journal=Z Gastroenterol |volume=42 |issue=10 |pages=1117–28 |year=2004 |pmid=15508057 |doi=10.1055/s-2004-813604 |url=}}</ref><ref name="pmid16633964">{{cite journal |vauthors=Ammann RW |title=Diagnosis and management of chronic pancreatitis: current knowledge |journal=Swiss Med Wkly |volume=136 |issue=11-12 |pages=166–74 |year=2006 |pmid=16633964 |doi=2006/11/smw-11182 |url=}}</ref>
* Direct tests include:
** [[Secretin]] stimulation test
** Pancreozymin-secretin test
*[[Secretin]] stimulation test is considered the gold standard functional test for diagnosis of chronic pancreatitis.
**The observation that bi-carbonate production is impaired early in chronic pancreatitis has led to the rationale of use of this test in early stages of disease.
***Sensitivity - 82%<ref name="pmid23711627">{{cite journal |vauthors=Ketwaroo G, Brown A, Young B, Kheraj R, Sawhney M, Mortele KJ, Najarian R, Tewani S, Dasilva D, Freedman S, Sheth S |title=Defining the accuracy of secretin pancreatic function testing in patients with suspected early chronic pancreatitis |journal=Am. J. Gastroenterol. |volume=108 |issue=8 |pages=1360–6 |year=2013 |pmid=23711627 |pmc=5388854 |doi=10.1038/ajg.2013.148 |url=}}</ref>
***Specificity- 86%<ref name="pmid23711627">{{cite journal |vauthors=Ketwaroo G, Brown A, Young B, Kheraj R, Sawhney M, Mortele KJ, Najarian R, Tewani S, Dasilva D, Freedman S, Sheth S |title=Defining the accuracy of secretin pancreatic function testing in patients with suspected early chronic pancreatitis |journal=Am. J. Gastroenterol. |volume=108 |issue=8 |pages=1360–6 |year=2013 |pmid=23711627 |pmc=5388854 |doi=10.1038/ajg.2013.148 |url=}}</ref>
 
===== (b) Indirect/ Non-invasive tests: =====
* Indirect tests are used to assess the complications of chronic pancreatitis.
* Indirect tests include:
** Faecal chymotrypsin, PABA-, pancreolauryl-
** Faecal elastase test
* Indirect tests are not sensitive to assess pancreatic insufficiency in the early course of disease.<ref name="pmid16633964">{{cite journal |vauthors=Ammann RW |title=Diagnosis and management of chronic pancreatitis: current knowledge |journal=Swiss Med Wkly |volume=136 |issue=11-12 |pages=166–74 |year=2006 |pmid=16633964 |doi=2006/11/smw-11182 |url=}}</ref><ref name="pmid11179244">{{cite journal |vauthors=Etemad B, Whitcomb DC |title=Chronic pancreatitis: diagnosis, classification, and new genetic developments |journal=Gastroenterology |volume=120 |issue=3 |pages=682–707 |year=2001 |pmid=11179244 |doi= |url=}}</ref>


==References==
==References==
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Latest revision as of 01:07, 8 January 2018

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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]

Other imaging findings

Other imaging findings may include MRCP, ERCP, and endoscopic ultrasonography. MRCP is the diagnostic study of choice. MRCP findings suggestive of chronic pancreatitis may include calcifications and pancreatic duct obstruction. ERCP findings diagnostic of chronic pancreatitis may include beaded appearance of the main pancreatic duct and ectatic side branches from the main pancreatic duct. Presence of stones is the most predictive finding seen on endoscopic ultrasonography. Other findings suggestive of chronic pancreatitis may include visible side branches, cysts, lobularity, an irregular main pancreatic duct, hyperechoic foci, dilation of the main pancreatic duct and hyperechoic margins of the main pancreatic duct. Pancreatic function tests may include direct tests such as secretin stimulation tests and indirect tests.

Other Imaging Findings

Other imaging findings may include:

MRCP:

  • The diagnostic study of choice.
  • Secretin-enhanced MRCP use has been increased recently for the early diagnosis of chronic pancreatitis.
  • Findings suggestive of chronic pancreatitis may include:
    • Calcifications
    • Pancreatic duct obstruction
  • It involves no radiation risk.
Case courtesy of Dr Praveen Jha, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/16287">rID: 16287</a>

Endoscopic retrograde cholangiopancreatography (ERCP):

  • ERCP is usually done when there is no evidence of
    • Calcifications on imaging
    • Steatorrhea
  • Findings diagnostic of chronic pancreatitis may include:
    • Beaded appearance of the main pancreatic duct
    • Ectatic side branches from the main pancreatic duct
  • According to Cambridge classification, patients are divided into 3 categories on the basis of ductal changes seen on ERCP[1][2]
Cambridge classification Ductal changes seen on ERCP
Cambridge I Equivocal changes
Cambridge II Mild to moderate changes
Cambridge III Considerable changes 

Endoscopic ultrasonography (EUS):

  • EUS is equally sensitive to ERCP and pancreatic function testing but the procedure requires high skill and usually performed by a skilled gastroenterologist.[3][4][5][6]
  • Presence of stones is the most predictive finding seen on EUS.
  • Other findings suggestive of chronic pancreatitis may include:[5]
    • Visible side branches
    • Cysts
    • Lobularity
    • An irregular main pancreatic duct
    • Hyperechoic foci and strands
    • Dilation of the main pancreatic duct
    • Hyperechoic margins of the main pancreatic duct

Pancreatic function tests:

(a) Direct/ Invasive tests:
  • Direct tests are used to assess pancreatic insufficiency in the early course of disease when patient has clinical symptoms but no radiology findings.
  • Direct tests involve pancreatic stimulation via meal or hormonal secretagogues and assessment of pancreatic secretions in the duodenal fluid.
  • Direct tests along with radiographic findings (pancreatic calcifications) are stll considered to be the gold standard for the diagnosis of chronic pancreatitis.[7][8][9][10]
  • The limitation of direct tests is that they are costly and cumbersome.[7][8][9][10]
  • Direct tests include:
    • Secretin stimulation test
    • Pancreozymin-secretin test
  • Secretin stimulation test is considered the gold standard functional test for diagnosis of chronic pancreatitis.
    • The observation that bi-carbonate production is impaired early in chronic pancreatitis has led to the rationale of use of this test in early stages of disease.
      • Sensitivity - 82%[11]
      • Specificity- 86%[11]
(b) Indirect/ Non-invasive tests:
  • Indirect tests are used to assess the complications of chronic pancreatitis.
  • Indirect tests include:
    • Faecal chymotrypsin, PABA-, pancreolauryl-
    • Faecal elastase test
  • Indirect tests are not sensitive to assess pancreatic insufficiency in the early course of disease.[10][12]

References

  1. ↑ Bozkurt T, Braun U, Leferink S, Gilly G, Lux G (1994). "Comparison of pancreatic morphology and exocrine functional impairment in patients with chronic pancreatitis". Gut. 35 (8): 1132–6. PMC 1375069. PMID 7523260.
  2. ↑ Axon AT, Classen M, Cotton PB, Cremer M, Freeny PC, Lees WR (1984). "Pancreatography in chronic pancreatitis: international definitions". Gut. 25 (10): 1107–12. PMC 1432537. PMID 6479687.
  3. ↑ Zuccaro G, Sivak MV (1992). "Endoscopic ultrasonography in the diagnosis of chronic pancreatitis". Endoscopy. 24 Suppl 1: 347–9. PMID 1633779.
  4. ↑ Catalano MF, Lahoti S, Geenen JE, Hogan WJ (1998). "Prospective evaluation of endoscopic ultrasonography, endoscopic retrograde pancreatography, and secretin test in the diagnosis of chronic pancreatitis". Gastrointest. Endosc. 48 (1): 11–7. PMID 9684658.
  5. ↑ 5.0 5.1 Wallace MB, Hawes RH, Durkalski V, Chak A, Mallery S, Catalano MF, Wiersema MJ, Bhutani MS, Ciaccia D, Kochman ML, Gress FG, Van Velse A, Hoffman BJ (2001). "The reliability of EUS for the diagnosis of chronic pancreatitis: interobserver agreement among experienced endosonographers". Gastrointest. Endosc. 53 (3): 294–9. PMID 11231386.
  6. ↑ Kahl S, Glasbrenner B, Leodolter A, Pross M, Schulz HU, Malfertheiner P (2002). "EUS in the diagnosis of early chronic pancreatitis: a prospective follow-up study". Gastrointest. Endosc. 55 (4): 507–11. PMID 11923762.
  7. ↑ 7.0 7.1 Boeck WG, Adler G, Gress TM (2001). "Pancreatic function tests: when to choose, what to use". Curr Gastroenterol Rep. 3 (2): 95–100. PMID 11276375.
  8. ↑ 8.0 8.1 Chowdhury RS, Forsmark CE (2003). "Review article: Pancreatic function testing". Aliment. Pharmacol. Ther. 17 (6): 733–50. PMID 12641496.
  9. ↑ 9.0 9.1 Siegmund E, Löhr JM, Schuff-Werner P (2004). "[The diagnostic validity of non-invasive pancreatic function tests--a meta-analysis]". Z Gastroenterol (in German). 42 (10): 1117–28. doi:10.1055/s-2004-813604. PMID 15508057.
  10. ↑ 10.0 10.1 10.2 Ammann RW (2006). "Diagnosis and management of chronic pancreatitis: current knowledge". Swiss Med Wkly. 136 (11–12): 166–74. doi:2006/11/smw-11182 Check |doi= value (help). PMID 16633964.
  11. ↑ 11.0 11.1 Ketwaroo G, Brown A, Young B, Kheraj R, Sawhney M, Mortele KJ, Najarian R, Tewani S, Dasilva D, Freedman S, Sheth S (2013). "Defining the accuracy of secretin pancreatic function testing in patients with suspected early chronic pancreatitis". Am. J. Gastroenterol. 108 (8): 1360–6. doi:10.1038/ajg.2013.148. PMC 5388854. PMID 23711627.
  12. ↑ Etemad B, Whitcomb DC (2001). "Chronic pancreatitis: diagnosis, classification, and new genetic developments". Gastroenterology. 120 (3): 682–707. PMID 11179244.


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