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: Evidence-Based Report on Diagnostic Guidelines

Epidemiology and Risk Factors:

Recommendation	Evidence Level	Strength of Recommendation
Data on population-based estimates of 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 pancreas carcinoma.

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 diagnosis of other conditions that can mimic CP.	Low	Conditional

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

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

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

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

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
		Strong