Role of original and modified Frey's procedures in chronic pancreatitis

Table 7 M-ANNHEIM scoring system for the grading of clinical features of chronic pancreatitis

Clinical features		Points
Patient report of pain
No pain without therapy	(patient reports requiring no pain medication)	0
Recurrent acute pancreatitis	(patient reports freedom from pain between attacks of acute pancreatitis)	1
No pain with therapy	(patient reports freedom from pain with pain medication or endoscopic intervention)	2
Intermittent pain	(patient reports intermittent pain-free episodes, either with or without therapy; possibly additional attacks of acute pancreatitis)	3
Continuous pain	(patient reports absence of pain-free episodes, either with or without therapy; possibly additional attacks of acute pancreatitis)	4
Pain control1
No medication		0
Use of non-opioid drugs or use of mild opioids (WHO step 1 or 2)		1
Use of potent opioids (WHO step 3) or endoscopic intervention		2
Surgical intervention12
Pancreatic surgical intervention for any reason		4
Exocrine insufficiency3
Absence of exocrine insufficiency		0
Presence of mild, moderate, or unproven exocrine insufficiency not requiring enzyme supplementation (including patient reports of intermittent diarrhea)		1
Presence of proven exocrine insufficiency (according to exocrine function tests) or presence of marked exocrine insufficiency defined as steatorrhea (> 7 g fac/24 h), normalized or markedly reduced by enzyme supplementation		2
Endocrine insufficiency
Absence of diabetes mellitus		0
Presence of diabetes mellitus		4
Morphologic status on pancreatic imaging (according to the Cambridge classification)
Normal		0
Equivocal		1
Mild		2
Moderate		3
Marked		4
Severe organ complication2 (not included in the Cambridge classification)
Absence of complications		0
Presence of possibly reversible complication4		2
Presence of irreversible complications4		4

¹The classification of pancreatic pain according to the severity index is done by combining the observed pain patterns together with their treatment interventions. For example, potent opioids (2 points) resulting in intermittent occurrence of abdominal pain (3 points) is 5 points on the severity index;

²Any surgical intervention and any severe complication are included in the calculation of the severity index starting from their first occurrence and continuing during the later course of the disease. Thus, if a patient has two different severe complications, both must be included separately in the calculation of the severity index;

³As tests for pancreatic exocrine function are relatively insensitive for detecting mild or moderate exocrine insufficiency, the presence of intermittent diarrhea and a typical description of the stool, suggestive of chronic pancreatitis, given by the patient (e.g., while, bulky, voluminous, with undigested food present), together with normal test results of exocrine function, are consequently classified as partial pancreatic exocrine insufficiency (1 point);

⁴Reversible severe complications: development of ascites, bleeding, pseudoaneurysm, obstruction or stricture of the ductus choledochus, pancreatic fistula, duodenal stenosis. Irreversible severe complications: portal or splenic vein thrombosis with or without portal hypertension, pancreatic cancer.