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1
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Yu P, Zhou X, Yue L, Zhang L, Zhou Y, Jiang F. Comparative diagnostic performance of imaging modalities in chronic pancreatitis: a systematic review and Bayesian network meta-analysis. BMC Med Imaging 2025; 25:1. [PMID: 39748339 PMCID: PMC11697682 DOI: 10.1186/s12880-024-01541-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2024] [Accepted: 12/19/2024] [Indexed: 01/04/2025] Open
Abstract
PURPOSE We aimed to perform a Bayesian network meta-analysis to assess the comparative diagnostic performance of different imaging modalities in chronic pancreatitis(CP). METHODS The PubMed, Embase and Cochrane Library databases were searched for relevant publications until March 2024. All studies evaluating the head-to-head diagnostic performance of imaging modalities in CP were included. Bayesian network meta-analysis was performed to compare the sensitivity and specificity between the imaging modalities. The Quality Assessment of Diagnostic Performance Studies (QUADAS-2) tool was used to evaluate the quality of studies. RESULTS This meta-analysis incorporated 17 studies. Network meta-analytic results indicated that endoscopic ultrasonography (EUS) achieved the highest surface under the cumulative ranking (SUCRA) value at 0.86 for sensitivity. Conversely, magnetic resonance imaging (MRI) demonstrated best specificity, recording the highest SUCRA value at 0.99. Ultrasonography (US) displayed comparatively lower sensitivity than endoscopic retrograde cholangiopancreatography (ERCP) (relative risk[RR]: 0.83, 95% Confidence Interval[CI]: 0.69-0.99) and EUS (RR: 0.73, 95% CI: 0.57-0.91). MRI outperformed all other imaging modalities in terms of specificity. CONCLUSIONS It appears that EUS demonstrates higher sensitivity, while MRI exhibits higher specificity in patients with chronic pancreatitis. However, it is crucial to note that our analysis was limited to the diagnostic performance and did not evaluate the cost-effectiveness of these various imaging modalities. Consequently, further extensive studies are needed to assess the benefit-to-risk ratios comprehensively.
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Affiliation(s)
- Ping Yu
- Department of Pharmacy, Taihe Hospital, Hubei Provincial Clinical Research Center for Umbilical Cord Blood Hematopoietic Stem Cells, Hubei University of Medicine, Shiyan, Hubei, 442000, China
| | - Xujia Zhou
- Department of Pharmacy, Taihe Hospital, Hubei Provincial Clinical Research Center for Umbilical Cord Blood Hematopoietic Stem Cells, Hubei University of Medicine, Shiyan, Hubei, 442000, China
- Department of Radiology, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, 442000, China
| | - Li Yue
- Office of Administration and Management, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, 442000, China
| | - Ling Zhang
- Department of Pharmacy, Taihe Hospital, Hubei Provincial Clinical Research Center for Umbilical Cord Blood Hematopoietic Stem Cells, Hubei University of Medicine, Shiyan, Hubei, 442000, China
| | - Yuan Zhou
- Department of Pharmacy, Taihe Hospital, Hubei Provincial Clinical Research Center for Umbilical Cord Blood Hematopoietic Stem Cells, Hubei University of Medicine, Shiyan, Hubei, 442000, China.
- Department of Respiratory, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, 442000, China.
| | - Fei Jiang
- Department of Pharmacy, Taihe Hospital, Hubei Provincial Clinical Research Center for Umbilical Cord Blood Hematopoietic Stem Cells, Hubei University of Medicine, Shiyan, Hubei, 442000, China.
- Department of Respiratory, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, 442000, China.
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Shintani S, Inatomi O, Hiroe K, Tomozawa Y, Inoue A, Kimura H, Nishida A, Tsuji Y, Watanabe Y, Andoh A. The diagnostic accuracy of endoscopic ultrasound-shear wave elastography in multiple pancreatic regions for chronic pancreatitis based on the Rosemont criteria. J Med Ultrason (2001) 2023; 50:485-492. [PMID: 37584779 DOI: 10.1007/s10396-023-01350-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/12/2023] [Indexed: 08/17/2023]
Abstract
PURPOSE Although endoscopic ultrasound (EUS) has been widely used for diagnosing chronic pancreatitis (CP), the assessment of fibrosis using the Rosemont criteria (RC) is generally subjective. Shear wave elastography using EUS (EUS-SWE) has been advocated as an objective approach to evaluating pancreatic fibrosis; however, it is unknown which pancreatic region should be selected for measurement. This study aims to compare the diagnostic accuracy in diagnosing CP by measurement site. METHODS Fifty patients with CP or suspected CP who underwent EUS-SWE were retrospectively analyzed. As per the RC, they were classified into two groups: CP and non-CP. Pancreatic stiffness was evaluated by measuring the velocities of the shear wave (Vs) in addition to determining the relevant cutoff value of Vs for diagnosing CP. The correlation between Vs and RC, and the RC factors affecting pancreatic stiffness were evaluated. RESULTS In the CP group, the Vs were notably higher in all regions (P < 0.001). The Vs for diagnostic accuracy of CP were highest in the body [area under the curve (AUC): 0.87]. A significant correlation was seen between the number of RC and Vs in all regions, with the correlation coefficient being highest in the pancreatic body (rs = 0.55). Multivariate analysis revealed that lobularity with honeycombing was an independent factor for pancreatic stiffness (P = 0.02). CONCLUSION The pancreatic body is a suitable region for assessing pancreatic stiffness using EUS-SWE. Additionally, quantifying Vs is a valuable objective indicator for diagnosing CP.
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Affiliation(s)
- Shuhei Shintani
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - Osamu Inatomi
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, Shiga, 520-2192, Japan.
| | - Kosuke Hiroe
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - Yuki Tomozawa
- Department of Radiology, Shiga University of Medical Science, Otsu, Japan
| | - Akitoshi Inoue
- Department of Radiology, Shiga University of Medical Science, Otsu, Japan
| | - Hidenori Kimura
- Department of Endoscopy, Shiga University of Medical Science, Otsu, Japan
| | - Atsushi Nishida
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - Yoshihisa Tsuji
- Department of General Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Yoshiyuki Watanabe
- Department of Radiology, Shiga University of Medical Science, Otsu, Japan
| | - Akira Andoh
- Department of Medicine, Shiga University of Medical Science, Seta Tsukinowa, Otsu, Shiga, 520-2192, Japan
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Vitali F, Zundler S, Jesper D, Strobel D, Wildner D, de Pretis N, Frulloni L, Crinó SF, Neurath MF. Endoscopic Ultrasound in Pancreatology: Focus on Inflammatory Diseases and Interventions. Visc Med 2023; 39:131-139. [PMID: 37899796 PMCID: PMC10601533 DOI: 10.1159/000533433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/03/2023] [Indexed: 10/31/2023] Open
Abstract
Background Endoscopic ultrasound (EUS) is a main tool in pancreatology for both diagnosis and therapy. It allows minimally invasive differentiation of various diseases, with a minimal degree of inflammation or anatomic variations. EUS also enables interventional direct access to the pancreatic parenchyma and the retroperitoneal space, the pancreatic duct, the pancreatic masses, cysts, vascular structures for diagnostic and therapeutic purposes. Summary This review aimed to summarize the new developments of EUS in the field of pancreatology, with special interest on inflammation and interventions. EUS enables way to perform pseudocyst drainage, necrosectomy, transenteral drainage and transenteric access of the main pancreatic duct, or the direct visualization or therapy of vascular structures adjacent to the pancreas. Key Messages EUS has a deep impact on pancreatology, and the development of new diagnostic and interventional approaches to the retroperitoneal space and the pancreas has increased in the last years exponentially, allowing minimal invasive diagnostics and therapy and avoiding surgery and percutaneous therapy.
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Affiliation(s)
- Francesco Vitali
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Sebastian Zundler
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Daniel Jesper
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Deike Strobel
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Dane Wildner
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Nicoló de Pretis
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Luca Frulloni
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Stefano Francesco Crinó
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Markus F. Neurath
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
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Yamamiya A, Irisawa A, Abe Y, Arisaka T, Ohnishi T, Hoshi K, Suzuki T, Nagashima K, Kashima K, Kunogi Y, Sakuma F, Fukushi K, Ishikawa M, Mizuguchi N, Yamaguchi S, Tominaga K, Goda K. Diagnosing chronic pancreatitis by endoscopic ultrasound assessing the association between ultrasound and pathological findings: A narrative review. DEN OPEN 2023; 3:e164. [PMID: 36176351 PMCID: PMC9478231 DOI: 10.1002/deo2.164] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/05/2022] [Accepted: 08/19/2022] [Indexed: 11/20/2022]
Abstract
Endoscopic ultrasound (EUS) is widely recognized for its non-invasiveness and for its usefulness in chronic pancreatitis (CP) diagnosis, including early CP. Although it is desirable to obtain a definitive diagnosis of CP by tissue sampling with EUS-guided fine needle aspiration, histopathological changes in CP are heterogeneous in terms of the extent and the distribution of lesions. Therefore, histopathological diagnosis of appropriate tissue sampling by EUS-fine needle aspiration is expected to be difficult. Furthermore, it is virtually impossible to match EUS images with pathological sections, making direct contrast between EUS findings and pathology difficult. This narrative review presents a discussion of the diagnosis of CP/early CP by EUS, particularly assessing the association between ultrasound and pathological findings. Recently, the histological corroboration and correlation of EUS findings related to CP have been clarified by surgical specimens, including those obtained from animal studies. Furthermore, remarkable advances have occurred in the objective and quantitative diagnosis of pancreatic fibrosis by EUS-elastography. Future technological advances in EUS are expected to improve the accuracy of diagnosis of pancreatic fibrosis at earlier stages.
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Affiliation(s)
- Akira Yamamiya
- Department of GastroenterologyDokkyo Medical University School of MedicineTochigiJapan
| | - Atsushi Irisawa
- Department of GastroenterologyDokkyo Medical University School of MedicineTochigiJapan
| | - Yoko Abe
- Department of GastroenterologyDokkyo Medical University School of MedicineTochigiJapan
| | - Takahiro Arisaka
- Department of GastroenterologyDokkyo Medical University School of MedicineTochigiJapan
| | - Toshihiko Ohnishi
- Department of GastroenterologyDokkyo Medical University School of MedicineTochigiJapan
| | - Koki Hoshi
- Department of GastroenterologyDokkyo Medical University School of MedicineTochigiJapan
| | - Tsunehiro Suzuki
- Department of GastroenterologyDokkyo Medical University School of MedicineTochigiJapan
| | - Kazunori Nagashima
- Department of GastroenterologyDokkyo Medical University School of MedicineTochigiJapan
| | - Ken Kashima
- Department of GastroenterologyDokkyo Medical University School of MedicineTochigiJapan
| | - Yasuhito Kunogi
- Department of GastroenterologyDokkyo Medical University School of MedicineTochigiJapan
| | - Fumi Sakuma
- Department of GastroenterologyDokkyo Medical University School of MedicineTochigiJapan
| | - Koh Fukushi
- Department of GastroenterologyDokkyo Medical University School of MedicineTochigiJapan
| | - Manabu Ishikawa
- Department of GastroenterologyDokkyo Medical University School of MedicineTochigiJapan
| | - Nasuka Mizuguchi
- Department of GastroenterologyDokkyo Medical University School of MedicineTochigiJapan
| | - Shintaro Yamaguchi
- Department of GastroenterologyDokkyo Medical University School of MedicineTochigiJapan
| | - Keiichi Tominaga
- Department of GastroenterologyDokkyo Medical University School of MedicineTochigiJapan
| | - Kenichi Goda
- Department of GastroenterologyDokkyo Medical University School of MedicineTochigiJapan
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Mazza S, Elvo B, Conti CB, Drago A, Verga MC, Soro S, De Silvestri A, Cereatti F, Grassia R. Endoscopic ultrasound diagnostic gain over computed tomography and magnetic resonance cholang iopancreatography in defining etiology of idiopathic acute pancreatitis. World J Gastrointest Endosc 2022;14:376-386. [DOI: 10.4253/wjge.v14.i6.376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/23/2022] [Accepted: 05/23/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND About 10%-30% of acute pancreatitis remain idiopathic (IAP) even after clinical and imaging tests, including abdominal ultrasound (US), contrast-enhanced computed tomography (CECT) and magnetic resonance cholangiopancreatography (MRCP). This is a relevant issue, as up to 20% of patients with IAP have recurrent episodes and 26% of them develop chronic pancreatitis. Few data are available on the role of EUS in clarifying the etiology of IAP after failure of one or more cross-sectional techniques.
AIM To evaluate the diagnostic gain after failure of one or more previous cross-sectional exams.
METHODS We retrospectively collected data about consecutive patients with AP and at least one negative test between US, CECT and MRCP, who underwent linear EUS between January 2017 and December 2020. We investigated the EUS diagnostic yield and the EUS diagnostic gain over different combinations of these cross-sectional imaging techniques for the etiologic diagnosis of AP. Types and frequency of EUS diagnosis were also analyzed, and EUS diagnosis was compared with the clinical parameters. After EUS, patients were followed-up for a median of 31.5 mo to detect cases of pancreatitis recurrence.
RESULTS We enrolled 81 patients (63% males, mean age 61 ± 18, 23% with previous cholecystectomy, 17% with recurrent pancreatitis). Overall EUS diagnostic yield for AP etiological diagnosis was 79% (20% lithiasis, 31% acute on chronic pancreatitis, 14% pancreatic solid or cystic lesions, 5% pancreas divisum, 5% autoimmune pancreatitis, 5% ductal abnormalities), while 21% remained idiopathic. US, CECT and MRCP, taken alone or in combination, led to AP etiological diagnosis in 16 (20%) patients; among the remaining 65 patients, 49 (75%) obtained a diagnosis at EUS, with an overall EUS diagnostic gain of 61%. Sixty-eight patients had negative US; among them, EUS allowed etiological diagnosis in 59 (87%). Sixty-three patients had a negative CECT; among them, 47 (74%) obtained diagnosis with EUS. Twenty-four had a negative MRCP; among them, 20 (83%) had EUS diagnosis. Twenty-one had negative CT + MRCP, of which 17 (81%) had EUS diagnosis, with a EUS diagnostic gain of 63%. Patients with biliary etiology and without previous cholecystectomy had higher median values of alanine aminotransferase (154 vs 25, P = 0.010), aspartate aminotransferase (95 vs 29, P = 0.018), direct bilirubin (1.2 vs 0.6, P = 0.015), gamma-glutamyl transpeptidase (180 vs 48, P = 0.006) and alkaline phosphatase (150 vs 72, P = 0.015) Chronic pancreatitis diagnosis was more frequent in patients with recurrent pancreatitis at baseline (82% vs 21%, P < 0.001). During the follow-up, AP recurred in 3 patients, one of which remained idiopathic.
CONCLUSION EUS is a good test to define AP etiology. It showed a 63% diagnostic gain over CECT + MRCP. In suitable patients, EUS should always be performed in cases of IAP. Further prospective studies are needed.
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Affiliation(s)
- Stefano Mazza
- Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Cremona 26100, Italy
| | - Biagio Elvo
- Gastroenterology and Endoscopy Unit, Federico II University, Napoli 80131, Italy
| | | | - Andrea Drago
- Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Cremona 26100, Italy
| | - Maria Chiara Verga
- Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Cremona 26100, Italy
| | - Sara Soro
- Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Cremona 26100, Italy
| | - Annalisa De Silvestri
- Biometry and Clinical Epidemiology, Scientific Direction, IRCCS San Matteo Hospital Foundation, Pavia 27100, Italy
| | - Fabrizio Cereatti
- Department of Gastroenterology and Digestive Endoscopy, Castelli Hospital, Ariccia (Rm) 00040, Italy
| | - Roberto Grassia
- Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Cremona 26100, Italy
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6
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Interventional endoscopy for abdominal transplant patients. Semin Pediatr Surg 2022; 31:151190. [PMID: 35725058 DOI: 10.1016/j.sempedsurg.2022.151190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Interventional endoscopy can play a significant role in the care and management of children pre-and post- abdominal solid organ transplantation. Such procedures primarily include endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), and balloon-assisted enteroscopy (BAE), though additional interventions are available using standard endoscopes (gastroscopes, colonoscopes) for therapeutics purposes such as endoscopic hemostasis. The availability of pediatric practitioners with the advanced training to effectively and safely perform these procedures are most often limited to large tertiary care pediatric centers. These centers possess the necessary resources and ancillary staff to provide the comprehensive multi-disciplinary care needed for these complex patients. In this review, we discuss the importance of interventional endoscopy in caring for transplant patients, during their clinical course preceding the potential need for solid organ transplantation and inclusion of a discussion related to endoscopic post-surgical complication management. Given the highly important role of interventional endoscopy in patients with recurrent and chronic pancreatitis, we also include a discussion related to this complex disease process leading up to those patients that may need pancreas surgery including total pancreatectomy with islet autotransplantation (TPIAT).
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Abstract
BACKGROUND Chronic pancreatitis (CP) is defined according to the recently proposed mechanistic definition as a pathological fibro-inflammatory syndrome of the pancreas in individuals with genetic, environmental, and/or other risk factors who develop persistent pathological responses to parenchymal injury or stress. METHODS The clinical practice guidelines for CP in Japan were revised in 2021 based on the 2019 Japanese clinical diagnostic criteria for CP, which incorporate the concept of a pathogenic fibro-inflammatory syndrome in the pancreas. In this third edition, clinical questions are reclassified into clinical questions, background questions, and future research questions. RESULTS Based on analysis of newly accumulated evidence, the strength of evidence and recommendations for each clinical question is described in terms of treatment selection, lifestyle guidance, pain control, treatment of exocrine and endocrine insufficiency, and treatment of complications. A flowchart outlining indications, treatment selection, and policies for cases in which treatment is ineffective is provided. For pain control, pharmacological treatment and the indications and timing for endoscopic and surgical treatment have been updated in the revised edition. CONCLUSIONS These updated guidelines provide clinicians with useful information to assist in the diagnosis and treatment of CP.
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8
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Saad M, Vitale DS. Endoscopic Advancements in Pediatric Pancreatitis. Front Pediatr 2022; 10:937136. [PMID: 35783303 PMCID: PMC9240213 DOI: 10.3389/fped.2022.937136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/27/2022] [Indexed: 11/22/2022] Open
Affiliation(s)
- Michelle Saad
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - David S Vitale
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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Schneider A, Hirth M. Pain Management in Chronic Pancreatitis: Summary of Clinical Practice, Current Challenges and Potential Contribution of the M-ANNHEIM Classification. Drugs 2021; 81:533-546. [PMID: 33587287 DOI: 10.1007/s40265-021-01472-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2021] [Indexed: 01/06/2023]
Abstract
Abdominal pain, diarrhea with weight loss, and endocrine insufficiency represent the dominant symptoms of chronic pancreatitis (CP). High intensity of pain and constant pain have been shown to reduce quality of life in CP and may result in disability and increased health resource utilization. Various basic challenges and unanswered questions still exist regarding the treatment of pain in CP. Recently, limited evidence has been gained that early surgery for painful disease might be associated with better treatment results. Thus, timing of pancreatic surgery in painful disease represents a major issue that needs to be clarified in future studies. In this context, surveillance of patients is necessary in clinical practice. It appears that a generally accepted classification of the disease represents a major requirement for inter-institutional comparison of data with future progress in clinical research. Among recently proposed classification systems, the M-ANNHEIM classification system of CP with its recently presented M-ANNHEIM Surgery Score might be a useful tool to picture the course of the disease and to monitor treatment results. Future research is required to clarify the possible role of this system in the management of pain in CP. In the present article, we provide an overview of current status, challenges, and unanswered questions in the treatment of pain in CP, and we demonstrate the potential benefits of the M-ANNHEIM classification system in the management of painful CP.
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Affiliation(s)
- Alexander Schneider
- Department of Gastroenterology and Hepatology, Medical Center Bad Hersfeld-Rotenburg, Bad Hersfeld, Germany. .,Department of Medicine II, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.
| | - Michael Hirth
- Department of Medicine II, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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10
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Is Cambridge scoring in chronic pancreatitis the same using ERCP and MRCP?: A need for revision of standards. Abdom Radiol (NY) 2021; 46:647-654. [PMID: 32740862 DOI: 10.1007/s00261-020-02685-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/29/2020] [Accepted: 07/22/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE Grading of chronic pancreatitis (CP) is a clinical and radiologic challenge. Retrograde cholangiopancreatography (ERCP) and magnetic resonance cholangiopancreatography (MRCP) use a version of the Cambridge criteria for ductal evaluation and CP staging, but interchangeability between the modalities lacks validation. This work compares ERCP and MRCP Cambridge scores and evaluates diagnostic performance of MRCP in a large cohort of patients with CP. METHODS A large radiology database was searched for CP patients who underwent MRCP between 2003 and 2013. Next, patients who also had an ERCP within 90 days of their MRCP were selected. These were categorized into mild, moderate, and severe CP using the standardized Cambridge classification for ERCP. Radiologists blinded to ERCP findings then rated MRCP with modified Cambridge scores. RESULTS The cohort comprised 325 patients (mean age 51 years; 56% female). By ERCP Cambridge classification, 122 had mild CP, 109 moderate CP, and 94 severe CP. MRCP and ERCP showed total agreement of Cambridge score in only 43% of cases. With ERCP as reference, the sensitivity and specificity of MRCP in detecting Cambridge scores 4 + 5 (main-duct predominant) were 75.9% and 64.3%, and for Cambridge score 3 (side-branch predominant) it was 60.0% and 76.9%, respectively. CONCLUSIONS There is a lack of strong concordance between ERCP- and MRCP-based grading of CP using the Cambridge criteria. MRCP had moderate to good performance in diagnosing side-branch predominant versus main-duct predominant CP. This suggests an inherent challenge in comparing literature and calls for a revision of the standards.
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11
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Piester TL, Liu QY. EUS in Pediatrics: A Multicenter Experience and Review. Front Pediatr 2021; 9:709461. [PMID: 34513763 PMCID: PMC8424044 DOI: 10.3389/fped.2021.709461] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/20/2021] [Indexed: 12/12/2022] Open
Abstract
Background/Aim: Endoscopic ultrasound (EUS) is a well-established tool used in the evaluation and treatment of a wide range of pathologies in adult medicine. EUS in pediatrics has been shown to be safe and technically effective, and its use continues to evolve. This article aims to describe the EUS experience at our tertiary-care centers with regard to safety, technical success, and its impact in clinical management. We also discuss the current and developing diagnostic and therapeutic uses for EUS in pediatrics such as in pancreaticobiliary disease, congenital anomalies, eosinophilic esophagitis, inflammatory bowel disease, and liver disease. Methods: This is a retrospective review of EUS performed by two pediatric gastroenterologists trained as endosonographers between April 2017 and November 2020. Patient demographics, procedure indication, procedure characteristics, technical success, and complications were collected. Literature review was performed to describe current and future uses of EUS in pediatrics. Results: Ninety-eight EUS were performed with 15 (15.3%) including fine needle aspiration/biopsy and 9 (9.2%) cases being therapeutic. Most common indications include choledocholithiasis (n = 31, 31.6%), pancreatic fluid collections (n = 18, 18.4%), chronic and acute recurrent pancreatitis (n = 14, 14.3%), and acute pancreatitis characterization (n = 13, 13.3%). Notable indications of pancreatic mass (n = 6, 6.1%) and luminal lesions/strictures (n = 6, 6.1%) were less common. Complications were limited with one instance of questionable GI bleeding after cystgastrostomy creation. Ninety-eight of 98 (100%) cases were technically successful. Conclusion/Discussion: EUS has been shown to be performed safely and successfully in the pediatric population by pediatric endosonographers. This study and review support its use in pediatric practice and demonstrate the wide variety of indications for EUS such as pancreatic cystgastrostomy, celiac plexus neurolysis, and evaluation of chronic pancreatitis. This literature review also demonstrates areas of potential development for EUS within the practice of pediatric gastroenterology.
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Affiliation(s)
- Travis L Piester
- Keck School of Medicine of the University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Quin Y Liu
- Cedars-Sinai Medical Center, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, United States
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12
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Abstract
Despite the increased global recognition of pediatric pancreatic diseases, there are limited data on the utility of sophisticated endoscopic procedures such as endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) in their management. Promising results of recent studies have highlighted the emerging therapeutic utility of EUS and ERCP in children. With these latest developments in mind, this article reviews the current literature regarding diagnostic and therapeutic uses, benefits, limitations, and clinical outcomes of EUS and ERCP in pediatric pancreatology.
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13
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The Roles of Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography in the Evaluation and Treatment of Chronic Pancreatitis in Children: A Position Paper From the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Pancreas Committee. J Pediatr Gastroenterol Nutr 2020; 70:681-693. [PMID: 32332479 DOI: 10.1097/mpg.0000000000002664] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Pediatric chronic pancreatitis is increasingly diagnosed. Endoscopic methods [endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography (ERCP)] are useful tools to diagnose and manage chronic pancreatitis. Pediatric knowledge and use of these modalities is limited and warrants dissemination. METHODS Literature review of publications relating to use of ERCP and EUS for diagnosis and/or management of chronic pancreatitis with special attention to studies involving 0--18 years old subjects was conducted with summaries generated. Recommendations were developed and voted upon by authors. RESULTS Both EUS and ERCP can be used even in small children to assist in diagnosis of chronic pancreatitis in cases where cross-sectional imaging is not sufficient to diagnose or characterize the disease. Children under 15 kg for EUS and 10 kg for ERCP can be technically challenging. These procedures should be done optimally by appropriately trained endoscopists and adult gastroenterology providers with appropriate experience treating children. EUS and ERCP-related risks both include perforation, bleeding and pancreatitis. EUS is the preferred diagnostic modality over ERCP because of lower complication rates overall. Both modalities can be used for management of chronic pancreatitis -related fluid collections. ERCP has successfully been used to manage pancreatic duct stones. CONCLUSION EUS and ERCP can be safely used to diagnose chronic pancreatitis in pediatric patients and assist in management of chronic pancreatitis-related complications. Procedure-related risks are similar to those seen in adults, with EUS having a safer risk profile overall. The recent increase in pediatric-trained specialists will improve access of these modalities for children.
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Accuracy of a novel noninvasive secretin-enhanced MRCP severity index scoring system for diagnosis of chronic pancreatitis: correlation with EUS-based Rosemont criteria. Radiol Med 2020; 125:816-826. [PMID: 32266691 DOI: 10.1007/s11547-020-01181-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 03/23/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE To evaluate the accuracy of a secretin-enhanced MRCP Chronic Pancreatitis Severity Index (CPSI) in the diagnosis of chronic pancreatitis (CP) based on endoscopic ultrasound (EUS) Rosemont criteria. METHODS In this retrospective study, 31 patients (20 women; median age 48 years, range 18-77) with known/suspected CP evaluated with both EUS and secretin-enhanced MRCP were included. CP severity was graded using a ten-point-scale secretin-enhanced MRCP-based CPSI scoring system which considered ductal, parenchymal and secretin-based dynamic abnormalities. Cases were categorized as normal, mild, moderate or severe CP. Correlation between CPSI and the EUS Rosemont criteria was performed using Cohen's kappa coefficient. Comparative evaluation of test performance was obtained using ROC analysis. RESULTS Using EUS Rosemont criteria, eight patients had features consistent/suggestive of CP, 20 patients were normal and three were indeterminate. On CPSI, five patients were normal, 12 had mild and 14 had moderate/severe CP. There was only fair agreement (k = 0.272) between CPSI and Rosemont criteria categories. CPSI showed 87.5% sensitivity, 69.6% specificity and 74.2% accuracy (cutoff value = 3.5 points; area under the curve = 0.804; p = 0.0026) for CP diagnosis based on EUS Rosemont criteria. CONCLUSION CPSI showed relatively high diagnostic accuracy for diagnosis of CP based on Rosemont criteria. The CPSI scoring system can be proposed as a noninvasive alternative to the EUS Rosemont criteria for CP diagnosis.
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Abstract
Chronic pancreatitis (CP) is an important gastrointestinal cause of morbidity worldwide. It can severely impair the quality of life besides life-threatening acute and long-term complications. Pain and pancreatic exocrine insufficiency (leading to malnutrition) impact the quality of life. Acute complications include pseudocysts, pancreatic ascites, and vascular complications. Long-term complications are diabetes mellitus and pancreatic cancer. Early diagnosis of CP is crucial to alter the natural course of the disease. However, majority of the cases are diagnosed in the advanced stage. The role of various imaging techniques in the diagnosis of CP is discussed in this review.
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Affiliation(s)
- Rohan Kamat
- Department of Radiodiagnosis and Imaging, PGIMER, Chandigarh, India
| | - Pankaj Gupta
- Department of Gastroenterology, PGIMER, Chandigarh, India
| | - Surinder Rana
- Department of Gastroenterology, PGIMER, Chandigarh, India
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Frøkjær JB, Akisik F, Farooq A, Akpinar B, Dasyam A, Drewes AM, Haldorsen IS, Morana G, Neoptolemos JP, Olesen SS, Petrone MC, Sheel A, Shimosoegawa T, Whitcomb DC. Guidelines for the Diagnostic Cross Sectional Imaging and Severity Scoring of Chronic Pancreatitis. Pancreatology 2018; 18:764-773. [PMID: 30177434 DOI: 10.1016/j.pan.2018.08.012] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 08/16/2018] [Accepted: 08/25/2018] [Indexed: 02/01/2023]
Abstract
The paper presents the international guidelines for imaging evaluation of chronic pancreatitis. The following consensus was obtained: Computed tomography (CT) is often the most appropriate initial imaging modality for evaluation of patients with suspected chronic pancreatitis (CP) depicting most changes in pancreatic morphology. CT is also indicated to exclude other potential intraabdominal pathologies presenting with symptoms similar to CP. However, CT cannot exclude a diagnosis of CP nor can it be used to exclusively diagnose early or mild disease. Here magnetic resonance imaging (MRI) and MR cholangiopancreatography (MRCP) is superior and is indicated especially in patients where no specific pathological changes are seen on CT. Secretin-stimulated MRCP is more accurate than standard MRCP in the depiction of subtle ductal changes. It should be performed after a negative MRCP, when there is still clinical suspicion of CP. Endoscopic ultrasound (EUS) can also be used to diagnose parenchymal and ductal changes mainly during the early stage of the disease. No validated radiological severity scoring systems for CP are available, although a modified Cambridge Classification has been used for MRCP. There is an unmet need for development of a new and validated radiological CP severity scoring system based on imaging criteria including glandular volume loss, ductal changes, parenchymal calcifications and parenchymal fibrosis based on CT and/or MRI. Secretin-stimulated MRCP in addition, can provide assessment of exocrine function and ductal compliance. An algorithm is presented, where these imaging parameters can be incorporated together with clinical findings in the classification and severity grading of CP.
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Affiliation(s)
- Jens Brøndum Frøkjær
- Department of Radiology, Aalborg University Hospital, Denmark; Department of Clinical Medicine, Aalborg University, Denmark.
| | - Fatih Akisik
- Department of Radiology, Indiana University, Indianapolis, USA
| | - Ammad Farooq
- Department of Radiology, Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - Burcu Akpinar
- Department of Radiology, Koc University School of Medicine, Istanbul, Turkey
| | - Anil Dasyam
- Department of Radiology, University of Pittsburgh and UPMC, Pittsburgh, PA, USA
| | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University, Denmark; Centre for Pancreatic Diseases, Department of Gastroenterology and Mech-Sense, Aalborg University Hospital, Denmark
| | | | - Giovanni Morana
- Radiological Department, Treviso General Hospital, Treviso, Italy
| | | | - Søren Schou Olesen
- Department of Clinical Medicine, Aalborg University, Denmark; Centre for Pancreatic Diseases, Department of Gastroenterology and Mech-Sense, Aalborg University Hospital, Denmark
| | - Maria Chiara Petrone
- Pancreas Translational and Clinical Research Center Vita Salute San Raffaele University, Milan, Italy
| | - Andrea Sheel
- Department of Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - Tooru Shimosoegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - David C Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, USA
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Arasaradnam RP, Brown S, Forbes A, Fox MR, Hungin P, Kelman L, Major G, O'Connor M, Sanders DS, Sinha R, Smith SC, Thomas P, Walters JRF. Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition. Gut 2018; 67:1380-1399. [PMID: 29653941 PMCID: PMC6204957 DOI: 10.1136/gutjnl-2017-315909] [Citation(s) in RCA: 197] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 02/28/2018] [Accepted: 03/11/2018] [Indexed: 02/07/2023]
Abstract
Chronic diarrhoea is a common problem, hence clear guidance on investigations is required. This is an updated guideline from 2003 for the investigations of chronic diarrhoea commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). This document has undergone significant revision in content through input by 13 members of the Guideline Development Group (GDG) representing various institutions. The GRADE system was used to appraise the quality of evidence and grading of recommendations.
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Affiliation(s)
- Ramesh P Arasaradnam
- University Hospital Coventry, Coventry, UK
- Department of Applied Biological Sciences, University of Coventry, Coventry, UK
- Clinical Sciences Research Institute, University of Warwick, Warwick, UK
| | | | - Alastair Forbes
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Mark R Fox
- University of Zürich, Zürich, Switzerland
- Abdominal Centre, St Claraspital, Basel, Switzerland
| | - Pali Hungin
- School of Medicine, Pharmacy & Health, University of Durham, Durham, UK
| | | | - Giles Major
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | | | | | - Rakesh Sinha
- Department of Radiology, South Warwickshire Hospitals, Warwick, UK
| | - Stephen Charles Smith
- Department of Clinical Biochemistry, Midlands and NW Bowel Cancer Screening Hub, Rugby, UK
| | - Paul Thomas
- Department of Gastroenterology, Musgrave Park Hospital, Taunton, UK
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Yield of Endoscopic Ultrasound in Children and Adolescent With Acute Recurrent Pancreatitis. J Pediatr Gastroenterol Nutr 2018; 66:461-465. [PMID: 29216022 DOI: 10.1097/mpg.0000000000001855] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Endoscopic ultrasound (EUS) is an established tool for evaluation of adults with acute recurrent pancreatitis (ARP) whereas data in pediatrics is limited. Our study assessed the role of EUS in identifying etiology including changes of chronic pancreatitis (CP) in children and adolescents with ARP. METHODS Children with ARP (≥2 episodes of acute pancreatitis [AP]) were prospectively evaluated with a detailed clinical proforma and EUS. Subjects with known etiology of ARP or CP on ultrasonography/computed tomography and magnetic resonance cholangiopancreatography (MRCP, Cambridge grade ≥3) were excluded. Parenchymal and ductal changes on EUS as per minimal standards terminology (MST) features were noted. RESULTS Thirty-two children (22 boys, age 14 [8-18] years) with ARP (median of 3 [2-5] episodes of AP) were enrolled. EUS was safe and technically successful in all. Gall bladder sludge was found in 1 (3%) case and none had other pancreatobiliary structural abnormalities. EUS diagnosis of CP (≥4 features) was made in 10/32 (31%) cases. Subjects with CP on EUS had a longer disease duration than those without CP (45 [10-97] vs 22 [8-78] months; P = ns). MRCP was normal in 28 and showed pancreas divisum in 1 case. Three cases had equivocal (Cambridge II) changes at initial MRCP and 2 of them had repeat MRCP, which showed definite (Cambridge IV) CP. All these 3 cases had CP on EUS. CONCLUSIONS EUS diagnosed CP (≥4 features) in 31% and biliary abnormality in 3% children with ARP. EUS is safe, sensitive, and useful for early diagnosis of CP in children with ARP.
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Engjom T, Sangnes DA, Havre RF, Erchinger F, Pham KDC, Haldorsen IS, Gilja OH, Dimcevski G. Diagnostic Accuracy of Transabdominal Ultrasound in Chronic Pancreatitis. ULTRASOUND IN MEDICINE & BIOLOGY 2017; 43:735-743. [PMID: 28108042 DOI: 10.1016/j.ultrasmedbio.2016.11.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 11/21/2016] [Accepted: 11/27/2016] [Indexed: 06/06/2023]
Abstract
The performance of transabdominal ultrasound (US) in chronic pancreatitis (CP) following the advances in US technology made during recent decades has not been explored. Our aim in this prospective study was to evaluate the diagnostic accuracy of modern abdominal US compared with the Mayo score in CP. One hundred thirty-four patients referred for suspected CP were included in the study. Fifty-four patients were assigned the diagnosis CP. After inclusion, transabdominal US was performed. Ductal features (calculi, dilations and caliber variations, side-branch dilations and hyper-echoic duct wall margins) and parenchymal features (calcifications, cysts, hyper-echoic foci, stranding, lobulation and honeycombing) were recorded. Features were counted and scored according to a weighting system defined at the international consensus meeting in Rosemont, Illinois (Rosemont score). Diagnostic performance indices (95% confidence interval) of US were calculated: The unweighted count of features had a sensitivity of 0.69 (0.54-0.80) and specificity of 0.97 (0.90-1). The Rosemont score had a sensitivity of 0.81 (0.69-0.91) and specificity of 0.97 (0.90-1). Exocrine pancreatic failure was most pronounced in Rosemont groups I and II (p < 0.001). We conclude that using both unweighted and weighted scores, the diagnostic accuracy of modern transabdominal US is good. The extent of pancreatic changes detected by the method is correlated with exocrine pancreatic function.
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Affiliation(s)
- Trond Engjom
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; National Centre for Ultrasound in Gastroenterology, Department of Medicine, Haukeland University Hospital, Bergen, Norway.
| | - Dag A Sangnes
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Roald F Havre
- National Centre for Ultrasound in Gastroenterology, Department of Medicine, Haukeland University Hospital, Bergen, Norway; Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Friedemann Erchinger
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Medicine, Voss Hospital, Voss, Norway
| | | | - Ingfrid S Haldorsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Radiology, Haukeland University Hospital, Bergen, Norway
| | - Odd H Gilja
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; National Centre for Ultrasound in Gastroenterology, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Georg Dimcevski
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Di Leo M, Leandro G, Singh SK, Mariani A, Bianco M, Zuppardo RA, Goni E, Rogger TM, Di Mario F, Guslandi M, De Cobelli F, Del Maschio A, Testoni PA, Cavestro GM. Low Alcohol and Cigarette Use Is Associated to the Risk of Developing Chronic Pancreatitis. Pancreas 2017; 46:225-229. [PMID: 27846144 DOI: 10.1097/mpa.0000000000000737] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the contribution of smoking and alcohol intake and pancreas divisum on the risk of developing chronic pancreatitis (CP). METHODS Consecutive patients with CP who underwent secretin-enhanced magnetic resonance cholangiopancreatography were compared with consecutive patients without pancreatic disease who underwent secretin-enhanced magnetic resonance cholangiopancreatography for irritable bowel syndrome. RESULTS We enrolled 145 consecutive CP patients and 103 irritable bowel syndrome patients from 2010 to 2014. In a univariate analysis, statistically significant differences in sex, mean age, and the duration and amount of cigarette and alcohol use were found. Per a receiver operating characteristic curve analysis, thresholds for cigarette and alcohol consumption were, respectively, 5.5 cigarettes and 13.5 g daily. In a multivariate analysis, independent risk factors for CP were male sex (odds ratio [OR], 2.05), smoking more than 5.5 cigarettes per day (OR, 2.72), and drinking more than 13.5 g/d (OR, 6.35). CONCLUSIONS In an Italian population, we confirmed smoking and alcohol as cofactors in the development of CP. This study shows that alcohol intake and smoking habits are 2 of the most important risk factors for the development of CP.
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Affiliation(s)
- Milena Di Leo
- From the *Gastrointestinal Endoscopy Unit, Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan; and †Gastroenterology Unit 1, Scientific Institute for Digestive Disease 'S. de Bellis' Hospital, Castellana Grotte, Italy ‡Institute for Digestive Liver Health, University College, London, United Kingdom; §Section of Gastroenterology Boston University School of Medicine Boston Medical Center, Boston, MA; ∥Department of Gastroenterology, Hepatology Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany; and ¶Department of Clinical Experimental Medicine, School of Medicine, University of Parma, Parma; and #Department of Radiology Center for Experimental Imaging, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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Issa Y, Kempeneers MA, van Santvoort HC, Bollen TL, Bipat S, Boermeester MA. Diagnostic performance of imaging modalities in chronic pancreatitis: a systematic review and meta-analysis. Eur Radiol 2017; 27:3820-3844. [PMID: 28130609 PMCID: PMC5544812 DOI: 10.1007/s00330-016-4720-9] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 09/20/2016] [Accepted: 12/16/2016] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Obtain summary estimates of sensitivity and specificity for imaging modalities for chronic pancreatitis (CP) assessment. METHODS A systematic search was performed in Cochrane Library, MEDLINE, Embase and CINAHL databases for studies evaluating imaging modalities for the diagnosis of CP up to September 2016. A bivariate random-effects modeling was used to obtain summary estimates of sensitivity and specificity. RESULTS We included 43 studies evaluating 3460 patients. Sensitivity of endoscopic retrograde cholangiopancreatography (ERCP) (82%; 95%CI: 76%-87%) was significant higher than that of abdominal ultrasonography (US) (67%; 95%CI: 53%-78%; P=0.018). The sensitivity estimates of endoscopic ultrasonography (EUS), magnetic resonance imaging (MRI), and computed tomography (CT) were 81% (95%CI: 70%-89%), 78% (95%CI: 69%-85%), and 75% (95%CI: 66%-83%), respectively, and did not differ significantly from each other. Estimates of specificity were comparable for EUS (90%; 95%CI: 82%-95%), ERCP (94%; 95%CI: 87%-98%), CT (91%; 95% CI: 81%-96%), MRI (96%; 95%CI: 90%-98%), and US (98%; 95%CI: 89%-100%). CONCLUSIONS EUS, ERCP, MRI and CT all have comparable high diagnostic accuracy in the initial diagnosis of CP. EUS and ERCP are outperformers and US has the lowest accuracy. The choice of imaging modality can therefore be made based on invasiveness, local availability, experience and costs. KEY POINTS • EUS, ERCP, MRI and CT have high diagnostic sensitivity for chronic pancreatitis • Diagnostic specificity is comparable for all imaging modalities • EUS and ERCP are outperformers and US has the lowest accuracy • The choice of imaging can be made based on clinical considerations.
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Affiliation(s)
- Y Issa
- Department of Surgery, Academic Medical Centre, Meibergdreef 9, 1100DD, Amsterdam, The Netherlands
| | - M A Kempeneers
- Department of Surgery, Academic Medical Centre, Meibergdreef 9, 1100DD, Amsterdam, The Netherlands
| | - H C van Santvoort
- Department of Surgery, Academic Medical Centre, Meibergdreef 9, 1100DD, Amsterdam, The Netherlands
| | - T L Bollen
- Department of Radiology, St Antonius Ziekenhuis, Koekoekslaan 1, 3430EM, Nieuwegein, The Netherlands
| | - S Bipat
- Department of Radiology, Academic Medical Centre, Meibergdreef 9, 1100DD, Amsterdam, The Netherlands
| | - M A Boermeester
- Department of Surgery, Academic Medical Centre, Meibergdreef 9, 1100DD, Amsterdam, The Netherlands.
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Abstract
Chronic diarrhea is a frequently encountered symptom in clinical practice. The etiologies for chronic diarrhea are diverse and broad with varying clinical implications. A useful method of categorizing chronic diarrhea to guide a diagnostic work-up is a pathophysiology-based framework. Chronic diarrhea may be categorized as malabsorptive, secretory, osmotic, and inflammatory or motility related. Frequently, overlap between categories may exist for any given diarrhea etiology and diagnostic testing must occur with an understanding of the differential diagnosis. Investigations to achieve a diagnosis for chronic diarrhea range from screening blood and stool tests to more directed testing such as diagnostic imaging, and endoscopic and histological evaluation. The pathophysiology-based framework proposed in this chapter will allow the clinician to select screening tests followed by targeted tests to minimize cost and complications to the patient, while providing a highly effective method to achieve an accurate diagnosis.
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Affiliation(s)
- M Raman
- University of Calgary, Calgary, AB, Canada.
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Di Leo M, Petrone MC, Zuppardo RA, Cavestro GM, Arcidiacono PG, Testoni PA, Mariani A. Pancreatic morpho-functional imaging as a diagnostic approach for chronic asymptomatic pancreatic hyperenzymemia. Dig Liver Dis 2016; 48:1330-1335. [PMID: 27623184 DOI: 10.1016/j.dld.2016.08.109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 07/08/2016] [Accepted: 08/03/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Magnetic resonance cholangio-pancreatography (MRCP) findings in people with chronic asymptomatic pancreatic hyperenzymemia (CAPH) have shifted the hypothesis that CAPH is always non-pathological. However, there have been no studies including both secretin-MRCP (S-MRCP) and endoscopic ultrasonography (EUS) to examine the pancreatic morphology in these subjects. AIM To prospectively assess the diagnostic approach for CAPH using both pancreatic EUS and S-MRCP. METHODS In a case-control prospective study from January 2010 to December 2014, 68 consecutive subjects with CAPH were scheduled to undergo S-MRCP and EUS (CAPH group) in a tertiary care setting. In the same period, the EUS findings of this group were compared with 68 patients examined by EUS alone for submucosal lesions of the gastric fundus, matched for sex and age (control group). RESULTS EUS detected pancreatic alterations in 60.3% of the CAPH group and 13.2% of controls (p<0.001). S-MRCP showed pancreatic alterations in 51.5% in the CAPH group. With the combined procedures, pancreatic abnormalities were detected in 63.3%. The diagnoses established by the two techniques were concordant in 51 (75%) of the 68 CAPH subjects; in the remaining 17 (25%) the two methods gave additional information. CONCLUSIONS In people with CAPH S-MRCP and EUS are both recommended in order to detect pancreatic abnormalities before this biochemical alteration is confirmed as benign CAPH, or Gullo's syndrome.
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Affiliation(s)
- Milena Di Leo
- Gastroenterology and Gastrointestinal Endoscopy Unit, Division of Experimental Oncology, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Maria Chiara Petrone
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Raffaella Alessia Zuppardo
- Gastroenterology and Gastrointestinal Endoscopy Unit, Division of Experimental Oncology, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Giulia Martina Cavestro
- Gastroenterology and Gastrointestinal Endoscopy Unit, Division of Experimental Oncology, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Pier Alberto Testoni
- Gastroenterology and Gastrointestinal Endoscopy Unit, Division of Experimental Oncology, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Mariani
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy.
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Abstract
OBJECTIVES To evaluate the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) in the detection of chronic pancreatitis (CP)-specific changes in the pediatric population. METHODS The study included 48 children with pancreatic disorders subjected to both endoscopic retrograde cholangiopancreatography (ERCP) and MRCP within a 1- to 4-month interval. The sensitivity, specificity, positive predictive value, and negative predictive value of MRCP in the detection of CP-specific changes were determined using ERCP as a diagnostic standard. RESULTS Diagnostic ERCP pancreatograms were obtained in 41 (85.4%) of 48 patients and diagnostic MRCP images in all 48 children. The sensitivity and positive predictive value of MRCP were 77.1% and 90%, respectively, and its specificity and negative predictive value amounted to 50% and 27.3%, respectively. The patients with consistent results of MRCP and ERCP (ie, true-positive and true-negative cases) and individuals with incompatible results of the tests (ie, false-positive and false-negative cases) differed in terms of their median age at MRCP (14.17 vs 10.33 years) and median CP stage according to the Cambridge Scale (4 vs 2). CONCLUSIONS Magnetic resonance cholangiopancreatography provides diagnostic information equivalent to ERCP in a large percentage of pediatric patients with CP and should be used as the imaging method of choice, especially if the likelihood of therapeutic intervention is low.
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Secretin-Stimulated Magnetic Resonance Imaging Assessment of the Benign Pancreatic Disorders: Systematic Review and Proposal for a Standardized Protocol. Pancreas 2016; 45:1092-103. [PMID: 27171509 DOI: 10.1097/mpa.0000000000000606] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This systemic review summarizes the current literature and general consensus on secretin-stimulated magnetic resonance imaging (s-MRI) of the benign pancreatic disorders and discusses important aspects on how s-MRI is optimally performed. The aim is to provide an overview, for clinicians and radiologist, of the s-MRI protocols and the range of clinical applications. Furthermore, the review will summarize the criteria for evaluation of pancreatic morphology and function based on s-MRI.The literature search indentified 69 original articles and 15 reviews. Chronic pancreatitis was the disease that was most frequently assessed by s-MRI (33%), followed by acute pancreatitis (9%). Dynamic thick-slab 2-dimensional magnetic resonance cholangiopancreatography was the most used imaging sequence (86%). The diameter of the main pancreatic duct (75%) and pancreatic exocrine function based on visual grading of duodenal filling (67%) were the most evaluated pancreatic features. Sufficient similarities between studies were identified to propose the most agreeable standardized s-MRI protocol for morphological and functional assessment of the pancreas. In the future, more research and increased collaboration between centers is necessary to achieve more consensus and optimization of s-MRI protocols.
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Abstract
OBJECTIVES The purpose of this study was to determine qualitative pancreatic magnetic resonance imaging (MRI) features that must be present to predict abnormal pancreatic secretory function in patients evaluated for chronic pancreatitis (CP). METHODS The MRIs of study subjects were reviewed by 2 abdominal radiologists; qualitative parenchyma and ductal features were recorded. Endoscopic pancreatic function test (ePFT) results (reference standard) were classified as normal (peak pancreatic fluid bicarbonate [HCO3-] ≥75 meq/L) or abnormal (<75). Abnormal ePFT was further classified as mild/moderate (74-65) and marked deficiency (<65). Statistical analysis was performed to assess the association between MRI features and abnormal ePFT. RESULTS The study cohort was composed of 93 subjects, mean age 49 years (range, 18-78 years), 65% females. Univariate analysis identified 9 qualitative MRI features significantly (P < 0.05) associated with abnormal pancreatic secretory function. Number of MRI features increases as peak pancreatic fluid [HCO3-] decreases (Pearson r = -0.629; P = 0.001). Receiver operating characteristic curve analysis determined that a threshold of 6 or more associated MRI features 64% sensitive and 94% specific for marked bicarbonate deficiency. CONCLUSIONS Qualitative MRI parenchymal and ductal features are associated with CP. Presence of 6 or more features results in a higher specificity for the diagnosis of CP in advanced disease.
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Abstract
Chronic pancreatitis (CP) represents a significant health care burden in the United States. Diagnosing it early and accurately is important for the efficient management of these patients. However, the early diagnosis of CP, when structural and functional pancreatic changes are subtle, remains difficult. Complicating this is the large cohort of patients with nonspecific abdominal pain who are often suspected of having early CP and who utilize significant health care resources in attempts at diagnosis and management. We present a review of the current diagnostic tests available for making an early diagnosis of CP. We further report our approach to patients suspected of having CP based on the available literature.
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Chiaro MD, Segersvärd R, Lohr M, Verbeke C. Early detection and prevention of pancreatic cancer: Is it really possible today? World J Gastroenterol 2014; 20:12118-12131. [PMID: 25232247 PMCID: PMC4161798 DOI: 10.3748/wjg.v20.i34.12118] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 01/23/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is the 4th leading cause of cancer-related death in Western countries. Considering the low incidence of pancreatic cancer, population-based screening is not feasible. However, the existence of a group of individuals with an increased risk to develop pancreatic cancer has been well established. In particular, individuals suffering from a somatic or genetic condition associated with an increased relative risk of more than 5- to 10-fold seem to be suitable for enrollment in a surveillance program for prevention or early detection of pancreatic cancer. The aim of such a program is to reduce pancreatic cancer mortality through early or preemptive surgery. Considering the risk associated with pancreatic surgery, the concept of preemptive surgery cannot consist of a prophylactic removal of the pancreas in high-risk healthy individuals, but must instead aim at treating precancerous lesions such as intraductal papillary mucinous neoplasms or pancreatic intraepithelial neoplasms, or early cancer. Currently, results from clinical trials do not convincingly demonstrate the efficacy of this approach in terms of identification of precancerous lesions, nor do they define the outcome of the surgical treatment of these lesions. For this reason, surveillance programs for individuals at risk of pancreatic cancer are thus far generally limited to the setting of a clinical trial. However, the acquisition of a deeper understanding of this complex area, together with the increasing request for screening and treatment by individuals at risk, will usher pancreatologists into a new era of preemptive pancreatic surgery. Along with the growing demand to treat individuals with precancerous lesions, the need for low-risk investigation, low-morbidity operation and a minimally invasive approach becomes increasingly pressing. All of these considerations are reasons for preemptive pancreatic surgery programs to be undertaken in specialized centers only.
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Sze KCP, Pirola RC, Apte MV, Wilson JS. Current options for the diagnosis of chronic pancreatitis. Expert Rev Mol Diagn 2014; 14:199-215. [PMID: 24512138 DOI: 10.1586/14737159.2014.883277] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The diagnostic options for chronic pancreatitis have evolved over recent years. The previous gold standard references for structural imaging and exocrine pancreatic function testing have both been supplanted and redesigned. Endoscopic retrograde pancreatography has now been overtaken by endoscopic ultrasound and magnetic resonance cholangiopancreatography, whilst the old technique for Dreiling tube pancreatic function testing has now been replaced by the endoscopic pancreatic function test. New advances in endoscopic ultrasound elastography have also extended the options for evaluating pancreatic masses to differentiate mass-forming chronic pancreatitis from malignancy. Genetic contribution to chronic pancreatitis is also now more widely recognized than ever before.
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Affiliation(s)
- Kenny Ching Pan Sze
- South Western Sydney Clinical School, University of New South Wales, Liverpool Hospital, Liverpool, NSW 2170, Australia
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Stevens T. Role of endoscopic ultrasonography in the diagnosis of acute and chronic pancreatitis. Gastrointest Endosc Clin N Am 2013; 23:735-47. [PMID: 24079787 DOI: 10.1016/j.giec.2013.06.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endoscopic ultrasonography (EUS) can be a useful tool for detecting underlying causes of acute pancreatitis and establishing the severity of fibrosis in chronic pancreatitis. Ancillary techniques include fine needle aspiration and core biopsy, bile collection for crystal analysis, pancreatic function testing, and celiac plexus block. This review focuses on the role of EUS in the diagnosis of acute and chronic pancreatitis.
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Affiliation(s)
- Tyler Stevens
- Department of Gastroenterology and Hepatology, Cleveland Clinic, 9500 Euclid Avenue, A31, Cleveland, OH 44195, USA.
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Fusaroli P, Kypraios D, Caletti G, Eloubeidi MA. Pancreatico-biliary endoscopic ultrasound: a systematic review of the levels of evidence, performance and outcomes. World J Gastroenterol 2012; 18:4243-4256. [PMID: 22969187 PMCID: PMC3436039 DOI: 10.3748/wjg.v18.i32.4243] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Revised: 08/01/2012] [Accepted: 08/03/2012] [Indexed: 02/06/2023] Open
Abstract
Our aim was to record pancreaticobiliary endoscopic ultrasound (EUS) literature of the past 3 decades and evaluate its role based on a critical appraisal of published studies according to levels of evidence (LE). Original research articles (randomized controlled trials, prospective and retrospective studies), meta-analyses, reviews and surveys pertinent to gastrointestinal EUS were included. All articles published until September 2011 were retrieved from PubMed and classified according to specific disease entities, anatomical subdivisions and therapeutic applications of EUS. The North of England evidence-based guidelines were used to determine LE. A total of 1089 pertinent articles were reviewed. Published research focused primarily on solid pancreatic neoplasms, followed by disorders of the extrahepatic biliary tree, pancreatic cystic lesions, therapeutic-interventional EUS, chronic and acute pancreatitis. A uniform observation in all six categories of articles was the predominance of LE III studies followed by LE IV, II b, II a, I b and I a, in descending order. EUS remains the most accurate method for detecting small (< 3 cm) pancreatic tumors, ampullary neoplasms and small (< 4 mm) bile duct stones, and the best test to define vascular invasion in pancreatic and peri-ampullary neoplasms. Detailed EUS imaging, along with biochemical and molecular cyst fluid analysis, improve the differentiation of pancreatic cysts and help predict their malignant potential. Early diagnosis of chronic pancreatitis appears feasible and reliable. Novel imaging techniques (contrast-enhanced EUS, elastography) seem promising for the evaluation of pancreatic cancer and autoimmune pancreatitis. Therapeutic applications currently involve pancreaticobiliary drainage and targeted fine needle injection-guided antitumor therapy. Despite the ongoing development of extra-corporeal imaging modalities, such as computed tomography, magnetic resonance imaging, and positron emission tomography, EUS still holds a leading role in the investigation of the pancreaticobiliary area. The major challenge of EUS evolution is its expanding therapeutic potential towards an effective and minimally invasive management of complex pancreaticobiliary disorders.
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Lee LS, Conwell DL. Update on Advanced Endoscopic Techniques for the Pancreas: Endoscopic Retrograde Cholangiopancreatography, Drainage and Biopsy, and Endoscopic Ultrasound. Radiol Clin North Am 2012; 50:547-61. [DOI: 10.1016/j.rcl.2012.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Krishna NB, Tummala P, Mehan CD, Reddy AV, Hartman JA, Agarwal B. Small and potentially resectable focal pancreatic lesions noted on CT/MRI scans in nonjaundiced patients: likelihood of neoplasia and utility of EUS. J Gastrointest Surg 2012; 16:793-800. [PMID: 22258870 DOI: 10.1007/s11605-011-1812-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 12/28/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Management of small and potentially resectable "mass" lesions encountered on CT/MRI scans in patients without obstructive jaundice (ObJ) is rather empirical since there is scant data on likelihood of neoplasm to formulate treatment strategies. We evaluated (1) the prevalence of neoplasm and (2) performance characteristics of EUS-FNA for diagnosing neoplasm in above-mentioned subset of patients. PATIENTS This is a retrospective analysis of 232 patients (without ObJ) with a focal pancreatic lesion, ≤ 25 mm and potentially resectable on CT/MRI who underwent EUS-FNA from 2002 to 2009. RESULTS Seventy-five patients (32.3%, 95% CI 26.6, 38.6) were finally diagnosed to have a neoplasm. Four of 92 (4.3%) lesions ≤ 15 mm, 13 of 57(22.8%) lesions 16-20 mm, and 35 of 83 (42.1%) lesions 21-25 mm had an adenocarcinoma. Larger lesion size, older patient age, and h/o recent weight loss significantly increased the likelihood of adenocarcinoma. EUS-FNA had 98.2% overall accuracy and 98.1% NPV with no significant differences based on lesion size. CONCLUSIONS In nonjaundiced patient with a potentially resectable pancreatic lesion ≤25 mm in size noted on CT/MRI scanning, EUS-FNA can provide useful adjunctive information to optimize the use of surgery and can potentially obviate the need for "wait and watch approach" with repeat imaging in their clinical management.
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Affiliation(s)
- Naveen B Krishna
- Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, 3635 Vista Avenue, FDT 9S, St. Louis, MO 63110, USA
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Pancreatic duct compliance after secretin stimulation: a novel endoscopic ultrasound diagnostic tool for chronic pancreatitis. Pancreas 2012; 41:290-4. [PMID: 21926934 PMCID: PMC3244551 DOI: 10.1097/mpa.0b013e318229db6b] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Endoscopic ultrasound (EUS) evaluation of pancreatic duct compliance after secretin stimulation (sEUS) along with EUS morphologic examination (EUS) and duodenal fluid [HCO3] measurement (endoscopic pancreatic function test, ePFT) in 1 endoscopic session has not been reported as a means of evaluating for chronic pancreatitis (CP). We evaluated the feasibility of the combined examination and compared EUS measurements of pancreatic ductal compliance with duodenal fluid [HCO3] for diagnosing CP. METHODS The study is a prospective case series of patients with suspected CP who underwent a combined EUS, sEUS, and ePFT examination in 1 endoscopic session. The main outcome measures were the feasibility of performing the combination examination and the correlation between ductal compliance and ePFT. RESULTS All examinations were completed in 1 endoscopic session, and there were no complications in 35 patients. Although there was a trend toward less change from baseline head and body ductal diameter in patients with CP, only the percent change from baseline in the tail was significant (CP 144.3% vs healthy patients 240.9%, P < 0.01). Regression analysis demonstrated fair correlation between maximum change in ductal diameter and duodenal fluid [HCO3] (r = 0.27). CONCLUSIONS Combined EUS, sEUS, and ePFTs are feasible and safe, with preliminary results demonstrating a positive correlation between pancreatic ductal compliance and duodenal fluid [HCO3].
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Almansa C, Bertani H, Noh KW, Wallace MB, Woodward TA, Raimondo M. The role of endoscopic ultrasound in the evaluation of chronic mesenteric ischaemia. Dig Liver Dis 2011; 43:470-4. [PMID: 21316317 DOI: 10.1016/j.dld.2011.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Revised: 12/16/2010] [Accepted: 01/04/2011] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Doppler transabdominal ultrasound is a validated screening test for chronic mesenteric ischaemia, but gas and obesity are limitations. Endoscopic ultrasound has been proposed as a comprehensive test to evaluate chronic upper abdominal pain and is capable of Doppler measurement. We aim to evaluate the accuracy of Doppler endoscopic ultrasound (D-EUS) as a single screening test to rule out chronic mesenteric ischaemia in patients with abdominal pain and compare it with Doppler transabdominal ultrasound (D-TUS). METHODS We enrolled all patients ≥50 years with chronic upper abdominal pain and vascular risk referred for endoscopic ultrasound. All were scheduled for D-EUS and D-TUS plus a confirmatory test if one of the previous resulted positive. We estimated the accuracy of both techniques comparing them using McNemar test. RESULTS 68 patients completed the study. Fifty-three (78%) underwent D-EUS, D-TUS, and a confirmatory test. Fifteen (38%) underwent follow-up after negative results. Three (4%) in the D-EUS group and 14 in the D-TUS (21%) were excluded due to artefacts. D-EUS presented a sensitivity of 63%, specificity of 84%, whilst D-TUS presented a sensitivity of 80% and a specificity of 78%. Specificity of D-EUS was not significantly different to D-TUS. CONCLUSIONS These results support the role of Doppler endoscopic ultrasound to exclude chronic mesenteric ischaemia as cause of chronic abdominal pain.
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Affiliation(s)
- Cristina Almansa
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
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36
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Abstract
Chronic pancreatitis (CP) remains an important healthcare problem that adversely affects quality of life. Endoscopic ultrasound (EUS) is a preferred test for the diagnosis of early CP. The Rosemont classification strictly defines and assigns weighting to the previously described ductal and parenchymal criteria. Recent histological correlation studies have improved our understanding of the accuracy of EUS criteria. Digital imaging analysis and complementary functional testing may complement endosonographic diagnosis. EUS-directed celiac plexus blockade and ductal access techniques have expanded the therapeutic armamentarium for pain management in CP.
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Affiliation(s)
- Tyler Stevens
- Department of Gastroenterology and Hepatology, Cleveland Clinic, 9500 Euclid Avenue, Desk A31, Cleveland, OH 44195, USA.
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Seicean A. Endoscopic ultrasound in chronic pancreatitis: where are we now? World J Gastroenterol 2010; 16:4253-4263. [PMID: 20818808 PMCID: PMC2937105 DOI: 10.3748/wjg.v16.i34.4253] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Revised: 06/12/2010] [Accepted: 06/19/2010] [Indexed: 02/06/2023] Open
Abstract
Endoscopic ultrasonography (EUS) is well suited for assessment of the pancreas due to its high resolution and the proximity of the transducer to the pancreas, avoiding air in the gut. Evaluation of chronic pancreatitis (CP) was an early target for EUS, initially just for diagnosis but later for therapeutic purposes. The diagnosis of CP is still accomplished using the standard scoring based on nine criteria, all considered to be of equal value. For diagnosis of any CP, at least three or four criteria must be fulfilled, but for diagnosis of severe CP at least six criteria are necessary. The Rosemont classification, more restrictive, aims to standardize the criteria and assigns different values to different features, but requires further validation. EUS-fine needle aspiration (EUS-FNA) is less advisable for diagnosis of diffuse CP due to its potential side effects. Elastography and contrast-enhanced EUS are orientation in differentiating a focal pancreatic mass in a parenchyma with features of CP, but they cannot replace EUS-FNA. The usefulness of EUS-guided celiac block for painful CP is still being debated with regard to the best technique and the indications. EUS-guided drainage of pseudocysts is preferred in non-bulging pseudocysts or in the presence of portal hypertension. EUS-guided drainage of the main pancreatic duct should be reserved for cases in which endoscopic retrograde cholangiopancreatography has failed owing to difficult cannulation of the papilla or difficult endotherapy. It should be performed only by highly skilled endoscopists, due to the high rate of complications.
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Castillo C. Endoscopic ultrasound in the papilla and the periampullary region. World J Gastrointest Endosc 2010; 2:278-87. [PMID: 21160627 PMCID: PMC2999148 DOI: 10.4253/wjge.v2.i8.278] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 06/22/2010] [Accepted: 06/29/2010] [Indexed: 02/05/2023] Open
Abstract
Endoscopic ultrasound (EUS) provides relevant information when an ampullary or periampullary tumor is suspected. Early detection, T and N staging and Fine Needle Aspiration plus cithologic confirmation, are some of the expected benefits. Exclusion of benign findings like choledocholithiasis or chronic pancreatitis is also important. A correct understanding of the complex ampullary and periampullary anatomy is needed. Knowledge of the individual clinical history and other previous diagnostic images all contribute to a successful EUS examination. Radial and lineal EUS images are uniquely detailed and, at the moment, it seems to be the best way to exclude or confirm malignant or benign findings. We propose a procedural algorithm, including EUS, for suspected ampullary or periampullary tumors. This review summarizes the vast amount of information to be found spread in the literature, and recognizes this small anatomic area as the origin for a clinical entity with proper clinical presentation, proper imaging and proper therapeutic resolutions. The benefits of performing EUS for its study are highlighted.
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Affiliation(s)
- Cecilia Castillo
- Cecilia Castillo, Endoscopy Service, Latin American Endoscopy Training Center, Clínica Alemana de Santiago, Universidad del Desarrollo, Vitacura 5951, Santiago, Chile
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Said K, Albiin N, Lindberg B, Brismar TB, Karrar A, Permert J, Bergquist A. Pancreatic duct changes are not associated with early signs of chronic pancreatitis at magnetic resonance imaging (MRI) in patients with primary sclerosing cholangitis. Scand J Gastroenterol 2010; 45:980-6. [PMID: 20384530 DOI: 10.3109/00365521003793741] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The association between chronic pancreatitis (CP) and primary sclerosing cholangitis (PSC) has been reported previously. The aims of the present study were to evaluate the presence of early pancreatic abnormalities and duct changes, using MRCP/MRI in PSC and to evaluate possible risk factors for these changes and their clinical importance. MATERIALS AND METHODS One hundred and three patients with PSC were identified among all MRI liver/pancreas referrals in 2001-2005. MRCP was used to grade pancreatic duct changes in three groups: grade 0 (normal), grade 1 (mild) and grade 2 (severe). For detection of early MRI signs of CP, the pancreas-spleen signal intensity ratio (SIR), the arterial and early venous phase ratio (A/PV ratio) and the age-related size of the pancreas were evaluated. RESULTS Pancreatic duct changes were found in 24% of the PSC patients. The pancreatic duct changes were associated with extrahepatic biliary involvement and long duration of PSC but not associated with pancreas-spleen SIR, A/PV ratio, pancreas size, previous post-ERCP or acute pancreatitis. Severe pancreatic duct changes were significantly associated to abdominal pain. Clinically significant CP was seen in one PSC patient (1%). CONCLUSIONS Pancreatic duct changes are associated with extrahepatic bile duct strictures and not with the early MRI signs of CP. Therefore, pancreatic duct changes seem to be part of the spectrum of PSC and should not be defined as CP. Pancreatic duct changes are of limited clinical importance but may contribute to abdominal pain in PSC.
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Affiliation(s)
- Karouk Said
- Division of Gastroenterology and Hepatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
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40
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Gardner TB, Levy MJ. EUS diagnosis of chronic pancreatitis. Gastrointest Endosc 2010; 71:1280-9. [PMID: 20598255 DOI: 10.1016/j.gie.2010.02.038] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Accepted: 02/18/2010] [Indexed: 02/06/2023]
Affiliation(s)
- Timothy B Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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41
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Stevens T, Lopez R, Adler DG, Al-Haddad MA, Conway J, Dewitt JM, Forsmark CE, Kahaleh M, Lee LS, Levy MJ, Mishra G, Piraka CR, Papachristou GI, Shah RJ, Topazian MD, Vargo JJ, Vela SA. Multicenter comparison of the interobserver agreement of standard EUS scoring and Rosemont classification scoring for diagnosis of chronic pancreatitis. Gastrointest Endosc 2010; 71:519-26. [PMID: 20189510 DOI: 10.1016/j.gie.2009.10.043] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Accepted: 10/14/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND EUS has less than optimal interobserver agreement for the diagnosis of chronic pancreatitis. The newly developed Rosemont consensus scoring system includes weighted criteria and stricter definitions for individual features. OBJECTIVE The primary aim was to compare the interobserver agreement of standard and Rosemont scoring. SETTING Multiple tertiary-care institutions. INTERVENTION Fifty EUS videos were interpreted by 14 experts. Each expert interpreted the videos on two occasions: First, the videos were read by using standard scoring (9 criteria). Second, after viewing a presentation of the Rosemont classification, the same experts re-read the videos by using Rosemont scoring. MAIN OUTCOME MEASUREMENTS Fleiss' kappa (K) statistics are reported with 95% confidence intervals (CI). RESULTS The interobserver agreement was "substantial" (K = 0.65 [95% CI, 0.52-0.77]) for Rosemont scoring and "moderate" (K = 0.54 [95% CI, 0.44-0.66]) for standard scoring; however, the difference was not statistically significant (P = 0.12). LIMITATIONS The sample size does not allow detection of differences in K of <0.25. CONCLUSION Use of the Rosemont classification did not significantly increase interobserver agreement for EUS diagnosis of chronic pancreatitis compared with standard scoring.
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Affiliation(s)
- Tyler Stevens
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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Zuccaro P, Stevens T, Repas K, Diamond R, Lopez R, Wu B, Conwell DL. Magnetic resonance cholangiopancreatography reports in the evaluation of chronic pancreatitis: a need for quality improvement. Pancreatology 2010; 9:764-9. [PMID: 20110743 DOI: 10.1159/000201304] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Accepted: 01/31/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND Numerous publications from academic centers suggest that magnetic resonance cholangiopancreatography (MRCP) can diagnose early chronic pancreatitis (CP) and assess pancreatic secretory reserve/function. However, the rigorous composite interpretation methods and quantitative secretory dynamics reported in these studies are not routinely measured in clinical practice. Therefore, the utility of routine MRCP reports in the clinical setting is unknown. STUDY DESIGN Cross-sectional study of patients referred to a tertiary center who underwent both MRCP and endoscopic pancreas function testing (ePFT) for assessment of chronic pancreatitis and abdominal pain. AIMS To compare MRCP and sMRCP reports to a reference standard pancreas function test for diagnosis of chronic pancreatitis. METHODS Source population: patients seen within a pancreas clinic at a tertiary referral center. MRCP and sMRCP reports were reviewed to record pancreas duct (dilation, side-branch changes), parenchyma enhancement (T(1), T(2) signal) and physiologic response (duodenal filling, pancreas duct response) to secretin. ePFT was categorized based on previously published data (normal peak bicarbonate >80 mEq/l). Referent values were calculated for MRCP and sMRCP using secretin ePFT as gold standard. RESULTS A total of 69 patients were identified (mean age 43.5 +/- 12; 65.2% female). 28 (40.6%) patients had abnormal ePFT based on their peak bicarbonate level. The mean bicarbonate values in the abnormal PFT and normal PFT groups were 59 +/- 13.9 and 95.3 +/- 12.6 mEq/l, respectively. Peak bicarbonate decreased with severity of chronic pancreatitis on MRCP (p = 0.0016). There was fair agreement of MRCP and ePFT (kappa 0.335 [0.113, 0.557]). The pre-stimulation pancreas duct changes reported were found to be the only predictor of abnormal pancreas function (p = 0.002). The post-stimulation findings of duodenal filling (p = 0.47), T(2)enhancement (p = 0.21) or change in pancreas duct caliber (p = 0.3) reported did not improve MRCP agreement with ePFT. Overall diagnostic accuracy, sensitivity and specificity were 70, 85 and 46%, respectively, for MRCP reports using ePFT as the gold standard. CONCLUSIONS Pancreas ductal features described on routine MRCP reports correlate with abnormal pancreas function. Current MRCP reports should be standardized to include all radiologic information available in hopes of predicting early chronic pancreatitis.
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Vitale GC, Davis BR, Zavaleta C, Vitale M, Fullerton JK. Endoscopic retrograde cholangiopancreatography and histopathology correlation for chronic pancreatitis. Am Surg 2009; 75:649-53; discussion 653. [PMID: 19725285 DOI: 10.1177/000313480907500803] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is debated as the gold standard for diagnosing and staging chronic pancreatitis (CP). The Cambridge classification grades CP on ECRP findings from normal (Grade I) to marked (Grade V). Comparison is needed with histopathology, which is considered the true gold standard to set the accuracy of any diagnostic test. A retrospective study included patients with CP who underwent ERCP and histopathology examination after surgical resection between 2001 and 2006. ERCP findings were staged according to the Cambridge classification. Thirty-one patients underwent initial diagnostic ERCP and surgical resection for chronic pancreatitis between 2001 and 2006 (61% women, 39% men). Patients with CP were diagnosed based on ERCP findings and the Cambridge classification as having normal (2 of 31 [6.5%]), equivocal (4 of 31 [13%]), mild (3 of 31 [9.7%]), moderate (15 of 31 [48%]), and marked (7 of 31 [23%]) pancreatitis. Patients experienced a mean of 5.5 ERCPs with pancreatic duct stenting before surgery and demonstrated a mean time of 25 months (range, 6 months to 3 years) between initial diagnosis and surgery. Surgeries for chronic pancreatitis included 13 (42%) subtotal pancreatectomies, 10 (32%) Whipples, and 8 (26%) distal pancreatectomies. The ERCP findings and histopathology reports correlated in 23 (74%) patients, whereas in eight (26%), findings did not correlate. The early disease group's (9 of 31 classified as normal, equivocal, or mild) ERCP findings correlated with histopathology in 6 of 9 patients (67%). Patients classified as moderate and marked had a correlation of 17 of 22 (77%). ERCP demonstrates a high correlation with pathology for assessing the severity of CP using the Cambridge classification grading system. Patients with normal, equivocal, or mild disease still represent a difficult patient subset for surgical decision-making. ERCP findings accurately predict pathology and thus should be used to help formulate the surgical plan.
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Affiliation(s)
- Gary C Vitale
- Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky 40292, USA.
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44
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Abstract
OBJECTIVES To provide histologic correlation of endoscopic ultrasound (EUS) findings believed to represent chronic pancreatitis (CP). METHODS Eighteen postmortem pancreatic specimens in patients dying of all causes were examined in vitro by EUS for features of CP: (1) echogenic foci, (2) hypoechoic foci, (3) echogenic main pancreatic duct (MPD), (4) accentuated lobular pattern, (5) cysts, (6) irregular MPD, (7) dilated MPD, (8) side branch dilation, and (9) calculi. The pancreata were then examined by 2 pathologists (blinded to the EUS/clinical findings) for histopathologic features of CP. RESULTS Six specimens were autolyzed, and in 1 specimen, MPD could not be seen by EUS. In the other 11 patients, 10 had evidence of CP by EUS (> or =3 features) and by histopathologic examination (> or =2 features). One patient did not have CP by both EUS and histologic examination. CONCLUSIONS Endoscopic ultrasound accurately detected CP, when compared with histopathologic examination. The presence of 3 or more features of CP correlates with the histologic diagnosis of CP, however, up to 3 features are frequently present in elderly patients dying of all causes. Future studies should address the clinical relevance and the specificity of EUS findings of CP in the older population.
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45
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Sand J, Nordback I. Acute pancreatitis: risk of recurrence and late consequences of the disease. Nat Rev Gastroenterol Hepatol 2009; 6:470-7. [PMID: 19581905 DOI: 10.1038/nrgastro.2009.106] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Research into the clinical management of acute pancreatitis has primarily focused on the immediate complications of the disease, whereas its late consequences have received less attention. These late sequelae of acute pancreatitis refer to complications that arise after the convalescence period, which lasts for 3-6 months after the initial episode. In patients who do not undergo necrosectomy that involves removal of the exocrine gland, pancreatic exocrine function usually improves rather than deteriorates during follow-up. By contrast, glucose intolerance is likely to worsen over time in all patients with acute pancreatitis. Despite the risk of late complications for patients with acute pancreatitis, their long-term quality of life is usually good. The number of pancreatitis episodes a patient has experienced is an important factor that determines the severity of late complications of acute pancreatitis. Risk factors for the recurrence of acute pancreatitis episodes have now been identified. This Review focuses on data from studies that investigated the risk factors for recurrent attacks of acute pancreatitis, and discusses the late consequences of this disease.
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Affiliation(s)
- Juhani Sand
- Division of Surgery, Gastroenterology and Oncology, Tampere University Hospital, Tampere, Finland.
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Catalano MF, Sahai A, Levy M, Romagnuolo J, Wiersema M, Brugge W, Freeman M, Yamao K, Canto M, Hernandez LV. EUS-based criteria for the diagnosis of chronic pancreatitis: the Rosemont classification. Gastrointest Endosc 2009; 69:1251-61. [PMID: 19243769 DOI: 10.1016/j.gie.2008.07.043] [Citation(s) in RCA: 336] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2008] [Accepted: 07/24/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND EUS is increasingly used in the diagnosis of chronic pancreatitis (CP). A number of publications in this field have used different EUS terminology, features, and criteria for CP, making it difficult to reproduce their findings and apply them in clinical practice. Moreover, traditional criteria such as the Cambridge classification for CP are arguably outdated and have lost their relevance. OBJECTIVE Our purpose was to establish consensus-based criteria for EUS features of CP. DESIGN Consensus study. MAIN OUTCOME MEASUREMENTS Thirty-two internationally recognized endosonographers anonymously voted on terminology of EUS features, rank order, and category (major vs minor criteria). Consensus was defined as greater than two thirds agreement among participants. RESULTS Major criteria for CP were (1) hyperechoic foci with shadowing and main pancreatic duct (PD) calculi and (2) lobularity with honeycombing. Minor criteria for CP were cysts, dilated ducts > or =3.5 mm, irregular PD contour, dilated side branches > or =1 mm, hyperechoic duct wall, strands, nonshadowing hyperechoic foci, and lobularity with noncontiguous lobules. LIMITATION Lack of broadly accepted reference standard. CONCLUSION In a complex disease such as CP that has no universally accepted reference standard, an EUS-based criterion for diagnosis can be determined by expert consensus opinion and the existing body of evidence. Here we present the new "Rosemont criteria" for the EUS diagnosis of CP.
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Pelli H, Lappalainen-Lehto R, Piironen A, Järvinen S, Sand J, Nordback I. Pancreatic damage after the first episode of acute alcoholic pancreatitis and its association with the later recurrence rate. Pancreatology 2009; 9:245-51. [PMID: 19407478 DOI: 10.1159/000212089] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2007] [Accepted: 07/03/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND Acute alcoholic pancreatitis (AAP) recurs in up to half of the patients, continuous alcohol consumption being an important risk factor. Changes in pancreatic function and morphology after acute pancreatitis have been characterized previously, but their association with later recurrences has not been adequately studied. PATIENTS AND METHODS In this prospective follow-up study, the pancreatic function of 54 patients (47 males and 7 females) with a median age of 49 years (range 25-71) and morphology (35 patients) were evaluated. Pancreatic morphology was evaluated by secretin-stimulated magnetic resonance pancreatography (SMRP). Patients were evaluated early (baseline) and at 2 years after the first episode of AAP. In order to evaluate later recurrences, the patients were followed for a median of 47 (range 28-66) months. RESULTS Of the 46 patients without previous diabetes, 17 patients (37%) developed impaired glucose metabolism during the 2 years following the first AAP. The prevalence of exocrine dysfunction decreased from 39% at baseline to 9% at 2 years. Of the patients with severe pancreatitis (n = 13, 24%), 31% had elevated glycosylated haemoglobin levels compared to 7% in patients with mild pancreatitis [p = 0.05, odds ratio (OR): 5.5, 95% confidence interval (CI): 1.04-29.0]. Twenty percent (7/35) of the patients had changes consistent with chronic pancreatitis on baseline SMRP, which persisted in all cases. Of the 29% patients with acute changes on baseline SMRP, the acute changes resolved in 50% and chronic pancreatitis was detected in the remaining 50% at 2 years. Development of chronic changes did not depend on continued alcohol consumption, as it was also found in 3 patients practising complete abstinence following their first attack of AAP. The presence of a chronic pseudocyst at 2 years predicted pancreatitis when compared to patients lacking pseudocyst formation: 4 (80%) versus 5 (17%) (p = 0.01, OR: 20.0, 95% CI: 1.83-219). CONCLUSION The severity of the first episode of AAP was associated with deteriorated diabetes control, but not with pancreatic exocrine dysfunction at 2 years. The number of patients with chronic changes on SMRP increased independently of alcohol consumption. Chronic pseudocyst formation seen on SMRP 2 years after AAP was significantly associated with recurrence of pancreatitis.
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Affiliation(s)
- Hanna Pelli
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
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Abstract
Imaging plays a crucial role in the diagnosis of acute and chronic pancreatitis in children. Ultrasound (US) is the primary imaging modality. The US study can be improved by incorporating high resolution imaging, color Doppler, harmonic imaging and panorama view. Computer tomography (CT) is widely used for further evaluation. MR imaging in combination with MR cholangiopancreaticography (MRCP) is emerging as the modality of choice. It is non-invasive and radiation-free. It has high potential to replace endoscopic retrograde cholangiopancreaticography (ERCP), too. The latter is becoming more of an interventional tool. This review discusses the current status and comparative diagnostic potential of US, MRCP and ERCP.
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Affiliation(s)
- Kassa Darge
- Division of Body Imaging, Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104-4399, USA.
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Bilgin M, Balci NC, Momtahen AJ, Bilgin Y, Klör HU, Rau WS. MRI and MRCP findings of the pancreas in patients with diabetes mellitus: compared analysis with pancreatic exocrine function determined by fecal elastase 1. J Clin Gastroenterol 2009; 43:165-70. [PMID: 18797409 DOI: 10.1097/mcg.0b013e3181587912] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
GOALS To review magnetic resonance imaging and magnetic resonance cholangiopancreatography (MRCP) findings in patients with diabetes mellitus (DM), with pancreatic exocrine insufficiency, and with combined pancreatic exocrine insufficiency and DM. STUDY MRI/MRCP findings of 82 consecutive patients with DM (n=28), pancreatic exocrine insufficiency (n=25), and combination of both (n=29) were evaluated and compared with MRI/MRCP findings of 21 healthy volunteers with normal pancreatic exocrine function. Pancreatic exocrine function was determined by fecal elastase 1. MRCP images were evaluated according to the Cambridge classification. MRI of the pancreas was assessed for pancreatic size, signal intensity ratio (SIR), and arterial/venous enhancement ratio (A/V). RESULTS On MRI, significant difference was present in terms of mean values of pancreatic size (P<0.0001), A/V (P<0.02), and SIR (P<0.005) between the control group and groups of patients with DM, pancreatic exocrine insufficiency, and combined DM and pancreatic exocrine insufficiency. No significant difference was observed between groups of patients with DM and pancreatic exocrine function alone in terms of pancreatic size, A/V, and SIR. Chronic pancreatitis MRCP findings were present with increasing frequency in groups of DM, pancreatic exocrine insufficiency, and combination of both. CONCLUSIONS MRI/MRCP findings suggesting chronic pancreatitis may exist in patients with DM comparable to patients with pancreatic exocrine insufficiency. The frequency and severity of MRI/MRCP findings increase when the patients have combined DM and pancreatic exocrine insufficiency.
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Affiliation(s)
- Mehmet Bilgin
- Department of Radiology, University Hospital Giessen and Marburg, Giessen, Germany
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