Diagnostic Imaging Pathways - Pancreatitis (Chronic)
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This pathway provides guidance on the imaging of adult patients with suspected chronic pancreatitis.
Date reviewed: April 2018
Date of next review: April 2021
Published: February 2019
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| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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Images
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| 1a |  |
Chronic Pancreatitis Image 1a and1b (Computed Tomography): Atrophic and heavily calcified (arrow) pancreas reflecting chronic pancreatitis. |
| 1b |  |
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Teaching Points
Teaching Points
Suggested approach for structural imaging in the diagnosis of chronic pancreatitis:
- Ultrasound is the initial imaging of choice for investigation of biliary tree to assess for gallstone disease
- CT is moderately accurate in diagnosis of suspected chronic pancreatitis and is the first line investigation of choice
- Other modalities, such as magnetic resonance cholangiopancreatography (MRCP), secretin augmented MRCP (sMRCP) and endoscopic ultrasound (EUS) can provide further diagnostic information relatively non-invasively and can help guide interventional management
- CT, MRI, EUS and ERCP have comparably high diagnostic accuracy so the choice of imaging modality may be made based on invasiveness, local availability, experience and costs 1
- In the event that structural imaging (with CT, MRCP and EUS) is equivocal, then ePFT is recommended as the next investigation of choice. This is because of its high negative predictive value (97%), and when combined with EUS it allows reliable exclusion of early chronic pancreatitis 2
- Endoscopic retrograde cholangiopancreatography (ERCP) is rarely recommended solely for diagnosis as MRCP and sMRCP are non-invasive alternatives with comparable accuracy. ERCP should be reserved for situations where non-invasive modalities are not available or therapeutic intervention is required for pancreatic pain and suspected main pancreatic duct obstruction, based on MRCP or EUS 3
us
Ultrasound
- Modality of choice for initial imaging of the biliary tract 4
- Ultrasound is able to diagnose chronic pancreatitis with a sensitivity of 60-70% and a specificity of 80-98% 1, 5, 6
- Ultrasound features of moderate to severe chronic pancreatitis include 6, 7
- Pancreatic calcification
- Pancreatic enlargement or atrophy
- Asymmetric and irregular contours of the pancreas
- Dilatation of pancreatic ducts
- Pancreatic calculi
- Heterogeneous parenchymal texture pattern with increased echogenicity
- Can be used to identify or follow up complications of chronic pancreatitis including pancreatic cysts or pseudocysts
- Advantages
- Noninvasive
- Inexpensive and rapid
- Useful for follow-up of fluid collections. Pseudocysts or "retention" cysts in chronic pancreatitis rarely undergo spontaneous resolution 6, 8
- No exposure to ionising radiation
- Disadvantages
- Limited by patient body habitus and overlying bowel gas
- Less sensitive than CT, MRI and EUS; 1 majority of findings are neither specific nor sensitive
- Pancreatic parenchymal echogenicity may be normal or decreased in chronic pancreatitis
ct
Computed Tomography (CT)
- Considered to be the best initial imaging test for chronic pancreatitis 9
- Helpful for the diagnosis of moderate to severe chronic pancreatitis and its complications 7
- Sensitivity of 74-90% and specificity of 85-91% for the diagnosis of chronic pancreatitis 1, 10
- Useful for exclusion of malignancy or mass
- CT features of advanced chronic pancreatitis include: 10, 11
- Pancreatic calcification and calculi
- Pancreatic atrophy or enlargement
- Gross main pancreatic duct changes
- Advantages
- Superior to transabdominal US in the detection of calcifications and large cystic or pseudocystic lesions and other complications such as splenic or portal venous thrombosis 10, 11
- Unlike US, not limited by obesity, abdominal gas or operator dependence
- Able to detect other conditions where symptoms may mimic those of chronic pancreatitis, such as leaking abdominal aortic aneurysm, perforated peptic ulcer or pancreatic cancer
- Disadvantages
- Not sensitive for detecting features of early-stage or mild-to-moderate chronic pancreatitis
- Not able to reliably detect anatomic variations such as pancreatic divisum
mrcp
Magnetic Resonance Cholangiopancreatography (MRCP) and Secretin-Stimulated MRCP (sMRCP)
- Sensitivity of 65-78% and specificity of 90-96% for the diagnosis of chronic pancreatitis. The sensitivity improves to 98% when combined with EUS 1, 12, 13
- More sensitive for the diagnosis of early and mild disease compared to CT and transabdominal US 7
- Secretin-stimulated MRCP (sMRCP) can measure exocrine pancreatic function, with the potential for early diagnosis of chronic pancreatitis, and distinction between early and established disease 14-16
- sMRCP can be useful in identifying pancreatic duct anomalies; e.g. pancreatic divisum 17, 18
- Advantages
- Non-invasive alternative to diagnostic ERCP, with comparable accuracy 19, 20
- Easily performed
- No exposure to contrast agents or radiation
- MRCP is more cost effective compared to ERCP
- Disadvantages
- Does not offer opportunity for therapeutic intervention
- Limited availability
eus
Endoscopic Ultrasound (EUS)
- Sensitivity and specificity of 75-93% and 90-93% respectively for the diagnosis of chronic pancreatitis When combined with MRCP, the sensitivity improves to 98% and the specificity approaches 100% 1, 12
- When EUS is combined with ePFT, the sensitivity for detecting chronic pancreatitis also approaches 100% 2
- Can detect changes of mild chronic pancreatitis that may not be identified on other imaging modalities, but can be confirmed by histology 21-26
- Diagnostic features include 7
- Main pancreatic duct dilatation (>3mm) and side branch duct ectasia
- Lobularity of the outer gland margin
- Heterogeneous echogenicity of parenchyma with small cystic changes
- Advantages
- Less invasive than ERCP with fewer complications 27
- Can be used for drainage of pseudocysts and for coeliac plexus blocks
- Disadvantages
epft
Direct Pancreatic Function Test: Endoscopic Pancreatic Function Test (ePFT)
- Secretin-induced endoscopic pancreatic function test (ePFT) is the gold standard for assessing exocrine pancreatic function 9
- ePFT has a high negative predictive value and can assist in exclusion of chronic pancreatitis 29-32
- In suspected cases with normal or equivocal pancreatic imaging, ePFT combined with EUS can assist in detection of early or minimal change chronic pancreatitis 2
- Has sensitivity of 86% and specificity 67%. When combined with EUS sensitivity increases to 100% 2
- Chronic pancreatitis is diagnosed when the peak bicarbonate concentration is less than 80mmol on secretin-stimulated PFT
- Advantages
- Endoscopy is widely available
- Allows for more reliable collection under direct vision and a shorter collection time
- Can be safely combined with EUS 33
- If positive, has a moderately high correlation with histologic evidence of chronic pancreatitis 2
- Disadvantages
- The potential complications and discomfort of endoscopy
- Limited availability of secretin
- Sensitivity to secretin formulations in some patients
ercp
Endoscopic Retrograde Cholangiopancreatography (ERCP)
- Previously considered the gold standard for structural imaging of chronic pancreatitis
- Should be reserved for patients where diagnosis has not been established by non-invasive or less-invasive studies or where therapeutic intervention is anticipated in cases of chronic pancreatic pain and suspected main pancreatic duct obstruction (stricture with prestenotic dilatation) based on MRCP or EUS 34
- ERCP is highly effective at visualizing ductal and duct-related findings in chronic pancreatitis, with a sensitivity of 71- 93% and a specificity of 89-100% for the diagnosis of chronic pancreatitis 1, 34
- Main indications for ERCP in chronic pancreatitis are: 35-37
- To identify biliary or pancreatic ductal abnormality or obstruction
- To clarify ductal anatomy prior to surgical intervention
- To define the relation between a fluid collection and the pancreatic duct prior to percutaneous or surgical drainage
- Advantages
- Superior sensitivity in detecting ductal changes compared with trans-abdominal US
- Provides therapeutic options, such as dilation, stone extraction, and stenting of the duct
- Possibility of procuring pancreatic juice during ERCP 37, 38
- Disadvantages 29, 39, 40
- Invasive procedure with a significant risk (~ 6%) of post-procedure complications such as acute pancreatitis, haemorrhage, perforation, sepsis, strictures, bile leakage and mortality 41-43
- Does not allow evaluation of the pancreatic parenchyma 9
- Requires direct cannulation of the common bile or pancreatic duct, unsuccessful cannulation rate of 3-9%
- Potential confounders to interpretation of ERCP include:
- Age-related ductal changes
- Post-acute pancreatitis ductal changes
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- 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(9):3820-44. (Review article). View the reference
- Albashir S, Bronner MP, Parsi MA, Walsh RM, Stevens T. Endoscopic ultrasound, secretin endoscopic pancreatic function test, and histology: correlation in chronic pancreatitis. Am J Gastroenterol. 2010;105(11):2498-503. (Level III evidence). View the reference
- Conwell DL, Lee LS, Yadav D, Longnecker DS, Miller FH, Mortele KJ, et al. American pancreatic association practice guidelines in chronic pancreatitis: evidence-based report on diagnostic guidelines. Pancreas. 2014;43(8):1143-62. (Guideline). View the reference
- Weltman DI, Zeman RK. Acute diseases of the gallbladder and biliary ducts. Radiol Clin North Am. 1994;32(5):933-50. (Review article). View the reference
- Bastid C, Sahel J, Filho M, Sarles H. Diameter of the main pancreatic duct in chronic calcifying pancreatitis. Measurement by ultrasonography versus pancreatography. Pancreas. 1990;5(5):524-7. (Level III evidence). View the reference
- Niederau C, Grendell JH. Diagnosis of chronic pancreatitis. Gastroenterology. 1985;88(6):1973-95. (Level III evidence). View the reference
- Siddiqi AJ, Miller F. Chronic pancreatitis: ultrasound, computed tomography, and magnetic resonance imaging features. Semin Ultrasound CT MR. 2007;28(5):384-94. (Review article). View the reference
- Rosso E, Alexakis N, Ghaneh P, Lombard M, Smart HL, Evans J, et al. Pancreatic pseudocyst in chronic pancreatitis: endoscopic and surgical treatment. Dig Surg. 2003;20(5):397-406. (Review article). View the reference
- Sze KC, Pirola RC, Apte MV, Wilson JS. Current options for the diagnosis of chronic pancreatitis. Expert Rev Mol Diagn. 2014;14(2):199-215. (Review article). View the reference
- Luetmer PH, Stephens DH, Ward EM. Chronic pancreatitis: reassessment with current CT. Radiology. 1989;171(2):353-7. (Level III evidence). View the reference
- Perez-Johnston R, Sainani NI, Sahani DV. Imaging of chronic pancreatitis (including groove and autoimmune pancreatitis). Radiol Clin North Am. 2012;50(3):447-66. (Review article). View the reference
- Pungpapong S, Wallace MB, Woodward TA, Noh KW, Raimondo M. Accuracy of endoscopic ultrasonography and magnetic resonance cholangiopancreatography for the diagnosis of chronic pancreatitis: a prospective comparison study. J Clin Gastroenterol. 2007;41(1):88-93. (Level III evidence). View the reference
- Remer EM, Baker ME. Imaging of chronic pancreatitis. Radiol Clin North Am. 2002;40(6):1229-42, v. (Review article). View the reference
- Sanyal R, Stevens T, Novak E, Veniero JC. Secretin-enhanced MRCP: review of technique and application with proposal for quantification of exocrine function. AJR Am J Roentgenol. 2012;198(1):124-32. (Level II evidence).View the reference
- Manfredi R, Perandini S, Mantovani W, Frulloni L, Faccioli N, Pozzi Mucelli R. Quantitative MRCP assessment of pancreatic exocrine reserve and its correlation with faecal elastase-1 in patients with chronic pancreatitis. La Radiologia medica. 2012;117(2):282-92. (Level III evidence). View the reference
- Balci NC, Smith A, Momtahen AJ, Alkaade S, Fattahi R, Tariq S, et al. MRI and S-MRCP findings in patients with suspected chronic pancreatitis: correlation with endoscopic pancreatic function testing (ePFT). J Magn Reson Imaging. 2010;31(3):601-6. (Level III evidence).View the reference
- Fukukura Y, Fujiyoshi F, Sasaki M, Nakajo M. Pancreatic duct: morphologic evaluation with MR cholangiopancreatography after secretin stimulation. Radiology. 2002;222(3):674-80. (Level II evidence). View the reference
- Hellerhoff KJ, Helmberger H, 3rd, Rosch T, Settles MR, Link TM, Rummeny EJ. Dynamic MR pancreatography after secretin administration: image quality and diagnostic accuracy. AJR Am J Roentgenol. 2002;179(1):121-9. (Level III evidence). View the reference
- Sica GT, Braver J, Cooney MJ, Miller FH, Chai JL, Adams DF. Comparison of endoscopic retrograde cholangiopancreatography with MR cholangiopancreatography in patients with pancreatitis. Radiology. 1999;210(3):605-10. (Level III-IV evidence). View the reference
- Takehara Y, Ichijo K, Tooyama N, Kodaira N, Yamamoto H, Tatami M, et al. Breath-hold MR cholangiopancreatography with a long-echo-train fast spin-echo sequence and a surface coil in chronic pancreatitis. Radiology. 1994;192(1):73-8. (Level III evidence). View the reference
- Catalano MF, Lahoti S, Geenen JE, Hogan WJ. Prospective evaluation of endoscopic ultrasonography, endoscopic retrograde pancreatography, and secretin test in the diagnosis of chronic pancreatitis. Gastrointest Endosc. 1998;48(1):11-7. (Level II-III evidence). View the reference
- Nattermann C, Goldschmidt AJ, Dancygier H. Endosonography in chronic pancreatitis--a comparison between endoscopic retrograde pancreatography and endoscopic ultrasonography. Endoscopy. 1993;25(9):565-70. (Level II-III evidence). View the reference
- Wiersema MJ, Hawes RH, Lehman GA, Kochman ML, Sherman S, Kopecky KK. Prospective evaluation of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in patients with chronic abdominal pain of suspected pancreatic origin. Endoscopy. 1993;25(9):555-64. (Level II-III evidence). View the reference
- Zimmerman MJ, Mishra G, Lewin D, Hawes RH, Coyle W, Adams DA, et al. Comparison of EUS findings with histopathology in chronic pancreatitis. Gastrointest Endosc. 1997;45(4):AB185. (Level III evidence). View the reference
- Bhutani MS, Arantes VN, Verma D, Moezzi J, Suryaprasad S, Kapadia AS, et al. Histopathologic correlation of endoscopic ultrasound findings of chronic pancreatitis in human autopsies. Pancreas. 2009;38(7):820-4. (Level III evidence). View the reference
- Varadarajulu S, Eltoum I, Tamhane A, Eloubeidi MA. Histopathologic correlates of noncalcific chronic pancreatitis by EUS: a prospective tissue characterization study. Gastrointest Endosc. 2007;66(3):501-9. (Level II evidence). View the reference
- Wallace MB, Hawes RH. Endoscopic ultrasound in the evaluation and treatment of chronic pancreatitis. Pancreas. 2001;23(1):26-35. (Review article). View the reference
- Petrone MC, Arcidiacono PG, Perri F, Carrara S, Boemo C, Testoni PA. Chronic pancreatitis-like changes detected by endoscopic ultrasound in subjects without signs of pancreatic disease: do these indicate age-related changes, effects of xenobiotics, or early chronic pancreatitis? Pancreatology. 2010;10(5):597-602. (Level II evidence). View the reference
- Conwell DL, Wu BU. Chronic pancreatitis: making the diagnosis. Clin Gastroenterol Hepatol. 2012;10(10):1088-95. (Review article). View the reference
- Ketwaroo G, Brown A, Young B, Kheraj R, Sawhney M, Mortele KJ, et al. Defining the accuracy of secretin pancreatic function testing in patients with suspected early chronic pancreatitis. Am J Gastroenterol. 2013;108(8):1360-6. (Level III evidence). View the reference
- Pelley JR, Gordon SR, Gardner TB. Abnormal duodenal [HCO3-] following secretin stimulation develops sooner than endocrine insufficiency in minimal change chronic pancreatitis. Pancreas. 2012;41(3):481-4. (Level III evidence). View the reference
- Toouli J, Biankin AV, Oliver MR, Pearce CB, Wilson JS, Wray NH. Management of pancreatic exocrine insufficiency: Australasian pancreatic club recommendations. Med J Aust. 2010;193(8):461-7. (Guideline). View the reference
- Stevens T, Dumot JA, Parsi MA, Zuccaro G, Vargo JJ. Combined endoscopic ultrasound and secretin endoscopic pancreatic function test in patients evaluated for chronic pancreatitis. Dig Dis Sci. 2010;55(9):2681-7. (Level III evidence). View the reference
- Adler DG, Lichtenstein D, Baron TH, Davila R, Egan JV, Gan SL, et al. The role of endoscopy in patients with chronic pancreatitis. Gastrointest Endosc. 2006;63(7):933-7. (Review article). View the reference
- NIH state-of-the-science statement on endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy. NIH Consens State Sci Statements. 2002;19(1):1-26. (Guideline). View the reference
- Axon AT. Endoscopic retrograde cholangiopancreatography in chronic pancreatitis. Cambridge classification. Radiol Clin North Am. 1989;27(1):39-50. (Review article). View the reference
- Bor R, Madácsy L, Fábián A, Szepes A, Szepes Z. Endoscopic retrograde pancreatography: When should we do it? World Journal of Gastrointestinal Endoscopy. 2015;7(11):1023-31. (Level II evidence). View the reference
- Lohr JM. What are the useful biological and functional markers of early-stage chronic pancreatitis? J Gastroenterol. 2007;42 Suppl 17:66-71. (Review article). View the reference
- Szary NM, Al-Kawas FH. Complications of endoscopic retrograde cholangiopancreatography: how to avoid and manage them. Gastroenterology & hepatology. 2013;9(8):496-504. (Review article). View the reference
- Bilbao MK, Dotter CT, Lee TG, Katon RM. Complications of endoscopic retrograde cholangiopancreatography (ERCP). A study of 10,000 cases. Gastroenterology. 1976;70(3):314-20. (Level II evidence). View the reference
- Johnson GK, Geenen JE, Bedford RA, Johanson J, Cass O, Sherman S, et al. A comparison of nonionic versus ionic contrast media: results of a prospective, multicenter study. Midwest Pancreaticobiliary Study Group. Gastrointest Endosc. 1995;42(4):312-6. (Level II-III evidence). View the reference
- Wang P, Li ZS, Liu F, Ren X, Lu NH, Fan ZN, et al. Risk factors for ERCP-related complications: a prospective multicenter study. Am J Gastroenterol. 2009;104(1):31-40. (Level II evidence). View the reference
- Williams EJ, Taylor S, Fairclough P, Hamlyn A, Logan RF, Martin D, et al. Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study. Endoscopy. 2007;39(9):793-801. (Level II evidence). View the reference
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