EUS in the diagnosis of early chronic pancreatitis: a prospective follow-up study

[Elastography in the evaluation of chronic pancreatitis]

Endoscopic ultrasound (EUS) has become an essential tool in the evaluation of pancreatic disease and can be considered the technique of choice for the diagnosis and staging of chronic pancreatitis (CP) and pancreatic cancer (PC). However, EUS has certain limitations, especially in the evaluation of patients with solid pancreatic masses (in the differential diagnosis of CP and PC). Furthermore there is variability in the EUS diagnostic criteria for CP. EUS-guided elastography is emerging as a highly useful tool in this setting. This modality has shown high diagnostic accuracy in the differential diagnosis of solid pancreatic masses, including differentiation between CP and PC. EUS-guided elastography has also been found to be useful in the diagnosis of CP, and can even classify patients according to the severity of their disease.

Conventional versus Rosemont endoscopic ultrasound criteria for chronic pancreatitis: comparing interobserver reliability and intertest agreement

BACKGROUND

The Rosemont criteria (RC) were recently proposed by expert consensus to standardize endoscopic ultrasound (EUS) features and thresholds for diagnosing chronic pancreatitis (CP); however, they are cumbersome and are not validated.

OBJECTIVE

To determine interobserver agreement between RC and conventional criteria (CC), and to assess intertest agreement in the diagnosis of CP.

METHODS

Thirty-six consecutive patients who underwent EUS for abdominal pain or pancreatitis were retrospectively reviewed. Anonymized images were independently chosen as best representations of the pancreatic body and reviewed by three experts who recorded the presence of CC and RC features. Agreement (proportion and kappa statistic) between CC and RC was calculated. Interobserver agreement within the CC and RC was assessed. Secondary comparisons with endoscopic retrograde cholangiopancreatography were made where available.

RESULTS

Using CC, 60 readings (83.3%) were negative for CP, while 12 readings (16.7%) were positive. Using RC, 59 readings (81.9%) were negative for CP, while 13 (18.1%) were positive. The weighted kappa for interobserver agreement for CC (four categories: normal⁄low probability, indeterminate, high probability or calcific) was 0.50, with 80.0% overall agreement, versus 0.27 and 68.1% for the four RC categories (normal, indeterminate, suggestive of and consistent with). Agreement on a positive diagnosis with CC was 86.1% (P=0.38 [McNemar's exact test]), with a kappa of 0.47; for RC, agreement was lower at 80.6% (P=0.016 [McNemar's exact test]), with a kappa of 0.38. For patients who underwent endoscopic retrograde cholangiopancreatography (n=12), false-negative and false-positive rates between CC and RC did not appear to be different.

CONCLUSIONS

The RC do not appear to achieve the goals of improving accuracy and interobserver agreement for diagnosing CP.

26. Pain in chronic pancreatitis

Chronic pancreatitis is defined as a progressive inflammatory response of the pancreas that has lead to irreversible morphological changes of the parenchyma (fibrosis, loss of acini and islets of Langerhans, and formation of pancreatic stones) as well as of the pancreatic duct (stenosis and pancreatic stones). Pain is one of the most important symptoms of chronic pancreatitis. The pathogenesis of this pain can only partly be explained and it is therefore often difficult to treat this symptom. The management of pain induced by chronic pancreatitis starts with lifestyle changes and analgesics. For the pharmacological management, the three-step ladder of the World Health Organization extended with the use of co-analgesics is followed. Interventional pain management may consist of radiofrequency treatment of the nervi splanchnici, spinal cord stimulation, endoscopic stenting or stone extraction possibly in combination with lithotripsy, and surgery. To date, there are no randomized controlled trials supporting the efficacy of radiofrequency and spinal cord stimulation. The large published series reports justify a recommendation to consider these treatment options. Radiofrequency treatment, being less invasive than spinal cord stimulation, could be tested prior to considering spinal cord stimulation. There are several other treatment possibilities such as endoscopic or surgical treatment, pancreatic enzyme supplementation and administration of octreotide and antioxidants. All may have a role in the management of pain induced by chronic pancreatitis.

Endoscopic ultrasonography findings in autoimmune pancreatitis

Endoscopic ultrasonography is an established diagnostic tool for pancreatic masses and chronic pancreatitis. In recent years there has been a growing interest in the worldwide medical community in autoimmune pancreatitis (AIP), a form of chronic pancreatitis caused by an autoimmune process. This paper reviews the current available literature about the endoscopic ultrasonographic findings of AIP and the role of this imaging technique in the management of this protean disease.

Chronic pancreatitis

Chronic pancreatitis is a progressive fibroinflammatory disease that exists in large-duct (often with intraductal calculi) or small-duct form. In many patients this disease results from a complex mix of environmental (eg, alcohol, cigarettes, and occupational chemicals) and genetic factors (eg, mutation in a trypsin-controlling gene or the cystic fibrosis transmembrane conductance regulator); a few patients have hereditary or autoimmune disease. Pain in the form of recurrent attacks of pancreatitis (representing paralysis of apical exocytosis in acinar cells) or constant and disabling pain is usually the main symptom. Management of the pain is mainly empirical, involving potent analgesics, duct drainage by endoscopic or surgical means, and partial or total pancreatectomy. However, steroids rapidly reduce symptoms in patients with autoimmune pancreatitis, and micronutrient therapy to correct electrophilic stress is emerging as a promising treatment in the other patients. Steatorrhoea, diabetes, local complications, and psychosocial issues associated with the disease are additional therapeutic challenges.

EUS compared with endoscopy plus transabdominal US in the initial diagnostic evaluation of patients with upper abdominal pain

BACKGROUND

Primary upper endoscopy (EGD) and transabdominal US (TUS) are often performed in patients with upper abdominal pain.

OBJECTIVE

Primary: Determine whether the combination of EGD and EUS was equivalent to EGD plus TUS in the diagnostic evaluation of upper abdominal pain. Secondary: Compare EUS versus TUS in detecting abdominal lesions, and compare EGD by using an oblique-viewing echoendoscope versus the standard, forward-viewing endoscope in detecting mucosal lesions.

DESIGN

Prospective, paired design.

SETTING

Six academic endoscopy centers.

PATIENTS

This study involved patients with upper abdominal pain referred for endoscopy.

INTERVENTION

All patients had EGD, EUS, and TUS. The EGD was done using both an oblique-viewing echoendoscope and the standard, forward-viewing endoscope (randomized order) by two separate endoscopists in a blinded fashion, followed by EUS. TUS was performed within 4 weeks of EGD/EUS, also in a blinded fashion.

FOLLOW-UP

telephone interviews and chart reviews.

MAIN OUTCOME MEASUREMENTS

Diagnose possible etiology of upper abdominal pain and detect clinically significant lesions.

RESULTS

A diagnosis of the etiology of upper abdominal pain was made in 66 of 172 patients (38%). The diagnostic rate was 42 of 66 patients (64%) for EGD plus EUS versus 41 of 66 patients (62%) for EGD plus TUS, which was statistically equivalent (McNemar test; P = .27). One hundred ninety-eight lesions were diagnosed with either EUS or TUS. EUS was superior to TUS for visualizing the pancreas (P < .0001) and for diagnosing chronic pancreatitis (P = .03). Two biliary stones were detected only by EUS. Two hundred fifty-one mucosal lesions were similarly diagnosed with EGD with either the standard, forward-viewing endoscope or the oblique-viewing echoendoscope (kappa = 0.48 [95% CI, .43-.54]). EGD with the standard, forward-viewing endoscope was preferred for biopsies.

LIMITATIONS

No cost analysis.

CONCLUSION

The combination of EGD with EUS is equivalent to EGD plus TUS for diagnosing a potential etiology of upper abdominal pain. EUS is superior to TUS for detecting chronic pancreatitis. EGD combined with EUS should be considered in the first-line diagnostic evaluation of patients with upper abdominal pain.

Role of pancreatic endoscopic ultrasonography in 2010

Endoscopic ultrasonography (EUS) was introduced 25 years ago aiming at better visualization of the pancreas compared to transabdominal ultrasonography. This update discusses the current evidence in 2010 concerning the role of EUS in the clinical management of patients with pancreatic disease. Major indications of EUS are: (1) Detection of common bile duct stones (e.g. in acute pancreatitis); (2) Detection of small exo- and endocrine pancreatic tumours; and (3) Performance of fine needle aspiration in pancreatic masses depending on therapeutic consequences. EUS seems to be less useful in cases of chronic pancreatitis and cystic pancreatic lesions. Moreover the constant improvement of computed tomography has limited the role of EUS in pancreatic cancer staging. On the other hand, new therapeutic options are available due to EUS, such as pancreatic cyst drainage and celiac plexus neurolysis, offering a new field in which new techniques may arise. So the main goal of this review is to determine the exact role of EUS in a number of pancreatic and biliary diseases.

Endoscopic ultrasound in chronic pancreatitis: Where are we now?

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.

Endoscopic ultrasound for the diagnosis of chronic pancreatitis

Endoscopic ultrasound (EUS) has become a well accepted test for the diagnosis of chronic pancreatitis. Advantages include its ability to detect subtle and severe changes of the pancreatic duct and parenchyma, and its relative safety compared with endoscopic retrograde cholangiopancreatography. Limitations include inter- and intra-observer variability, operator dependence, and an incomplete understanding of its true accuracy. The Rosemont classification has recently been proposed as a weighted, standardized method that may improve EUS chronic pancreatitis scoring. This paper reviews the published evidence regarding the accuracy of EUS in chronic pancreatitis diagnosis, and enumerates the emerging technologies that have been recently studied which may ultimately improve endosonographic imaging of the pancreas.

The revised Japanese clinical diagnostic criteria for chronic pancreatitis

In Japan, we are now using the clinical diagnostic criteria for chronic pancreatitis (CP) that were revised in 2001 to add the findings of magnetic resonance cholangiopancreatography to the criteria compiled by the Japan Pancreas Society (JPS) in 1995. Because the current criteria are set for diagnosing advanced CP, they are unlikely to improve patients' prognoses. In addition, they seem unsuitable for current clinical practice because exocrine pancreatic function tests, which have become obsolete in Japan, are included in the diagnostic factors. For these reasons, the Research Committee on Intractable Pancreatic Diseases supported by the Ministry of Health, Labour and Welfare of Japan, the JPS and the Japanese Society of Gastroenterology have revised the criteria. The revised criteria are unique in that they contain an introduction to the concept of early CP. It is a challenge aimed at improvement of the long-term prognosis of CP patients by early diagnosis and therapeutic intervention in this disease. We need to determine and clarify the clinico-pathological outcome of early CP by a prospective long-term follow-up of the patients in this category.

Endoscopic ultrasound in the evaluation of pancreaticobiliary disorders

The close proximity of the endoscopic ultrasound probe to the pancreas coupled with the ability to perform fine needle aspiration has made endoscopic ultrasound an extremely important technique for the evaluation of both benign and malignant pancreaticobiliary disorders. In parallel to the widespread importance of diagnostic endoscopic ultrasound, the therapeutic and interventional applications of this procedure are expanding and may become a major breakthrough in the management of pancreaticobiliary diseases. This article focuses on the utility and recent advances of endoscopic ultrasound in the diagnostic evaluation pancreaticobiliary disorders and analyses the data of well established interventional procedures such as celiac plexus neurolysis and pseudocyst drainage. Moreover, the more innovative procedures, such endoscopic ultrasound-guided biliary and pancreatic ducts access and drainage and the experimental use of direct endoscopic ultrasound-guided therapy of both solid and cystic pancreatic lesions will also be reviewed.

Histopathologic correlation of endoscopic ultrasound findings of chronic pancreatitis in human autopsies

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.

Diagnostic yield of ERCP and secretin-enhanced MRCP and EUS in patients with acute recurrent pancreatitis of unknown aetiology

BACKGROUND

Magnetic resonance cholangio-pancreatography (MRCP), endoscopic ultrasonography (EUS), and endoscopic cholangio-pancreatography (ERCP) are the most frequently employed second-step procedures to detect biliary and pancreatic abnormalities in patients with acute recurrent pancreatitis (ARP) of unknown aetiology. MRCP and EUS both give a better view of the bilio-pancreatic ductal system after secretin stimulation (MRCP-S, EUS-S). EUS also serves to identify changes in the pancreatic parenchyma consistent with chronic pancreatitis, at an early stage. However, no studies have compared MRCP-S, EUS-S, and ERCP in the diagnosis of recurrent pancreatitis.

AIM

To prospectively compare the diagnostic yield of MRCP-S, EUS-S, and ERCP in the evaluation of patients with acute recurrent pancreatitis with non-dilated ducts, of unknown aetiology.

METHODS

Forty-four consecutive patients with ARP were prospectively scheduled to undergo MRCP-S, EUS-S and ERCP, in accordance with a standard protocol approved by the institutional review board. Diagnoses such as biliary microlithiasis, congenital variants of the pancreatic ducts, chronic pancreatitis and sphincter of Oddi dysfunction were compared between the three procedures. The diagnosis of chronic pancreatitis was established according to ductal morphology by MRCP-S and ERCP, ductal and parenchymal morphology by EUS-S.

RESULTS

The three procedures combined achieved a diagnosis that could have explained the recurrence of pancreatitis in 28/44 patients (63.6%). EUS-S recognized ductal and/or parenchymal abnormalities with the highest frequency (35/44 patients, 79.5%). Both MRCP-S and EUS-S were superior to ERCP for detecting pancreatic ductal abnormalities. EUS-S showed up pancreatic parenchymal changes in more than half the cases. Both EUS and MRCP secretin kinetics were concordant in identifying two cases with sphincter of Oddi dysfunction.

CONCLUSIONS

The diagnostic yield of EUS-S in recurrent pancreatitis with non-dilated ducts and unknown aetiology was 13.6% and 16.7% higher than MRCP-S and ERCP respectively (although not significant), which both gave substantially similar diagnostic yields. In no case did ERCP alone find a diagnosis missed by the other two procedures. MRCP-S and EUS-S should both be used in the diagnostic work-up of idiopathic recurrent pancreatitis as complementary, first-line, techniques, instead of ERCP.

A proposal for differentiation between early- and advanced-stage autoimmune pancreatitis by endoscopic ultrasonography

AIM

We evaluated the characteristic endoscopic ultrasonography (EUS) findings of early autoimmune pancreatitis (AIP).

METHODS

Nineteen patients with AIP were identified from our database. We reviewed the following features of EUS as being potentially characteristic of early AIP: hyperechoic foci, hyperechoic strands, lobularity, hyperechoic pancreatic duct margins and reduced echogenicity. According to the Cambridge classification for chronic pancreatitis, we classified AIP into early AIP (Grades 0-2) and advanced AIP (Grades 3-5) and examined the histopathological findings in each stage of AIP.

RESULTS

There were nine cases of early AIP and 10 cases of advanced AIP. Five of the nine early cases of AIP showed spontaneous remission without corticosteroid therapy (P < 0.05). The EUS findings were as follows (early vs advanced): hyperechoic foci, 100% (9/9) vs 100% (10/10); hyperechoic strands, 66.7% (6/9) vs 70% (7/10); lobularity, 77.8% (7/9) vs 20% (2/10); hyperechoic pancreatic duct margin, 88.9% (8/9) vs 30% (3/10); reduced echogenicity, 88.9% (8/9) vs 90% (9/10). Lobularity and hyperechoic pancreatic duct margin were detected at a significantly higher frequency in early AIP than in the advanced AIP patients (P < 0.05). Regarding the histopathological findings, acinar cells were better preserved in the cases of early AIP, whereas acinar cells were reduced in number and replaced by massive fibrosis in the patients with advanced AIP.

CONCLUSIONS

Lobularity and hyperechoic pancreatic duct margin are characteristic EUS features of early AIP, which has a more favorable prognosis, and shows a higher frequency of spontaneous remission and preservation of acinar cells, than advanced AIP.

EUS-based criteria for the diagnosis of chronic pancreatitis: the Rosemont classification

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.

[A review of current methods in the diagnostics of morphological changes in chronic pancreatitis]

Chronic pancreatitis is a disease with well-defined histopathology, however, the diagnosis is not based on the grading of histological changes, but on the features registered by the methods of morphological and functional diagnostic procedures. The correct diagnosis of chronic pancreatitis is easy in advanced stages, but difficult in early stages of the disease. In this review, we present the current methods used (echosonography, computer tomography, magnetic resonance, endoscopic retrograde cholangiopancreatography, endoscopic echosonography) in the diagnostics of chronic pancreatitis.

Evaluation of duct-cell and acinar-cell function and endosonographic abnormalities in patients with suspected chronic pancreatitis

BACKGROUND & AIMS

Endoscopic ultrasound (EUS) detects mild and severe structural abnormalities of the pancreas that correlate with fibrosis. Direct pancreatic function tests (PFTs) detect mild exocrine insufficiency associated with early fibrosis. The primary aim of this study was to compare EUS structural criteria with duct-cell and acinar-cell function.

METHODS

Fifty patients evaluated for chronic pancreatitis underwent combined EUS and secretin endoscopic PFTs (ePFT) on day 1 and CCK ePFT on day 2. EUS images were videotaped and interpreted by consensus of 3 blinded expert reviewers.

RESULTS

There were inverse correlations of EUS consensus score with both duct-cell bicarbonate secretion (R = -0.71, P < .001) and acinar-cell lipase secretion (R = -0.52, P < .001). With secretin ePFT as reference standard, EUS (>or=4 criteria) showed a sensitivity of 71% (95% confidence interval [CI], 53%-89%) and specificity of 92% (95% CI, 75%-99%). With CCK ePFT as reference standard, EUS had a sensitivity of 63% (95% CI, 43%-82%) and specificity of 85% (95% CI, 71%-98%). Main duct dilation, irregularity, calcifications, and visible side-branches were most predictive of exocrine insufficiency (positive predictive value >80% for both acinar- and duct-cell insufficiency).

CONCLUSIONS

Acinar- and duct-cell function decreases as EUS structural abnormalities increase. EUS has fair sensitivity and very good specificity compared with secretin and CCK functional reference standards.

Endoscopic ultrasound in pancreatic disease--its influence on surgical decision-making. An update 2008

Endoscopic ultrasonography (EUS) was introduced about 25 years ago with the primary aim of better visualization of the pancreas as compared to transabdominal ultrasonography. This review discusses the current evidence in 2008 concerning the role of EUS in the clinical management of patients, with a special emphasis on its impact on surgical therapy. According to the literature, good indications are detection of common bile duct stones (e.g. in acute pancreatitis), the detection of small exo- and endocrine pancreatic tumors, the performance of fine-needle aspiration in pancreatic masses depending on therapeutic consequences. In other areas such as diagnosis of chronic pancreatitis and cystic pancreatic lesions, the contribution of EUS seems limited. Pancreatic cancer staging is discussed controversially due to conflicting evidence and certainly has lost grounds due to improvements in CT technology. Therapeutic EUS is, however, more widely accepted and may replace other techniques, e.g. in pancreatic cyst drainage and celiac plexus neurolysis; further techniques of interest are being developed.

Morphological and functional evaluation of the pancreatic duct with secretin-stimulated magnetic resonance cholangiopancreatography in alcoholic pancreatitis patients

OBJECTIVES

The aim of this investigation was to evaluate the pancreatographic findings and dynamics of pancreatic duct diameter, as determined by secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP), in patients with acute alcoholic pancreatitis or chronic alcoholic pancreatitis and in a control group.

METHODS

S-MRCP was performed in patients with acute alcoholic pancreatitis who did not manifest the functional and radiological (ultrasonography and computed tomography) criteria of chronic pancreatitis (n = 21), in patients with chronic alcoholic pancreatitis (n = 28) and in a control group (n = 16). The diameter of the main pancreatic duct (MPD) was monitored before secretin administration and at 3 and 10 min after secretin administration. Morphological features were also assessed before and after the administration of secretin.

RESULTS

All ductal diameters were significantly larger in chronic alcoholic pancreatitis (P < 0.0001). There were no differences in MPD caliber between patients with acute alcoholic pancreatitis and the control group. The percentage of variation between basal MPD diameter and at 3 min post-secretin administration was lower in patients with chronic (35.5%) pancreatitis than in those with acute alcoholic pancreatitis (52.3%) and the control group (52.5%). There were no significant differences between patients with acute alcoholic pancreatitis and the control group in terms of the frequency of visualization of side branches, ductal narrowing, intraluminal filling defects, and ductal irregularity. One patient with acute alcoholic pancreatitis presented ductal criteria of chronic pancreatitis following the administration of secretin.

CONCLUSIONS

The dynamics of MPD visualized on S-MRCP in patients with acute alcoholic pancreatitis is similar to that observed in the control group and different from that observed in patients with chronic alcoholic pancreatitis. There were no significant differences between patients with acute alcoholic pancreatitis and the control group in terms of morphological pancreatographic features.

Diagnosis and treatment of chronic pancreatitis: an analysis of 303 cases

AIM: To investigate the diagnosis and treatment status of chronic pancreatitis (CP) and its etiology-related factors.

METHODS: The clinical data of 303 CP patients in West China Hospital of Sichuan University from 1996 to 2006 were retrospectively analyzed.

RESULTS: Etiologically, patients with biliary diseases or over 5-year alcohol-drinking history accounted for a percentage of 30.7% and 37.0%, respectively. Furthermore, among biliary CP patients, 31.2% were found with a long-term alcohol-drinking history. Abdominal pain was the most common symptom, which covered a percentage of 86.8%. Complications were found in 146 of 303 CP patients (48.2%). Imaging techniques confirmed 196 patients (64.7%), while 38.9%, 53.5% and 7.6% of all the patients received drug treatment, surgical treatment and endoscopic treatment, respectively.

CONCLUSION: CP occurrence usually results from multiple etiological factors with a higher complication rate. Imaging examinations play an important role in the diagnosis of this disease.

Comparison of endoscopic ultrasound and endoscopic retrograde pancreatography for the prediction of pancreatic exocrine insufficiency

Endoscopic retrograde pancreatography (ERP) is a sensitive test for the early ductal changes of chronic pancreatitis. More recently, endoscopic ultrasound (EUS) has also been proposed as a sensitive structural test for chronic pancreatitis. Few studies have compared EUS and ERP using an external reference standard. Direct pancreatic function tests (PFT) are an acceptable reference standard for chronic pancreatitis since they detect mild exocrine insufficiency. Our aim was to compare structural abnormalities as revealed by ERP and EUS for the prediction of exocrine insufficiency. Eight-three patients who underwent EUS, ERP, and secretin PFT for the evaluation of pancreatitis were identified from our database. Exocrine insufficiency was defined as a secretin PFT peak bicarbonate concentration <80 mEq/l. Based on the number of abnormal sonographic criteria observed, EUS findings were categorized as normal (<2 criteria), mild (3-5 criteria) or severe (6-9 criteria or calcifications). ERP findings were categorized based on the Cambridge classification. ERP and EUS did not differ significantly in either sensitivity (72% vs 68%, P = 0.52) or specificity (76% vs 79%, P = 0.40). ERP and EUS were similarly associated with exocrine insufficiency both in the presence of minimal (OR 3.4 and 4.9, respectively) and severe structural changes (OR 12 and 24, respectively). We consider EUS to have a diagnostic accuracy for the structural diagnosis of early- and late-stage chronic pancreatitis similar to that of ERP.

Suspected chronic pancreatitis with normal MRCP: findings on MRI in correlation with secretin MRCP

PURPOSE

To review pancreatic MRI findings and their relationship with estimated pancreatic exocrine function on secretin-stimulated MR cholangiopancreatography (S-MRCP) in patients with clinically suspected chronic pancreatitis and normal baseline MRCP findings.

MATERIALS AND METHODS

MRI findings of 26 patients with normal pancreatic duct diameter and without side branch ectasia on MRCP were evaluated. A single radiologist assessed pancreatic size, pancreatic signal intensity ratio (SIR), and arterial enhancement ratio (A/V) at head, body, and tail of the pancreas on T(1)-weighted fat-suppressed and serial contrast-enhanced images at a single session. Combined findings were graded with a composite score. Serial S-MRCP was performed at the same session with standard MRI. Correlation and differences between MRI findings and associated grade of duodenal filling (DF) or the degree of pancreatic duct caliber change (PDC) were analyzed.

RESULTS

Seven patients revealed normal and 19 patients abnormal MRI findings. Significant correlation was present between the degree of DF and mean values of pancreatic size (r = 0.748), SIR (r = 0.610), A/V (r = 0.466), composite score (r = 0.833), and PDC (r = 0.554) separately. PDC correlated with SIR (r = 0.413) and composite score (r = 0.452), but not with A/V or pancreatic size. Significant differences were present between normal and abnormal DF grades in terms of mean values of associated findings of size (P = 0.001), SIR (P = 0.008), A/V (P = 0.019), and PDC (P = 0.001).

CONCLUSION

Patients with clinically suspected chronic pancreatitis and normal MRCP findings may have a spectrum of MRI findings that correlate with the estimated pancreatic exocrine insufficiency on S-MRCP with the increasing number of combined findings.

Diagnosis of mild chronic pancreatitis (Cambridge classification): Comparative study using secretin injection-magnetic resonance cholangiopancreatography and endoscopic retrograde pancreatography

AIM: To investigate the usefulness of secretin injection-MRCP for the diagnosis of mild chronic pancreatitis.

METHODS: Sixteen patients having mild chronic pancreatitis according to the Cambridge classification and 12 control subjects with no abnormal findings on the pancreatogram were examined for the diagnostic accuracy of secretin injection-MRCP regarding abnormal branch pancreatic ducts associated with mild chronic pancreatitis (Cambridge Classification), using endoscopic retrograde cholangiopancreatography (ERCP) for comparison.

RESULTS: The sensitivity and specificity for abnormal branch pancreatic ducts determined by two reviewers were respectively 55%-63% and 75%-83% in the head, 57%-64% and 82%-83% in the body, and 44%-44% and 72%-76% in the tail of the pancreas. The sensitivity and specificity for mild chronic pancreatitis were 56%-63% and 92%-92%, respectively. Interobserver agreement (κ statistics) concerning the diagnosis of an abnormal branch pancreatic duct and of mild chronic pancreatitis was good to excellent.

CONCLUSION: Secretin injection-MRCP might be useful for the diagnosis of mild chronic pancreatitis.

Magnetic resonance imaging and magnetic resonance cholangiopancreatography findings compared with fecal elastase 1 measurement for the diagnosis of chronic pancreatitis

OBJECTIVES

To correlate magnetic resonance cholangiopancreatography (MRCP) and magnetic resonance imaging (MRI) findings of the pancreas with the pancreatic exocrine function determined by fecal elastase 1 concentration.

METHODS

Magnetic resonance imaging and MRCP findings of 81 consecutive patients with clinically suspected chronic pancreatitis and 21 healthy volunteers were evaluated. All subjects underwent MRI/MRCP and fecal elastase 1 testing within 1 to 4 weeks' interval. Magnetic resonance cholangiopancreatography images were evaluated according to Cambridge classification. Magnetic resonance imaging of the pancreas was assessed for pancreatic size, signal, and arterial enhancement.

RESULTS

All volunteers had normal fecal elastase 1 levels (>200 microg/g) and normal MRI/MRCP findings. Thirty-one of 56 patients revealed MRI and/or MRCP findings despite normal fecal elastase 1 concentration. Four of 25 patients revealed normal MRI and MRCP findings despite low fecal elastase 1 concentration (<200 microg/g). Magnetic resonance imaging findings of size (P = 0.00001), arterial enhancement (P = 0.00001), and parenchymal signal (P = 0.001) were significantly different among the control group, patients with normal fecal elastase 1 levels, and patients with low fecal elastase 1 levels. Magnetic resonance cholangiopancreatography findings (P = 0.00001), pancreatic size (P = 0.00001), arterial enhancement (P = 0.014), and parenchymal signal (P = 0.004) on MRI correlated with the fecal elastase 1 concentration.

CONCLUSIONS

Magnetic resonance imaging/MRCP findings correlate with fecal elastase 1 concentration and may precede pancreatic exocrine insufficiency in the early stages of chronic pancreatitis.

Endoscopic ultrasound and IL-8 in pancreatic juice to diagnose chronic pancreatitis

BACKGROUND/AIM

Pancreatic juice (PJ) [IL-8] has been proposed as a marker for pancreatic diseases. We compared the accuracy of PJ [IL-8] and endoscopic ultrasound (EUS) to diagnose chronic pancreatitis (CP).

METHODS

79 patients with symptoms suspicious for CP were enrolled. PJ emptied into the duodenum was collected during an upper endoscopy with IV secretin and [IL-8] was measured. CP was diagnosed when PJ [IL-8] was >20 pg/ml. CP was diagnosed at EUS when >or=4 of the 9 established criteria were present. CP was diagnosed by using composite gold standard: ERCP, histology, CT or MRI, and clinical follow-up (mean 20 months).

RESULTS

38 patients had CP, whereas 41 patients had no pancreatic disease. To diagnose CP, PJ [IL-8] was significantly less sensitive compared to EUS (47 vs. 71%), but equally accurate (71 vs. 80%) and specific (93 vs. 88%). By combining PJ [IL-8] and EUS, sensitivity and specificity significantly increased to 82% (either IL-8 or EUS positive) and 100% (both IL-8 and EUS positive).

CONCLUSIONS

Both PJ [IL-8] and EUS are accurate diagnostic modalities for CP. PJ collection can be performed at the time of EUS. PJ [IL-8] and EUS are complementary with higher sensitivity and specificity when used together.

Histopathologic correlates of noncalcific chronic pancreatitis by EUS: a prospective tissue characterization study

BACKGROUND

Studies that correlated EUS features of chronic pancreatitis (CP) with histopathology are retrospective and only include patients with severe disease or calcific pancreatitis. Controversies regarding the significance of EUS features of noncalcific CP (NCCP) remain unresolved.

OBJECTIVE

To correlate EUS criteria for NCCP with histology from surgical specimens.

DESIGN

Prospective study.

SETTING

Tertiary referral center.

PATIENTS

All patients who underwent EUS for pancreaticobiliary indications and subsequent pancreatic surgery. Patients with calcific pancreatitis were excluded.

METHODS

Individual CP features on EUS were carefully documented with relation to different parts of the pancreas. Standard EUS criteria for CP were adopted. All patients underwent surgery within 2 months of EUS. A single pathologist blinded to EUS findings reviewed the specimens and graded fibrosis (total score, 12; >or=6=unequivocal CP). A quantitative receiver operating characteristic (ROC) curve analysis was performed, and Spearman rank correlation coefficients were calculated.

MAIN OUTCOME MEASUREMENTS

Correlate EUS criteria for NCCP, with histology from surgical specimens.

RESULTS

Of the 42 patients evaluated, NCCP was diagnosed histologically in 21 patients (50%). None of the patients had CP diagnosis by CT. ROC curve analysis revealed that 4 or more EUS criteria provided the best sensitivity (90.5%), specificity (85.7%), and accuracy (88.1%) for diagnosing NCCP. Parenchymal EUS features that were significantly associated with histopathologic NCCP were foci (P<.0001), stranding (P<.001), and lobulations (P=.04); ductal features that were significantly associated with histopathologic NCCP were dilated (P<.0001) or irregular main pancreatic duct (P<.0001), side branches (P<.001), and hyperechoic duct margins (P=.03). There was a significant correlation between the number of EUS criteria and severity of NCCP on histology (r=0.85; P<.0001).

LIMITATIONS

Small number of patients.

CONCLUSIONS

An excellent correlation exists between EUS and histologic findings of NCCP.

EUS elastography of the pancreas: feasibility and pattern description of the normal pancreas, chronic pancreatitis, and focal pancreatic lesions

BACKGROUND

Initial clinical applications have shown that US elastography might be able to distinguish tissues because of their specific consistency.

OBJECTIVE

(1) To investigate the feasibility of EUS elastography of the pancreas and (2) to describe elastographic patterns of the normal pancreas and the pancreas affected by inflammatory or focal disease.

DESIGN

Prospective single-center study.

SETTING

Academic center of the University of Witten/Herdecke.

PATIENTS

Twenty patients with normal pancreas, 20 patients with chronic pancreatitis, and 33 patients with focal pancreatic lesion, histologically later proven in 32 of these 33 cases.

INTERVENTIONS

Commercially available US equipment was used. The elasticity of tissue was reconstructed in real time within a sample area and was translated into a color scale imaging relative tissue elasticity within this area. Representative loops of at least 20 seconds were recorded regarding each region of interest.

RESULTS

Adequate elastographic recordings could be obtained in all 73 patients. Patients with hypoechoic and intermediately echogenic normal pancreas revealed a relatively homogeneous elastographic pattern. Thirty-one focal lesions, including 30 neoplasms and most of the chronically inflamed pancreata had a honeycomb pattern dominated by hard strands. This pattern showed analogies to the histologic structure of 10 resected tumors. Other patients with chronic pancreatitis and those with hyperechoic healthy pancreas had miscellaneous elastographic appearances.

CONCLUSIONS

EUS elastography of the pancreas is feasible and produces plausible results. The examination of homogeneous tissue is impaired by the relative scale used. Chronic pancreatitis and hard tumors cannot be distinguished by elastography, probably because of their similar fibrous structure.

Diagnostic performance of EUS for chronic pancreatitis: a comparison with histopathology

BACKGROUND

EUS has been proposed as a minimally invasive and accurate test to detect chronic pancreatitis (CP).

OBJECTIVE

To investigate the correlation between EUS criteria and histopathology grading in patients with presumed CP.

DESIGN

Retrospective study.

SETTING AND PATIENTS

Patients who received pancreatic surgery according to presumed CP from the Medical University of South Carolina surgical database between 1995 and 2003 were identified and included if EUS was performed within 1 year before surgery. The number of EUS criteria for CP was compared with a histologic fibrosis score (FS).

MAIN OUTCOME MEASUREMENTS

Sensitivity and specificity of number of EUS criteria compared with FS.

RESULTS

Seventy-one patients were identified (38 women). Median FS was 7 (range, 0-12). Of the patients with calcifications: calcifications were detected by EUS in 30 (42%), 14 (47%) had calcifications missed by other imaging modalities, and 28 (93%) were confirmed to have abnormal histology (FS > or = 2). Of the patients without calcifications: in the 41 patients without calcifications on EUS, 36 (88%) had FS > or = 2; median FS was 5 (range, 0-12); the correlation between the number of EUS criteria and FS was low but statistically significant (r = 0.40; P = .01). Three or more EUS criteria provided the best balance of sensitivity (83.3%) and specificity (80.0%) for predicting abnormal histology.

LIMITATIONS

Retrospective study. All patients were believed to need surgery.

CONCLUSIONS

A threshold of 3 or more EUS criteria provides the best balance of sensitivity and specificity for histologic pancreatic fibrosis. Calcifications seen by EUS but missed by other imaging are common in this group of patients.

Chronic pancreatitis: challenges and advances in pathogenesis, genetics, diagnosis, and therapy

Chronic pancreatitis (CP) is characterized by progressive pancreatic damage that eventually results in significant impairment of exocrine as well as endocrine functions of the gland. In Western societies, the commonest association of chronic pancreatitis is alcohol abuse. Our understanding of the pathogenesis of CP has improved in recent years, though important advances that have been made with respect to delineating the mechanisms responsible for the development of pancreatic fibrosis (a constant feature of CP) following repeated acute attacks of pancreatic necroinflammation (the necrosis-fibrosis concept). The pancreatic stellate cells (PSCs) are now established as key cells in fibrogenesis, particularly when activated either directly by toxic factors associated with pancreatitis (such as ethanol, its metabolites or oxidant stress) or by cytokines released during pancreatic necroinflammation. In recent years, research effort has also focused on the genetic abnormalities that may predispose to CP. Genes regulating trypsinogen activation/inactivation and cystic fibrosis transmembrane conductance regulator (CFTR) function have received particular attention. Mutations in these genes are now increasingly recognized for their potential 'disease modifier' role in distinct forms of CP including alcoholic, tropical, and idiopathic pancreatitis. Treatment of uncomplicated CP is usually conservative with the major aim being to effectively alleviate pain, maldigestion and diabetes, and consequently, to improve the patient's quality of life. Surgical and endoscopic interventions are reserved for complications such as pseudocysts, abscess, and malignancy.

Application of endoscopic ultrasonography in the diagnosis and interventional treatment of pancreatic diseases

Pancreas is located behind the peritoneum without bone tissues, and general body examination and imaging detection have some limitations in the diagnosis of pancreatic diseases, which leads to the failure of early diagnosis. Endoscopic ultrasonography can provide us with high-resolution images of the pancreas the nearby structures, and it is an effective imaging modality for the diagnosis of pancreatic diseases with a high specificity and sensitivity. In this article, we reviewed the value of endoscopic ultrasonography in the diagnosis and interventional therapy for panceatic diseases.

The M-ANNHEIM classification of chronic pancreatitis: introduction of a unifying classification system based on a review of previous classifications of the disease

BACKGROUND

Several classification systems of chronic pancreatitis have been proposed to provide a basis for treatment and research. All of these previous classifications were designed at the height of pancreatic research of their respective times; thus, each represented the most current knowledge available to pancreatologists at the time. However, none of these classifications provide simultaneously a simple standardized system for the clinical classification of chronic pancreatitis according to etiology, clinical stage, and severity of the disease, nor are they consistently useful for directing clinical practice and comparing interinstitutional data. Thus, we aimed to develop a new classification system of chronic pancreatitis to provide a framework for studying the interaction of various risk factors on the course of the disease.

METHODS

We reviewed the literature on the clinical course of all different forms of chronic pancreatitis, and we reviewed all previous classification systems of the disease. This approach provided a basis for the development of a new and unifying classification of chronic pancreatitis.

RESULTS

We established the M-ANNHEIM multiple risk factor classification system based on the current knowledge of acute and chronic pancreatitis. This classification allows patients to be categorized according to the etiology, clinical stage, and severity of their disease. The severity of pancreatic inflammation was assessed using a scoring system that takes into account the clinical symptoms and treatment options of chronic pancreatitis. Finally, four hypothetical patients were categorized according to the M-ANNHEIM classification system to provide examples of its applicability in clinical practice.

CONCLUSIONS

The M-ANNHEIM multiple risk factor classification system is simple, objective, accurate, and relatively noninvasive, and it incorporates etiology, different stages of the disease, and various degrees of clinical severity. This new classification system will be helpful for investigating the impact and interaction of various risk factors on the course of the disease and will facilitate the comparison and combination of interinstitutional data.

Diagnosis of early-stage chronic pancreatitis by secretin-enhanced magnetic resonance cholangiopancreatography

A diagnostic means of detecting chronic pancreatitis at an early stage, when the disease is still reversible, needs to be developed. Magnetic resonance cholangiopancreatography (MRCP) has recently been evolving as an important tool for the evaluation of chronic pancreatitis. In patients with moderate chronic pancreatitis, the pancreatic parenchyma displays an abnormal enhancement pattern on T1-weighted sequences after gadolinium administration. The presence of a signal intensity ratio of <1.7 in the arterial phase and/or delayed peak enhancement after contrast administration has a sensitivity of 92% and a specificity of 75% for the demonstration of early chronic pancreatitis. The secretin-induced pancreatic T2 signal intensity changes are significantly reduced in patients with a mild exocrine pancreatic insufficiency as compared with healthy volunteers. MRCP visualizes fluid in the pancreatic and biliary ducts as high signal intensity on heavily T2-weighted sequences. However, visualization of normal or minimally dilated pancreatic ducts by MRCP is more challenging because of their small size. Secretin administration stimulates fluid and bicarbonate secretion by the exocrine pancreas; consequently, it improves the pancreatic duct and side-branch delineation and allows an evaluation of the exocrine pancreatic function. Side-branch ectasia, mild ductal dilatation with loss of the normal gentle taper, and mural irregularities are the pathognomonic MRCP features of early-stage chronic pancreatitis. Through measurement of the duodenal filling, secretin-MRCP allows quantitative assessment of the exocrine pancreatic function, even in patients with a mild exocrine insufficiency. The morphology of the pancreatic ducts, particularly in the early stages, does not always correlate with the functional status. MRCP permits visualization of the ductal changes and furnishes functional information on the pancreas; this combination may enhance its diagnostic accuracy so that MRCP can become a valuable diagnostic means in early-stage chronic pancreatitis.

Accuracy of endoscopic ultrasonography and magnetic resonance cholangiopancreatography for the diagnosis of chronic pancreatitis: a prospective comparison study

BACKGROUND

The diagnosis of chronic pancreatitis (CP) remains challenging. Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) have been proposed as highly accurate diagnostic modalities. Although endoscopic retrograde cholangiopancreatography (ERCP) has been previously used as a gold standard, it is associated with a small but significant risk. We aim to compare the accuracy of EUS and MRCP with the composite gold standard using ERCP, surgical pathology, and/or long-term clinical follow-up.

METHODS

Ninety-nine patients with clinical signs and/or symptoms suggestive of CP were prospectively enrolled. The diagnosis of CP by MRCP was established when one or more of these features were present: main duct dilation without obstruction, dilated side branches, intraductal stones, ductal irregularity, reduced T1-signal intensity, parenchymal atrophy, and reduced secretory response to secretin administration. The diagnosis of CP by EUS was made when 4 or more of the established criteria were present. Accuracy of all criteria used ("EUS only," "MRCP only," "either EUS or MRCP," and "both EUS and MRCP") was compared with the composite gold standard.

RESULTS

Forty patients were diagnosed with CP by the composite gold standard whereas the remaining 59 patients were controls. EUS only seemed more sensitive but equally specific compared with MRCP only to diagnose CP. The combination of EUS and MRCP had a sensitivity of 98% for either EUS or MRCP and a specificity of 100% for both EUS and MRCP.

CONCLUSIONS

EUS and MRCP are highly accurate modalities for the diagnosis of CP and are complementary when used together. If confirmed in larger series, the diagnosis of CP by both EUS and MRCP is highly predictive and ERCP is unlikely to add any useful information.

Pancreatic imaging: current and emerging technologies

This review discusses the current imaging modalities for the diagnosis and staging of solid and cystic pancreatic lesions and for the assessment of acute and chronic pancreatitis, and the future role of emerging technologies in the management of pancreatic diseases. Multidetector row spiral computed tomography is superior to conventional single-detector row spiral computed tomography in the detection and staging of pancreatic adenocarcinoma. Positron emission tomography is a sensitive but relatively nonspecific diagnostic modality. Positron emission tomography-computed tomography fusion may improve the staging accuracy for pancreatic cancer. Echo-enhanced ultrasound may have an emerging role in evaluating pancreatic masses. Endoscopic ultrasound with fine needle aspiration for cytology is the single best method for diagnosis and staging of nonmetastatic pancreatic cancer with a high accuracy for determining tumor resectability. In acute pancreatitis, a modification of the standard computed tomography severity index, which places greater emphasis on extrapancreatic complications, has shown superior correlation with various patient outcome measures. Endoscopic retrograde cholangiopancreatography is still the test of choice for morphological evaluation of chronic pancreatitis, whereas magnetic resonance cholangiopancreatography offers a noninvasive alternative in selected patients. Endoscopic ultrasound can be useful for detecting early chronic pancreatitis. Secretin-stimulated imaging techniques may eventually provide a noninvasive method of reliably assessing pancreatic exocrine function.

Yield of EUS-guided FNA of pancreatic masses in the presence or the absence of chronic pancreatitis

BACKGROUND

Evaluation of a focal pancreatic mass in the setting of chronic pancreatitis (CP) is a diagnostic challenge. The objectives of the study were to compare the diagnostic yield and accuracy of EUS-guided FNA (EUS-FNA) in the evaluation of pancreatic-mass lesions in the presence or the absence of CP and to identify predictors of CP before EUS-FNA of pancreatic-mass lesions.

METHODS

The study design was analysis of data collected prospectively on all patients with solid pancreatic-mass lesions who underwent EUS-FNA at a tertiary referral center. A total of 282 consecutive patients underwent 300 EUS-FNA procedures of pancreatic-mass lesions over a 3-year period. The diagnostic yield and the accuracy of EUS-FNA was compared between patients with and without CP. CP was defined by the presence of more than 4 EUS criteria.

RESULTS

Final diagnosis was adenocarcinoma in 210 (70%), benign disease in 64 (21%), other pathology in 19 (6%), and indeterminate in 4 (2%); 3 patients (1%) were lost to follow-up. CP was noted in 75/300 (25%) patients. A lower sensitivity for EUS-FNA was observed in patients with CP than in those without CP (73.9% vs. 91.3%; p = 0.02). While patients with CP had a higher negative predictive value (88.9% vs. 45.5%; p < 0.001), no significant differences were observed for specificity (100% vs. 93.8%), positive predictive value (100% vs. 99.5%), and accuracy (91.5% vs. 91.4%) between those with and without CP. False-negative cytology was encountered in 24 cases: 6/71 (8%) with CP vs. 18/222 (8%) without CP. Patients with CP required more EUS-FNA passes to establish a diagnosis vs. those without CP (median, 5 vs. 2; p < 0.001). On multivariable analysis, age < 50 years (p < 0.001), male gender (p < 0.001), black race (p = 0.001), and the absence of jaundice (p = 0.005) were significantly associated with CP. The impact of EUS-FNA on long-term clinical management was not analyzed. The impact of individual EUS features of CP on sensitivity of EUS-FNA was not evaluated. By protocol, mass lesions that were benign required more passes to definitively exclude malignancy.

CONCLUSIONS

EUS-FNA has a low sensitivity for pancreatic-mass lesions in the setting of CP. This decreased sensitivity can be overcome by performing more numbers of passes at FNA, which improves diagnostic accuracy. Demographic features and clinical presentation are predictive of underlying CP in patients with pancreatic-mass lesions.

EUS-guided Trucut biopsy of suspected nonfocal chronic pancreatitis

BACKGROUND

The diagnosis of early chronic pancreatitis (CP) is difficult, and the role of EUS-FNA cytology for this indication remains unclear. The aim of this study is to determine the utility and the safety profile of EUS-guided Trucut biopsy (EUS-TCB) for the histologic diagnosis of suspected nonfocal CP.

METHODS

After radial EUS, patients with suspected CP (> or =3 EUS criteria) underwent attempted transgastric EUS-TCB of the pancreas. Histopathologic specimens were examined by one pathologist and were classified as nondiagnostic, normal pancreas, and probable or definite CP. Within 1 week after EUS, ERCP was performed by an endoscopist blinded to the EUS results. The severity of CP by ERCP was stratified by the Cambridge classification. Agreement between tests for the diagnosis of CP was evaluated by a kappa statistic.

RESULTS

Of 45 patients screened, 15 declined and 30 (12 men and 18 women, mean age 44 years) underwent diagnostic EUS. Of these, 18 (60%) had suspected CP and 16 underwent attempted biopsy. Calcific pancreatitis in two patients precluded EUS-TCB. EUS-TCB results were as follows: probable CP (1), normal pancreas (8), nondiagnostic (6), device malfunction (1). Complications after EUS-TCB occurred in two patients with normal pancreatic biopsies were the following: acute pancreatitis (1) and abdominal pain without pancreatitis (1), both of whom were hospitalized and discharged within 23 hours. Six patients refused ERCP and two (per protocol) did not undergo ERCP. For the remaining 22, agreement between diagnostic EUS and ERCP was moderate (kappa, 0.40). Agreement between EUS and ERCP with EUS-TCB were poor (kappa, 0) and fair (kappa, 0.25), respectively.

CONCLUSIONS

Transgastric EUS-TCB of suspected nonfocal CP infrequently demonstrates histologic CP in clinically suspected disease. Because of potential complications and limited diagnostic yield, this technique is not currently recommended for evaluation of these patients.