Endoscopic ultrasound for the diagnosis of chronic pancreatitis

Endoscopic ultrasound diagnostic gain over computed tomography and magnetic resonance cholangiopancreatography in defining etiology of idiopathic acute pancreatitis

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.

Endoscopic ultrasound diagnostic gain over computed tomography and magnetic resonance cholangiopancreatography 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]

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.

Utility of endoscopic ultrasound in idiopathic acute recurrent pancreatitis

Idiopathic acute recurrent pancreatitis (IARP) is defined as at least two episodes of acute pancreatitis with the complete or near-complete resolution of symptoms and signs of pancreatitis between episodes, without an identified cause. There is a paucity of information about the usefulness of endoscopic ultrasound (EUS) in IARP.

Diagnosis and treatment in chronic pancreatitis: an international survey and case vignette study

BACKGROUND

The aim of the study was to evaluate the current opinion and clinical decision-making process of international pancreatologists, and to systematically identify key study questions regarding the diagnosis and treatment of chronic pancreatitis (CP) for future research.

METHODS

An online survey, including questions regarding the diagnosis and treatment of CP and several controversial clinical case vignettes, was send by e-mail to members of various international pancreatic associations: IHPBA, APA, EPC, ESGE and DPSG.

RESULTS

A total of 288 pancreatologists, 56% surgeons and 44% gastroenterologists, from at least 47 countries, participated in the survey. About half (48%) of the specialists used a classification tool for the diagnosis of CP, including the Mayo Clinic (28%), Mannheim (25%), or Büchler (25%) tools. Overall, CT was the preferred imaging modality for evaluation of an enlarged pancreatic head (59%), pseudocyst (55%), calcifications (75%), and peripancreatic fat infiltration (68%). MRI was preferred for assessment of main pancreatic duct (MPD) abnormalities (60%). Total pancreatectomy with auto-islet transplantation was the preferred treatment in patients with parenchymal calcifications without MPD abnormalities and in patients with refractory pain despite maximal medical, endoscopic, and surgical treatment. In patients with an enlarged pancreatic head, 58% preferred initial surgery (PPPD) versus 42% initial endoscopy. In patients with a dilated MPD and intraductal stones 56% preferred initial endoscopic ± ESWL treatment and 29% preferred initial surgical treatment.

CONCLUSION

Worldwide, clinical decision-making in CP is largely based on local expertise, beliefs and disbeliefs. Further development of evidence-based guidelines based on well designed (randomized) studies is strongly encouraged.

Chronic Pancreatitis: A Review

This is to incorporate the recent trends in chronic pancreatitis. Extensive literature search was done from Pubmed and Ovid SP. Full text articles and abstracts related to chronic pancreatitis were reviewed and the article was prepared. Chronic pancreatitis is evolving fast on its etiology and treatment areas. The main etiological factors are pointing towards genetic, alcohol, and smoking. Autoimmune has also been added as a cause. Endoscopic ultra sound (EUS) becoming the standard diagnostic procedure. Surgery is becoming the treatment of choice for pain and mechanical complications and not the endotherapy in the long-term follow-up. The numbers of surgeries are getting narrowed down. The two etiological groups of chronic pancreatitis namely alcohol + smoking and genetic getting clearer, where the later group present at an early age. Endoscopic ultrasound and imaging with secretin is diagnostic of chronic pancreatitis before the structural changes. Endotherapy is found to be inferior to surgery in long-term pain relief. Diagnostic criteria for autoimmune pancreatitis are established. Pancreaticogenic diabetes (Type3c) and its problem associated with fat malabsorption are being understood.

Evaluation of Qualitative Magnetic Resonance Imaging Features for Diagnosis of Chronic Pancreatitis

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.

Endoscopic ultrasound in the evaluation of chronic upper abdominal pain of unknown etiology: a retrospective chart review examining the efficacy of EUS in determining a new diagnosis

GOALS

To explore the utility of endoscopic ultrasound (EUS) in the evaluation of chronic upper abdominal pain (UAP) of undetermined etiology.

BACKGROUND

Chronic UAP is a common problem with a challenging diagnosis and management. The role of EUS in the diagnosis of UAP may minimize additional testing; however, few studies describe the percentage of new diagnoses yielded in these patients.

STUDY

We conducted a retrospective analysis by reviewing electronic medical records at Scott and White Memorial Hospital, Texas A&M Health Sciences Center for patients with abdominal pain for ≥ 12 months not explained by previous workup referred for EUS for chronic UAP from January 1, 1998 through October 1, 2007. Patients with previous EUS in past 12 months were excluded from the study. Patient demographic data and imaging performed 6 months before and 24 months after EUS were reviewed and results documented.

RESULTS

EUS was successful at diagnosing a new clinical etiology of chronic UAP in 33 patients (8.89%) with previous workup that was unrevealing for a definitive diagnosis. The most frequent diagnoses included pancreaticobiliary tree abnormalities, chronic pancreatitis, and fatty liver disease.

CONCLUSIONS

Our results support the fact that the majority of patients UAP with prior imaging will have no identifiable organic etiology found on EUS to explain their pain; however, we suggest that EUS be considered in patients with suspected pancreatic or biliary pathology.

Endoscopic ultrasound in the diagnosis and treatment of pancreatic disease

Endoscopic ultrasound (EUS) is an important part of modern gastrointestinal endoscopy and now has an integral role in the diagnostic evaluation of pancreatic diseases. Furthermore, as EUS technology has advanced, it has increasingly become a therapeutic procedure, and the prospect of multiple applications of interventional EUS for the pancreas is truly on the near horizon. However, this review focuses on the established diagnostic and therapeutic roles of EUS that are used in current clinical practice. In particular, the diagnostic evaluation of acute pancreatitis, chronic pancreatitis, cystic pancreatic lesions and solid masses of the pancreas are discussed. The newer enhanced imaging modalities of elastography and contrast enhancement are evaluated in this context. The main therapeutic aspects of pancreatic EUS are then considered, namely celiac plexus block and celiac plexus neurolysis for pain control in chronic pancreatitis and pancreas cancer, and EUS-guided drainage of pancreatic fluid collections.

Endoscopic ultrasound and pancreatic applications: what the radiologist needs to know

As the technology has improved, endoscopic ultrasound (EUS) has taken on an important role in the diagnosis of a number of different neoplastic and non-neoplastic pancreatic diseases. EUS can provide high-resolution images with subtle anatomic detail, and has also taken on an important role in the targeted biopsy of the pancreas and adjacent structures. This review seeks to familiarize radiologists with the role of EUS in the diagnosis of chronic and autoimmune pancreatitis, solid pancreatic masses, and cystic pancreatic neoplasms.

Defining the accuracy of secretin pancreatic function testing in patients with suspected early chronic pancreatitis

OBJECTIVES

The diagnosis of chronic pancreatitis in patients with characteristic symptoms but normal pancreatic imaging is challenging. Assessment of pancreatic function through secretin pancreatic function testing (SPFT) has been advocated in this setting, but its diagnostic accuracy is not fully known.

METHODS

This was a retrospective review of patients who received SPFT at our tertiary care institution between January 1995 and December 2008 for suspected chronic pancreatitis. For all patients, medical records were reviewed for evidence of subsequent development of chronic pancreatitis by imaging and/or pathology. Patients were then categorized as "true positive" or "true negative" for chronic pancreatitis based on follow-up imaging or histologic evidence.

RESULTS

In all, 116 patients underwent SPFT. Of the 27 patients who tested positive, 7 were lost to follow-up. Of the remaining 20 SPFT-positive patients, 9 (45%) developed radiologic or histologic evidence of chronic pancreatitis after a median of 4 years (1-11 years). Of the 89 patients who had negative SPFT testing, 19 were lost to follow-up. Of the remaining 70 patients, 2 were eventually diagnosed with chronic pancreatitis based on subsequent imaging/histology after a median follow-up period of 7 years (3-11 years). The sensitivity of the SPFT in diagnosing chronic pancreatitis was 82% with a specificity of 86%. The positive predictive value (PPV) of chronic pancreatitis was 45% with a negative predictive value (NPV) of 97%.

CONCLUSIONS

In patients with suspected early chronic pancreatitis and normal pancreatic imaging, SPFT is highly accurate at ruling out early chronic pancreatitis with a NPV of 97%.

Endoscopic ultrasonography of the pancreas as an indirect method to predict pancreatic exocrine insufficiency in patients with chronic pancreatitis

OBJECTIVES

Functional evaluation of the pancreas is hindered by invasiveness and/or methodological difficulties. Endoscopic ultrasonography (EUS) provides with highly accurate images of pancreatic ducts and parenchyma. The aim of the study was to analyze the probability of pancreatic exocrine insufficiency (PEI) according to EUS criteria in patients with a diagnosis of chronic pancreatitis.

METHODS

A total of 128 consecutive patients (mean age, 52 years; 104 men) with chronic pancreatitis were prospectively included. Pancreatic exocrine insufficiency was diagnosed by the carbon 13-mixed triglyceride breath test. Endoscopic ultrasonography was performed and EUS criteria of chronic pancreatitis evaluated by 2 different experienced endosonographers who were blinded to the results of the pancreatic function test.

RESULTS

Forty-eight patients (37.5%) had PEI. The percentage of patients with PEI increased linearly with the number of EUS criteria. The presence of intraductal calcifications, hyperechogenic foci with shadowing, and dilation of the main pancreatic duct were significantly and independently associated to PEI. The probability of PEI in the presence of calculi in the main pancreatic duct is 80% and increases to 82.8% if, in addition, the main duct is dilated.

CONCLUSIONS

Endoscopic ultrasonography findings allow predicting the probability of PEI in patients with chronic pancreatitis and thus the need for pancreatic enzyme replacement therapy.

Diagnostic value of endoscopic ultrasound and endoscopic ultrasound-guided fine needle aspiration biopsy in pancreatic diseases

AIM: To investigate the diagnostic value of endoscopic ultrasound (EUS) and EUS-guided fine needle aspiration (EUS-FNA) biopsy in pancreatic diseases.

METHODS: The clinical data for 62 patients with pancreatic diseases who underwent EUS (including 32 undergoing EUS-FNA) were retrospective analyzed.

RESULTS: Of 62 patients, 26 had pancreatic cancer, 20 had chronic pancreatitis, 10 had pancreatic cyst, and 2 had islet cell adenoma. The rates of achieving final diagnosis by B ultrasound, CT scan, and EUS/EUS-FNA were 46.2%, 69.2%, and 88.5% in patients with pancreatic cancer, 50%, 66.7%, and 100% in patients with chronic pancreatitis, 50%, 83.3%, and 100% in patients with pancreatic cyst. Pancreatic occupying lesions can be confirmed by EUS-FNA, through which we found 2 cases of islet cell adenoma.

CONCLUSION: EUS is more accurate than B ultrasound and CT scan in the diagnosis of pancreatic diseases. EUS in combination with EUS-FNA can further enhance the diagnostic accuracy of pancreatic diseases.