Guidelines for the Diagnostic Cross Sectional Imaging and Severity Scoring of Chronic Pancreatitis☆
Introduction
Aiming to produce the first truly International Guidelines on chronic pancreatitis (CP), John P Neoptolemos, David C Whitcomb and Tooru Shimosegawa in 2016 embarked on a joint venture with endorsement from the four International Societies (International Association of Pancreatology (IAP), American Pancreatic Association (APA), Japan Pancreas Society (JPS) and European Pancreatic Club (EPC)). The core committee identified international experts to ensure multidisciplinary representation within subgroups focusing on the different key topics of CP, and calls for volunteers to participate in the process were also circulated across the societies. Although different guidelines exist, such as the recent European consensus [1], the aim was to create a consensus that was mechanism based, truly international and multidisciplinary. The first major step was to agree the definition of CP which after several meetings agreed to adopt the mechanistic definition of CP [2]. For further description of this definition of CP and the process behind the international consensus guideline work, please see Appendix A and references [2,3]. Although imaging provides outstanding morphological and some functional information about the pancreas, many of the early features are non-specific. Thus, the diagnosis of CP, and especially early CP, requires assessment of risk factors, clinical features, different biomarkers including imaging and exclusion of diseases with overlapping features of CP [2,[4], [5], [6]].
The members of the imaging working group were appointed to represent worldwide specialists in pancreatic imaging with representatives from radiology, gastroenterology and surgery. It was also decided to focus on imaging in adults, and on cross sectional imaging (computed tomography (CT) and magnetic resonance imaging (MRI)) since this is the primary diagnostic approach at most institutions. Since a separate guideline work is planned about ultrasound, transabdominal ultrasound was not included in this guideline and the usefulness of endoscopic ultrasound (EUS) is addressed in one question for detailed diagnosing and grading of CP as supplement to cross sectional imaging. JBF was appointed as chairman of the group. Thirteen questions deemed to be the most urgent and clinically relevant in CP were identified.
Section snippets
Methods
The imaging working group provided a structured format for a narrative review of each question, and included instructions how to evaluate the level of evidence according to the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach (see http://www.uptodate.com/home/grading-tutorial). The strengths of the recommendations were graded as strong (1) or weak (2), and the levels of quality of evidence as high (A), moderate (B) or low (C). Finally, the working group
Results
Question 1: What are the indications for CT in the investigation of CP?
CT is indicated as part of a diagnostic algorithm when there is clinical suspicion of CP, in the presence of typical symptoms and recognized risk factors. CT is also indicated to exclude other potential intraabdominal pathologies presenting with symptoms similar to CP. In patients with established CP, CT is indicated to assess complications and the need for further interventions.
(Quality assessment: High; Strength of
Summary
CT is often the most appropriate initial imaging modality for the evaluation of patients with suspected CP. All patients with a suspected diagnosis of CP should in most cases undergo a baseline CT imaging. The diagnosis of mild/early CP remains challenging. However, MRI/MRCP and especially secretin-stimulated MRCP, or alternatively EUS, is more accurate in the depiction of these subtle changes. There is a need for a validated radiological scoring system based on imaging criteria including
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Recommendations from the Working Group for the International Consensus Guidelines for Chronic Pancreatitis in collaboration with the International Association of Pancreatology, American Pancreatic Association, Japan Pancreas Society and European Pancreatic Club (IAP – APA – JPS – EPC).