Elsevier

Pancreatology

Volume 18, Issue 7, October 2018, Pages 764-773
Pancreatology

Guidelines for the Diagnostic Cross Sectional Imaging and Severity Scoring of Chronic Pancreatitis

https://doi.org/10.1016/j.pan.2018.08.012Get rights and content

Abstract

The paper presents the international guidelines for imaging evaluation of chronic pancreatitis. The following consensus was obtained: Computed tomography (CT) is often the most appropriate initial imaging modality for evaluation of patients with suspected chronic pancreatitis (CP) depicting most changes in pancreatic morphology. CT is also indicated to exclude other potential intraabdominal pathologies presenting with symptoms similar to CP. However, CT cannot exclude a diagnosis of CP nor can it be used to exclusively diagnose early or mild disease. Here magnetic resonance imaging (MRI) and MR cholangiopancreatography (MRCP) is superior and is indicated especially in patients where no specific pathological changes are seen on CT. Secretin-stimulated MRCP is more accurate than standard MRCP in the depiction of subtle ductal changes. It should be performed after a negative MRCP, when there is still clinical suspicion of CP. Endoscopic ultrasound (EUS) can also be used to diagnose parenchymal and ductal changes mainly during the early stage of the disease.

No validated radiological severity scoring systems for CP are available, although a modified Cambridge Classification has been used for MRCP. There is an unmet need for development of a new and validated radiological CP severity scoring system based on imaging criteria including glandular volume loss, ductal changes, parenchymal calcifications and parenchymal fibrosis based on CT and/or MRI. Secretin-stimulated MRCP in addition, can provide assessment of exocrine function and ductal compliance. An algorithm is presented, where these imaging parameters can be incorporated together with clinical findings in the classification and severity grading of CP.

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

References (85)

  • E. Rajan et al.

    Age-related changes in the pancreas identified by EUS: a prospective evaluation

    Gastrointest Endosc

    (2005)
  • M.C. Petrone et al.

    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)
  • M.F. Catalano et al.

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

    Gastrointest Endosc

    (2009)
  • G. Trikudanathan et al.

    Evaluation of Rosemont criteria for non-calcific chronic pancreatitis (NCCP) based on histopathology – a retrospective study

    Pancreatology

    (2017)
  • M.B. Wallace et al.

    The reliability of EUS for the diagnosis of chronic pancreatitis: interobserver agreement among experienced endosonographers

    Gastrointest Endosc

    (2001)
  • P.A. Testoni et al.

    MRCP-secretin test-guided management of idiopathic recurrent pancreatitis: long-term outcomes

    Gastrointest Endosc

    (2008)
  • E. Pamuklar et al.

    MR imaging of the pancreas

    Magn. Reson. Clin. N. Am.

    (2005)
  • R.F. Thoeni et al.

    Pancreatic imaging. Computed tomography and magnetic resonance imaging

    Radiol. Clin.

    (1993)
  • J.M. Lohr et al.

    United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis (HaPanEU)

    United Eur. Gastroenterol. J.

    (2017)
  • D.C. Whitcomb et al.

    International consensus statements on early chronic pancreatitis. 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, PancreasFest working group and european pancreatic Club EPC) consensus guidelines for chronic pancreatitis

    Pancreatology

    (2018)
  • D.C. Whitcomb

    Better biomarkers for pancreatic diseases

    Pancreas

    (2015)
  • D.C. Whitcomb

    Peering into the “black box” of the complex chronic pancreatitis syndrome

    Pancreas

    (2016)
  • A.J. Atkinson et al.

    Biomarkers and surrogate endpoints: preferred definitions and conceptual framework

    Clin Pharmacol Ther

    (2001)
  • D.L. Conwell et al.

    American pancreatic association practice guidelines in chronic pancreatitis: evidence-based report on diagnostic guidelines

    Pancreas

    (2014)
  • P.H. Luetmer et al.

    Chronic pancreatitis: reassessment with current CT

    Radiology

    (1989)
  • J. Kirkegård et al.

    Chronic pancreatitis and pancreatic cancer risk: a systematic review and meta-analysis

    Am J Gastroenterol

    (2017)
  • M.L. Ramsey et al.

    Complications of chronic pancreatitis

    Dig Dis Sci

    (2017)
  • A. Hoffmeister et al.

    English language version of the S3-consensus guidelines on chronic pancreatitis: definition, aetiology, diagnostic examinations, medical, endoscopic and surgical management of chronic pancreatitis

    Z Gastroenterol

    (2015)
  • A.B. Lowenfels et al.

    Prognosis of chronic pancreatitis: an international multicenter study. International pancreatitis study group

    Am J Gastroenterol

    (1994)
  • L. Buscail et al.

    Endoscopic ultrasonography in chronic pancreatitis: a comparative prospective study with conventional ultrasonography, computed tomography, and ERCP

    Pancreas

    (1995)
  • B. Glasbrenner et al.

    Modern diagnostics of chronic pancreatitis

    Eur J Gastroenterol Hepatol

    (2002)
  • A. Schneider et al.

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

    J Gastroenterol

    (2007)
  • S. Gangi et al.

    Time interval between abnormalities seen on CT and the clinical diagnosis of pancreatic cancer: retrospective review of CT scans obtained before diagnosis

    Am J Roentgenol

    (2004)
  • D.V. Sahani et al.

    Autoimmune pancreatitis: disease evolution, staging, response assessment, and CT features that predict response to corticosteroid therapy

    Radiology

    (2009)
  • T.N. Walsh et al.

    Minimal change chronic pancreatitis

    Gut

    (1992)
  • P.J. Robinson et al.

    Pancreatitis: computed tomography and magnetic resonance imaging

    Eur Radiol

    (2000)
  • T. Bozkurt et al.

    Comparison of pancreatic morphology and exocrine functional impairment in patients with chronic pancreatitis

    Gut

    (1994)
  • R. Manfredi et al.

    Severe chronic pancreatitis versus suspected pancreatic disease: dynamic MR cholangiopancreatography after secretin stimulation

    Radiology

    (2000)
  • A. Amodio et al.

    Prospective evaluation of subjects with chronic asymptomatic pancreatic hyperenzymemia

    Am J Gastroenterol

    (2012)
  • Y. Issa et al.

    Diagnostic performance of imaging modalities in chronic pancreatitis: a systematic review and meta-analysis

    Eur Radiol

    (2017)
  • S. Maurea et al.

    Comparative diagnostic evaluation with MR cholangiopancreatography, ultrasonography and CT in patients with pancreatobiliary disease

    Radiol Med

    (2009)
  • H. Irie et al.

    Comparison of helical CT and MR imaging in detecting and staging small pancreatic adenocarcinoma

    Abdom. Imag.

    (1997)
  • Cited by (70)

    • Aetiological risk factors are associated with distinct imaging findings in patients with chronic pancreatitis: A study of 959 cases from the Scandinavian Baltic Pancreatic Club (SBPC) imaging database

      2021, Pancreatology
      Citation Excerpt :

      A few previous studies have explored the normal size of the pancreas using one dimensional anterior-posterior measurements [42,43]. Comprehensive measurements of pancreatic volume are not feasible for multicentre studies [11] A consented definition of pancreatic atrophy does not exist [6]. Recently, two separate groups suggested using measurement of the pancreatic body at the level of the left margin of the vertebral body with AP diameters of 21 mm, 14 mm, and 7 mm as thresholds for varying degrees of atrophy [10,11].

    • Surgical management of chronic calcified pancreatitis

      2021, Surgery in Practice and Science
    • Epidemiology of chronic pancreatitis in the world: research progress

      2024, Academic Journal of Naval Medical University
    View all citing articles on Scopus

    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).

    View full text