S3 Guideline for Chronic Pancreatitis – Diagnosis, Classification and Therapy for the Radiologist

Abstract

Chronic pancreatitis shows an increasing prevalence and incidence mainly in the Western Hemisphere. Early diagnosis and therapy are frequently delayed because of non-specific symptoms as well as non-specific blood values. The German Society of Digestive and Metabolic Diseases (DGVS) organized the preparation and publication of an interdisciplinary S3 level guideline with the support of the German Radiological Society (DRG) as 1 of 11 contributing societies. In this article we present and discuss the main topics of the guideline regarding the diagnosis, differential diagnosis and therapy of complications of this complex chronic disease with a focus on clinical and scientific radiologists.

Key Points:

• Ultarsound represents the perfect first line imaging modality

• For further diagnostic werk up MRI with MRCP are recommended for the differential diagnosis of pancreatic cancer

• For clinical studies the modified (CT, MRI) Cambridge classification is recommended

Citation Format:

• Schreyer AG, Jung M, Riemann JF et al. S3 Guideline for Chronic Pancreatitis – Diagnosis, Classification and Therapy for the Radiologist. Fortschr Röntgenstr 2014; 186: 1002 – 1008

Zusammenfassung

Die chronische Pankreatitis hat vor allem in der westlichen Welt in ihrer Inzidenz und Prävalenz stark zugenommen. Durch die unspezifischen Symptome zu Beginn dieser chronischen Erkrankung bei fehlenden spezifischen Laborparametern ist die Diagnose und Therapie häufig verzögert. Über mehrere Jahre wurde die aktuelle neue deutsche S3-Leitlinie „Chronische Pankreatitis“ unter der organisatorischen Leitung der Deutschen Gesellschaft für Verdauung- und Stoffwechselkrankheiten (DGVS) mit Beteiligung der Deutschen Röntgengesellschaft (DRG) als eine von 11 kollaborierenden Gesellschaften interdisziplinär erarbeitet und veröffentlicht. Im vorliegenden Artikel möchten wir alle für den klinisch und wissenschaftlich arbeitenden Radiologen wichtigen Punkte für die Diagnose, Differentialdiagnose sowie Therapie von Komplikationen dieses komplexen chronischen Krankheitsbildes basierend auf der neuen Leitlinie zusammenstellen und diskutieren.

Key words

pancreas - CT - pancreatitis - MR imaging

• References

• 1 Dufour MC, Adamson MD. The epidemiology of alcohol-induced pancreatitis. Pancreas 2003; 27: 286-290
• 2 Ammann RW, Akovbiantz A, Largiader F et al. Course and outcome of chronic pancreatitis. Longitudinal study of a mixed medical-surgical series of 245 patients. Gastroenterology 1984; 86: 820-828
• 3 Miyake H, Harada H, Kunichika K et al. Clinical course and prognosis of chronic pancreatitis. Pancreas 1987; 2: 378-385
• 4 Lankisch PG, Lohr-Happe A, Otto J et al. Natural course in chronic pancreatitis. Pain, exocrine and endocrine pancreatic insufficiency and prognosis of the disease. Digestion 1993; 54: 148-155
• 5 Lowenfels AB, Maisonneuve P, Cavallini G et al. Prognosis of chronic pancreatitis: an international multicenter study. International Pancreatitis Study Group. The American journal of gastroenterology 1994; 89: 1467-1471
• 6 Levy P, Mathurin P, Roqueplo A et al. A multidimensional case-control study of dietary, alcohol, and tobacco habits in alcoholic men with chronic pancreatitis. Pancreas 1995; 10: 231-238
• 7 Yan MX, Li YQ. Gall stones and chronic pancreatitis: the black box in between. Postgraduate medical journal 2006; 82: 254-258
• 8 Burtin P, Person B, Charneau J et al. Pancreas divisum and pancreatitis: a coincidental association?. Endoscopy 1991; 23: 55-58
• 9 DiMagno EP, Go VL, Summerskill WH. Relations between pancreatic enzyme ouputs and malabsorption in severe pancreatic insufficiency. The New England journal of medicine 1973; 288: 813-815
• 10 Catalano MF, Geenen JE. Diagnosis of chronic pancreatitis by endoscopic ultrasonography. Endoscopy 1998; 30 Suppl 1: A111-A115
• 11 Catalano MF, Lahoti S, Geenen JE et al. Prospective evaluation of endoscopic ultrasonography, endoscopic retrograde pancreatography, and secretin test in the diagnosis of chronic pancreatitis. Gastrointestinal endoscopy 1998; 48: 11-17
• 12 Catalano MF, Sahai A, Levy M et al. EUS-based criteria for the diagnosis of chronic pancreatitis: the Rosemont classification. Gastrointestinal endoscopy 2009; 69: 1251-1261
• 13 Chong AK, Hawes RH, Hoffman BJ et al. Diagnostic performance of EUS for chronic pancreatitis: a comparison with histopathology. Gastrointestinal endoscopy 2007; 65: 808-814
• 14 Adamek HE, Albert J, Breer H et al. Pancreatic cancer detection with magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography: a prospective controlled study. Lancet 2000; 356: 190-193
• 15 Buscail L, Escourrou J, Moreau J et al. Endoscopic ultrasonography in chronic pancreatitis: a comparative prospective study with conventional ultrasonography, computed tomography, and ERCP. Pancreas 1995; 10: 251-257
• 16 Wiersema MJ, Hawes RH, Lehman GA et al. Prospective evaluation of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in patients with chronic abdominal pain of suspected pancreatic origin. Endoscopy 1993; 25: 555-564
• 17 Gebel M, Stiehl M, Freise J. Value of sonographic imaging of the pancreatic duct for the diagnosis of chronic pancreatitis and pancreatic cancer compared to ERCP. Ultraschall in Med 1985; 6: 127-130
• 18 Sai JK, Suyama M, Kubokawa Y et al. Diagnosis of mild chronic pancreatitis (Cambridge classification): comparative study using secretin injection-magnetic resonance cholangiopancreatography and endoscopic retrograde pancreatography. World journal of gastroenterology: WJG 2008; 14: 1218-1221
• 19 Bali MA, Golstein P, Deviere J et al. Evaluation of somatostatin inhibitory effect on pancreatic exocrine function using secretin-enhanced dynamic magnetic resonance cholangiopancreatography: a crossover, randomized, double blind, placebo-controlled study. Pancreas 2006; 32: 346-350
• 20 Donati F, Boraschi P, Gigoni R et al. Secretin-stimulated MR cholangio-pancreatography in the evaluation of asymptomatic patients with non-specific pancreatic hyperenzymemia. European journal of radiology 2010; 75: e38-e44
• 21 Manfredi R, Lucidi V, Gui B et al. Idiopathic chronic pancreatitis in children: MR cholangiopancreatography after secretin administration. Radiology 2002; 224: 675-682
• 22 Darge K, Anupindi S. Pancreatitis and the role of US, MRCP and ERCP. Pediatric radiology 2009; 39 (Suppl. 02) S153-S157
• 23 Kahl S, Glasbrenner B, Leodolter A et al. EUS in the diagnosis of early chronic pancreatitis: a prospective follow-up study. Gastrointestinal endoscopy 2002; 55: 507-511
• 24 Kahl S, Glasbrenner B, Zimmermann S et al. Endoscopic ultrasound in pancreatic diseases. Digestive diseases 2002; 20: 120-126
• 25 Gebel M, Stiehl M, Freise J. Value of sonographic imaging of the pancreatic duct for the diagnosis of chronic pancreatitis and pancreatic cancer compared to ERCP. Ultraschall in der Medizin 1985; 6: 127-130
• 26 Glasbrenner B, Kahl S, Malfertheiner P. Modern diagnostics of chronic pancreatitis. European journal of gastroenterology & hepatology 2002; 14: 935-941
• 27 Sarner M, Cotton PB. Classification of pancreatitis. Gut 1984; 25: 756-759
• 28 Tamura R, Ishibashi T, Takahashi S. Chronic pancreatitis: MRCP versus ERCP for quantitative caliber measurement and qualitative evaluation. Radiology 2006; 238: 920-928
• 29 Testoni PA, Mariani A, Curioni S et al. MRCP-secretin test-guided management of idiopathic recurrent pancreatitis: long-term outcomes. Gastrointestinal endoscopy 2008; 67: 1028-1034
• 30 Nattermann C, Goldschmidt AJ, Dancygier H. Endosonography in chronic pancreatitis. A comparative study of endoscopic retrograde pancreatography and endoscopic sonography. Ultraschall in der Medizin 1992; 13: 263-270
• 31 Balthazar EJ, Robinson DL, Megibow AJ et al. Acute pancreatitis: value of CT in establishing prognosis. Radiology 1990; 174: 331-336
• 32 Rickes S, Uhle C, Kahl S et al. Echo enhanced ultrasound: a new valid initial imaging approach for severe acute pancreatitis. Gut 2006; 55: 74-78
• 33 Arvanitakis M, Delhaye M, De Maertelaere V et al. Computed tomography and magnetic resonance imaging in the assessment of acute pancreatitis. Gastroenterology 2004; 126: 715-723
• 34 Lerch MM, Stier A, Wahnschaffe U et al. Pancreatic pseudocysts: observation, endoscopic drainage, or resection?. Deutsches Arzteblatt international 2009; 106: 614-621
• 35 Fritscher-Ravens A, Brand L, Knofel WT et al. Comparison of endoscopic ultrasound-guided fine needle aspiration for focal pancreatic lesions in patients with normal parenchyma and chronic pancreatitis. The American journal of gastroenterology 2002; 97: 2768-2775
• 36 Will U, Mueller A, Topalidis T et al. Value of endoscopic ultrasonography-guided fine needle aspiration (FNA) in the diagnosis of neoplastic tumor(-like) pancreatic lesions in daily clinical practice. Ultraschall in der Medizin 2010; 31: 169-174
• 37 Kim JK, Altun E, Elias Jr J et al. Focal pancreatic mass: distinction of pancreatic cancer from chronic pancreatitis using gadolinium-enhanced 3D-gradient-echo MRI. Journal of magnetic resonance imaging: JMRI 2007; 26: 313-322
• 38 Ardengh JC, Paulo GA, Nakao FS et al. Endoscopic ultrasound guided fine-needle aspiration core biopsy: comparison between an automatic biopsy device and two conventional needle systems. Acta gastroenterologica Latinoamericana 2008; 38: 105-115
• 39 Chari ST, Smyrk TC, Levy MJ et al. Diagnosis of autoimmune pancreatitis: the Mayo Clinic experience. Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 2006; 4: 1010-1016 ; quiz 1934
• 40 Barthet M, Bugallo M, Moreira LS et al. Management of cysts and pseudocysts complicating chronic pancreatitis. A retrospective study of 143 patients. Gastroenterologie clinique et biologique 1993; 17: 270-276
• 41 Bradley EL, Clements Jr JL, Gonzalez AC. The natural history of pancreatic pseudocysts: a unified concept of management. American journal of surgery 1979; 137: 135-141
• 42 Udd M, Leppaniemi AK, Bidel S et al. Treatment of bleeding pseudoaneurysms in patients with chronic pancreatitis. World journal of surgery 2007; 31: 504-510
• 43 Rosch T, Schusdziarra V, Born P et al. Modern imaging methods versus clinical assessment in the evaluation of hospital in-patients with suspected pancreatic disease. The American journal of gastroenterology 2000; 95: 2261-2270
• 44 Wiggermann P, Grutzmann R, Weissenbock A et al. Apparent diffusion coefficient measurements of the pancreas, pancreas carcinoma, and mass-forming focal pancreatitis. Acta radiologica 2012; 53: 135-139
• 45 Sandrasegaran K, Nutakki K, Tahir B et al. Use of diffusion-weighted MRI to differentiate chronic pancreatitis from pancreatic cancer. Am J Roentgenol American journal of roentgenology 2013; 201: 1002-1008
• 46 Ichikawa T, Erturk SM, Motosugi U et al. High-b value diffusion-weighted MRI for detecting pancreatic adenocarcinoma: preliminary results. Am J Roentgenol American journal of roentgenology 2007; 188: 409-414
• 47 Chowdhury R, Bhutani MS, Mishra G et al. Comparative analysis of direct pancreatic function testing versus morphological assessment by endoscopic ultrasonography for the evaluation of chronic unexplained abdominal pain of presumed pancreatic origin. Pancreas 2005; 31: 63-68
• 48 Pungpapong S, Wallace MB, Woodward TA et al. Accuracy of endoscopic ultrasonography and magnetic resonance cholangiopancreatography for the diagnosis of chronic pancreatitis: a prospective comparison study. Journal of clinical gastroenterology 2007; 41: 88-93
• 49 Stevens T, Conwell DL, Zuccaro Jr G et al. A prospective crossover study comparing secretin-stimulated endoscopic and Dreiling tube pancreatic function testing in patients evaluated for chronic pancreatitis. Gastrointestinal endoscopy 2008; 67: 458-466
• 50 Stevens T, Conwell DL, Zuccaro Jr G et al. Comparison of endoscopic ultrasound and endoscopic retrograde pancreatography for the prediction of pancreatic exocrine insufficiency. Digestive diseases and sciences 2008; 53: 1146-1151
• 51 Stevens T, Zuccaro Jr G, Dumot JA et al. Prospective comparison of radial and linear endoscopic ultrasound for diagnosis of chronic pancreatitis. Endoscopy 2009; 41: 836-841
• 52 Hollerbach S, Ruser J, Ochs A et al. Current status of abdominal pancreatic ultrasound. A retrospective analysis of 585 pancreatic ultrasound examinations. Medizinische Klinik 1994; 89: 7-13
• 53 Lohr M, Kloppel G. Pathology of the pancreas in chronic type 1 diabetes mellitus: B-cell content, exocrine atrophy and angiopathy. Verhandlungen der Deutschen Gesellschaft fur Pathologie 1987; 71: 114-119