Accuracy of magnetic resonance cholangiopancreatography in the diagnosis of pancreas divisum

Incidence and Clinical Implications of Anatomical Variations in the Pancreas and Its Ductal System: A Systematic Review and Meta-Analysis

OBJECTIVE

This systematic review analyzes the anatomical variants in the pancreas and its ductal system to report on their association with pancreatic pathologies.

METHODS

We conducted a search of the MEDLINE, Scopus, Web of Science, Google Scholar, CINAHL, and LILACS databases from their inception to July 2023. The methodological quality was assessed with the Anatomical Quality Assessment (AQUA) tool. Finally, the pooled prevalence was estimated using a random effects model.

RESULTS

55 studies were found that met the eligibility criteria. The overall prevalence of pancreas divisum (PD) was 18% (95% CI = 15-21%). The prevalence of PD associated with pancreatitis was 30% (95% CI = 1-61%).

CONCLUSIONS

An anatomical variant of the pancreas such as PD may be the cause of bile duct obstruction, resulting in various clinical complications, such as pancreatitis. Hence, knowing this variant is extremely important for surgeons, especially for those who treat the gastroduodenal region.

Swedish national guidelines for chronic pancreatitis

Chronic pancreatitis (CP) should be suspected in the case of recurrent upper abdominal pain of unknown origin and/or clinical signs of exocrine pancreatic insufficiency (EPI). Alcohol is the most common etiological factor associated with CP, others being smoking, male gender, and hereditary forms. CP is often associated with recurrent episodes of acute exacerbations.As of today, there is no accepted clinical definition of CP. However, irreversible morphological changes within the pancreas often occur, including dilatation of the main and branch pancreatic ducts, calcifications in ducts and parenchyma, parenchymal atrophy, and development of pseudocysts, though less so in the early phase of CP.

Current State of Imaging of Pediatric Pancreatitis: AJR Expert Panel Narrative Review

Pancreatitis is as common in children as it is in adults, though causes and accepted imaging strategies differ in children. In this narrative review we discuss the epidemiology of childhood pancreatitis and key imaging features for pediatric acute, acute recurrent, and chronic pancreatitis. We rely heavily on our collective experience in discussing advantages and disadvantages of different imaging modalities; practical tips for optimization of ultrasound, CT, and MRI with MRCP in children; and image interpretation pearls. Challenges and considerations unique to imaging pediatric pancreatitis are discussed, including timing of imaging, role of secretin-enhanced MRCP, utility of urgent MRI, severity prediction, autoimmune pancreatitis, and best methods for serial imaging. We suggest a methodical approach to pancreatic MRI interpretation in children and have included a sample structured report, and we provide consensus statements according to our experience imaging children with pancreatitis.

North American Society for Pediatric Gastroenterology, Hepatology and Nutrition and the Society for Pediatric Radiology Joint Position Paper on Noninvasive Imaging of Pediatric Pancreatitis: Literature Summary and Recommendations

ABSTRACT

The reported incidence of pediatric pancreatitis is increasing. Noninvasive imaging, including ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI), play important roles in the diagnosis, staging, follow-up, and management of pancreatitis in children. In this position paper, generated by members of the Pancreas Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the Abdominal Imaging Committee of The Society for Pediatric Radiology (SPR), we review the roles of noninvasive imaging in pediatric acute, acute recurrent, and chronic pancreatitis. We discuss available evidence related to noninvasive imaging, highlighting evidence specific to pediatric populations, and we make joint recommendations for use of noninvasive imaging. Further, we highlight the need for research to define the performance and role of noninvasive imaging in pediatric pancreatitis.

Identification and management of pancreas divisum

Introduction: Pancreas divisum is the most common congenital malformation of the pancreas with the majority asymptomatic. The etiological role, pathogenesis, clinical significance and management of pancreas divisum in pancreatic disease has not been clearly defined and our understanding is yet to be fully elucidated.Areas covered: This review describes the role of pancreas divisum in the development of pancreatic disease and the ambiguity related to it. In our attempt to offer clarity, a comprehensive search on PubMed, Ovid, Embase and Cochrane Library from inception to May 2019 was undertaken using key words "pancreas divisum", "idiopathic recurrent acute pancreatitis" and "chronic pancreatitis".Expert opinion: Current research fails to define a clear association between pancreas divisum and pancreatic disease. Though debatable, several studies do suggest a pathological role of pancreas divisum in pancreatic disease and a benefit of minor papilla therapy in the setting of acute recurrent pancreatitis. Surgical and endoscopic therapeutic modalities have not been directly compared. With the current data available, it would be imprudent to advise a definitive line of management for pancreatic disease associated with pancreas divisum and should involve a comprehensive discussion with the individual patient to define expectations before embarking on any medical and/or interventional therapy.

Is MRCP necessary to diagnose pancreas divisum?

Background

The purpose of this study is to compare the performance of three-dimensional magnetic resonance cholangiopancreatography (3D-MRCP) with non-MRCP T2-weighted magnetic resonance imaging (MRI) sequences for diagnosis of pancreas divisum (PD).

Methods

This is a retrospective study of 342 consecutive patients with abdominal MRI including 3D-MRCP. 3D-MRCP was a coronal respiration-navigated T2-weighted sequence with 1.5 mm slice thickness. Non-MRCP T2-weighted sequences were (1) a coronal inversion recovery sequence (TIRM) with 6 mm slice thickness and (2) a transverse single shot turbo spin echo sequence (HASTE) with 4 mm slice thickness. For 3D-MRCP, TIRM, and HASTE, presence of PD and assessment of evaluability were determined in a randomized manner. A consensus read by two radiologists using 3D-MRCP, non-MRCP T2-weighted sequences, and other available imaging sequences served as reference standard for diagnosis of PD. Statistical analysis included performance analysis of 3D-MRCP, TIRM, and HASTE and testing for noninferiority of non-MRCP T2-weighted sequences compared with 3D-MRCP.

Results

Thirty-three of 342 patients (9.7%) were diagnosed with PD using the reference standard. Sensitivity/specificity of 3D-MRCP for detecting PD were 81.2%/69.7% (p < 0.001). Sensitivity/specificity of TIRM and HASTE were 92.5%/93.9 and 98.1%/97.0%, respectively (p < 0.001 each). Grouped sensitivity/specificity of non-MRCP T2-weighted sequences were 99.8%/91.0%. Non-MRCP T2-weighted sequences were non-inferior to 3D-MRCP alone for diagnosis of PD. 20.2, 7.3%, and 2.3% of 3D-MRCP, TIRM, and HASTE, respectively, were not evaluable due to motion artifacts or insufficient duct depiction.

Conclusions

Non-MRCP T2-weighted MRI sequences offer high performance for diagnosis of PD and are noninferior to 3D-MRCP alone.

Trial registration

Not applicable.

Pancreas divisum: a reemerging risk factor for pancreatic diseases

Pancreas divisum (PD) is the most common developmental anatomic variant of pancreatic duct. The attention towards the PD has grown significantly since there are reports that this condition may cause acute relapsing pancreatitis, chronic pancreatitis and chronic abdominal pain syndrome. Furthermore, over the years, there have been multiple reports of PD associated with different types of tumors. There is evidence that PD can be associated with pancreatic tumors (up to 12.5% of cases). The golden standard for diagnosing PD is endoscopic retrograde cholangiopancreatography, but since it is an invasive procedure magnetic resonance cholangiopancreatography with secretin is a good alternative. In case the patient is symptomatic, endoscopic or surgical treatment should be performed. This review describes the key points of the pathophysiology, diagnostic modalities, risks of pancreatitis and tumors, as well as treatment options of PD.

Magnetic iron oxide nanoparticles as novel and efficient tools for atherosclerosis diagnosis

Cardiovascular complications derivate from atherosclerosis are the main cause of death in western world. An early detection of vulnerable atherosclerotic plaques is primordial for a better care of patients suffering the pathology. In this context nanotechnology has emerged as a promising tool to achieve this goal. Nanoparticles based on magnetic iron oxide (MNPs) have been extensively studied in cardiovascular diseases diagnosis, as well as in the treatment and diagnostic of other pathologies. The present review aims to describe and analyze the most current literature regarding to this topic, offering the level of detail required to reproduce the experimental tasks providing a critical input of the latest available reports. The current diagnostic features are presented and compared, highlighting their advantages and disadvantages. Information on novel technology intended to this purpose is also recompiled and in deep analyzed. Special emphasis is placed in magnetic nanotechnology, remarking the possibility to assess selective and multifunctional systems to the early detection of artherosclerotic pathologies. Finally, in view of the state of the art, the future perspectives about the trends on MNPs in artherosclerorsis diagnostic and treatment have also been addressed.

The Value of Secretin-Enhanced MRCP in Patients With Recurrent Acute Pancreatitis

OBJECTIVE

The purpose of this study is to assess the additional value of secretin-enhanced MRCP over conventional (non-secretin-enhanced) MRCP in diagnosing disease in patients with recurrent acute pancreatitis.

MATERIALS AND METHODS

A retrospective review of a radiology database found 72 patients with recurrent acute pancreatitis who had secretin-enhanced MRCP and ERCP correlation within 3 months of each other between January 2007 and December 2011. Of these patients, 54 had no history of pancreatic tumor or surgery and underwent MRI more than 3 months after an episode of acute pancreatitis. In addition, 57 age- and sex-matched control subjects with secretin-enhanced MRCP and ERCP correlation and without a diagnosis of recurrent acute pancreatitis or chronic pancreatitis were enrolled as the control group. All studies were anonymized, and secretin-enhanced MRCP images (image set A) were separated from conventional 2D and 3D MRCP and T2-weighted images (image set B). Image sets A and B for each patient were assigned different and randomized case numbers. Two blinded reviewers independently assessed both image sets for ductal abnormalities and group A image sets for exocrine response to secretin.

RESULTS

There were statistically significantly more patients with recurrent acute pancreatitis with reduced exocrine function compared with patients in the control group (32% vs 9%; p < 0.01) on secretin-enhanced images. Patients with recurrent acute pancreatitis were more likely to have side branch dilation (p = 0.02; odds ratio, 3.6), but not divisum, compared with the control group. Secretin-enhanced images were superior to non-secretin-enhanced images for detecting ductal abnormalities in patients with recurrent acute pancreatitis, with higher sensitivity (76% vs 56%; p = 0.01) and AUC values (0.983 vs 0.760; p < 0.01).

CONCLUSION

Up to one-third of patients with recurrent acute pancreatitis showed exocrine functional abnormalities. Secretin-enhanced MRCP had a significantly higher yield for ductal abnormalities than did conventional MRI and should be part of the MRCP protocol for investigation of patients with recurrent acute pancreatitis.

Acute obstructive pancreatitis after pancreas-sparing total duodenectomy in a patient with pancreas divisum: a case report

Background

Pancreas-sparing total duodenectomy (PSTD) is an ideal recommended procedure for patients with multiple duodenal adenomas or early duodenal cancer. We herein report a rare but serious complication of PSTD.

Case presentation

A 20-year-old woman with duodenal adenocarcinoma underwent PSTD. On postoperative day one, she complained of severe abdominal pains. Her serum amylase and serum pancreatic amylase levels were extremely elevated (Amy, 1296 IU/L; P-Amy, 1273 IU/L). With contrast enhanced CT, acute obstructive pancreatitis with pancreas divisum due to the ligation of the dorsal pancreatic duct was highly suspected. An emergency operation was performed to relieve the pancreatic duct obstruction, and an additional anastomosis between the dorsal pancreatic duct and jejunum was performed. The patient’s postoperative course was mostly uneventful, and her discomfort improved immediately.

Conclusion

When we perform pancreas-sparing total duodenectomy, some form of pancreatography is necessary to exclude pancreas divisum.

The Accuracies of Diagnosing Pancreas Divisum by Magnetic Resonance Cholangiopancreatography and Endoscopic Ultrasound: A Systematic Review and Meta-analysis

Magnetic resonance cholangiopancreatography (MRCP), MRCP after secretin stimulation (S-MRCP) and endoscopic ultrasonography (EUS) are all selected to diagnose pancreas divisum. However, the accuracies of three diagnosis remain unclear. The aim is to address the diagnostic accuracies of MRCP, S-MRCP and EUS on pancreas divisum. We searched PubMed, MEDLINE and EMBASE databases from inception to January, 2015. Of the 536 citations retrieved, 16 studies were included. For MRCP diagnosis on pancreas divisum, the area under the hierarchical summary receiver-operating characteristic (HSROC) curve was 0.90 (95% confidence interval [CI] 0.87 to 0.92), and for S-MRCP and EUS, 0.99 (95% CI 0.97 to 0.99) and 0.97 (95% CI 0.96 to 0.98). Sensitivity and specificity for MRCP were 0.59 (95% CI 0.45 to 0.71) and 0.99 (95% CI 0.96 to 1.00); for S-MRCP, 0.83 (95% CI 0.66 to 0.92) and 0.99 (95% CI 0.96 to 1.00); for EUS, 0.85 (95% CI 0.67 to 0.94) and 0.97 (95% CI 0.90 to 0.99). Comprehensive comparison of three diagnostic techniques to pancreas divisum, S-MRCP was more reliable than MRCP and EUS on the effect of the diagnostic test.

Secretin-Stimulated Magnetic Resonance Imaging Assessment of the Benign Pancreatic Disorders: Systematic Review and Proposal for a Standardized Protocol

This systemic review summarizes the current literature and general consensus on secretin-stimulated magnetic resonance imaging (s-MRI) of the benign pancreatic disorders and discusses important aspects on how s-MRI is optimally performed. The aim is to provide an overview, for clinicians and radiologist, of the s-MRI protocols and the range of clinical applications. Furthermore, the review will summarize the criteria for evaluation of pancreatic morphology and function based on s-MRI.The literature search indentified 69 original articles and 15 reviews. Chronic pancreatitis was the disease that was most frequently assessed by s-MRI (33%), followed by acute pancreatitis (9%). Dynamic thick-slab 2-dimensional magnetic resonance cholangiopancreatography was the most used imaging sequence (86%). The diameter of the main pancreatic duct (75%) and pancreatic exocrine function based on visual grading of duodenal filling (67%) were the most evaluated pancreatic features. Sufficient similarities between studies were identified to propose the most agreeable standardized s-MRI protocol for morphological and functional assessment of the pancreas. In the future, more research and increased collaboration between centers is necessary to achieve more consensus and optimization of s-MRI protocols.

Endoscopic retrograde pancreatography: When should we do it?

Endoscopic retrograde pancreatography (ERP) is an accurate imaging modality in the diagnosis of pancreatobiliary diseases. However, its use has been substantially reduced due to the invasiveness of procedure, the risk of complications and the widespread availability of non-invasive cross-section imaging techniques (computed tomography, magnetic resonance imaging, and endoscopic ultrasound). Since the introduction of endoscopic sphincterotomy, ERP has transformed from diagnostic method to an almost exclusively therapeutic procedure. Pancreatic duct injection substantially increased the risk of post-ERP pancreatitis (1.6%-15.7%); therefore, according to international guidelines ERP is recommended only in cases where biliary intervention is required. However, the role of ERP in the management of pancreatic diseases is currently not clearly defined, but in some cases the filling of pancreatic duct may provide essential information complementing the results of non-invasive imaging techniques. The aim of this publication is to systematically summarize the literature dealing with the diagnostic yield of ERP. We would like to define the precise indications of ERP and overview a diagnostic protocol of pancreatic diseases depending on international guidelines and the opinion of Hungarian experts, because it may improve the diagnostic accuracy, minimize of burden of patients and reduce the risk of procedure related complications.

The utility of secretin-enhanced MRCP in diagnosing congenital anomalies

PURPOSE

To assess the additional value of secretin-enhanced MRCP (SMRCP) over conventional MRCP in diagnosing divisum.

METHODS

Retrospective HIPAA-compliant and IRB-approved review found 140 patients with SMRCP and ERCP correlation within 6 months of each other. All studies were anonymized and the SMRCP images (SMRCP image set) were separated from 2D and 3D MRCP and axial and coronal T2-weighted images (conventional MRI image set). Each image set on each patient was assigned different and randomized case numbers. Two reviewers (R1 and R2) independently reviewed the image sets for divisum vs. no divisum, complete divisum vs. incomplete divisum, and the certainty of diagnosis (1 = definitely certain, 2 = moderately certain, and 3 = unsure). ERCP findings were taken as gold standard.

RESULTS

There was no difference in age and gender between the divisum (n = 97, with 13 incomplete divisum) and no divisum (n = 43) groups. In diagnosing divisum anatomy, the sensitivity was higher for SMRCP compared to conventional MRI for R1 (84.5 vs. 72.2, p = 0.02) but not R2 (89.7 vs. 84.4, p = 0.25). The specificity was higher in SMRCP image set compared to conventional MRI (R1: 88.1 vs. 76.2, p = 0.01; R2: 81.4 vs. 65.1, p < 0.001). The mean area under ROC curve was higher for SMRCP image set (R1: 0.86 vs. 0.74, p = 0.01; R2: 0.87 vs. 0.74, p = 0.01). The certainty of diagnosis was higher in SMRCP image set compared to conventional MRI (p = 0.02 for both reviewers). SMRCP was not found to be superior in distinguishing incomplete from complete divisum. The main reasons for erroneous SMRCP diagnosis were the presence of an ansa loop in the main duct and ductal strictures due to chronic pancreatitis.

CONCLUSION

Even though the reviewers had more sequences (axial and coronal) to evaluate in the non-secretin image set, there was some improvement in diagnosing divisum with SMRCP.

Evaluating Adults With Idiopathic Pancreatitis for Genetic Predisposition: Higher Prevalence of Abnormal Results With Use of Complete Gene Sequencing

OBJECTIVES

In adults with unexplained pancreatitis, the yield of complete gene versus select exosome sequencing on mutation detection and distinguishing clinical characteristics associated with mutations requires clarification. We sought to (1) compare frequency of mutations identified using different techniques and (2) compare clinical characteristics between adults with and without mutations.

METHODS

This is a cohort study of adults with unexplained pancreatitis who underwent genetic testing between January 2008 and December 2012. We compare probabilities of having a positive mutation with complete gene sequencing versus alternatives and describe differences in characteristics among patients with and without mutations.

RESULTS

Of the 370 patients, 67 (18%) had a genetic mutation; 24 (6%) were of high risk. Mutations were significantly more prevalent with use of complete sequencing (42%) versus other approaches (8%, P < 0.0001). Most (44/67, 66%) with a mutation had no family history. Those with high-risk mutations were more likely to have a family history of chronic pancreatitis (21% vs 4%, P = 0.002). Patients with pancreas divisum were more likely to have mutations (27% vs 14%, P = 0.0007).

CONCLUSION

Among individuals with adult-onset pancreatic disease, the probability of finding any mutation, including high risk, is significantly higher using complete gene sequencing. The impact on patients and providers requires further investigation.

Anatomic variants of the pancreatic duct and their clinical relevance: an MR-guided study in the general population

OBJECTIVES

To investigate the frequency of pancreatic duct (PD) variants and their effect on pancreatic exocrine function in a population-based study using non-invasive secretin-stimulated magnetic resonance cholangiopancreatography (sMRCP).

METHODS

Nine hundred and ninety-five volunteers, 457 women and 538 men, aged 51.9 ± 13.4 years, underwent navigator-triggered, T2-weighted, 3D turbo spin echo MRCP on a 1.5 T system after 1 unit/kg secretin administration. Two readers evaluated images for PD variants. Pancreatic exocrine function and morphological signs of chronic pancreatitis such as abnormalities of the main PD, side branch dilatation, and pancreatic cysts were evaluated and related to PD variants using a Kruskal-Wallis test and post hoc analysis.

RESULTS

Of all sMRCP, 93.2% were of diagnostic quality. Interobserver reliability for detection of PD variants was found to be kappa 0.752 (95 %CI, 0.733 - 0.771). Normal PD variants were observed in 90.4% (n = 838/927). Variants of pancreas divisum was identified in 9.6% (n = 89/927). Abnormalities of the main PD, side branch dilatation, and pancreatic cysts were observed in 2.4%, 16.6%, and 27.7%, respectively, and were not significantly different between pancreas divisum and non-divisum group (P = 0.122; P = 0.152; P = 0.741). There was no association between PD variants and pancreatic exocrine function (P = 0.367).

CONCLUSION

PD variants including pancreas divisum are not associated with morphological signs of chronic pancreatitis or restriction of pancreatic exocrine function.

KEY POINTS

MRCP allows the evaluation of pancreatic duct variants and morphological change. Pancreatic duct variants are not associated with morphological signs of chronic pancreatitis. Pancreas divisum is not accompanied by restriction of pancreatic exocrine function. Pancreatic duct variants including pancreas divisum are limited in their clinical relevance.

Administration of secretin (RG1068) increases the sensitivity of detection of duct abnormalities by magnetic resonance cholangiopancreatography in patients with pancreatitis

BACKGROUND & AIMS

Administration of secretin improves noninvasive imaging of the pancreatic duct with magnetic resonance cholangiopancreatography (MRCP). We performed a large prospective study to investigate whether synthetic human secretin (RG1068)-stimulated MRCP detects pancreatic duct abnormalities with higher levels of sensitivity than MRCP.

METHODS

We performed a phase 3, multicenter, baseline-controlled study of patients with acute or acute recurrent pancreatitis who were scheduled to undergo endoscopic retrograde cholangiopancreatography (ERCP) between March 26, 2008, and October 28, 2009. Patients underwent a baseline MRCP that was immediately followed by administration of RG1068 and repeat MRCP and then underwent ERCP within 30 days; they were followed up for 30 days. MRCP and ERCP images were read centrally by 3 radiologists and 2 endoscopists, respectively, who were all independent and blinded; pancreatic duct abnormalities were evaluated. The accuracy of MRCP was evaluated using ERCP as the standard.

RESULTS

In total, 258 patients were enrolled in the study; 251 MRCP image sets were assessed, and 236 patients had evaluable ERCPs. Pancreatic duct abnormalities were observed in 60.2% of ERCP images. All radiologists identified duct abnormalities in RG1068-ciné MRCP image sets with significantly higher levels of sensitivity (P < .0001) than in images from MRCP, with minimal loss of specificity. Adverse events were reported in 38.0% of patients after MRCP and 68.1% after ERCP. Of the 55 patients who experienced a serious adverse event, 3 (1.2%) and 52 (20.5%) of the events were reported to be temporally associated with MRCP and ERCP, respectively. The adverse events most frequently considered related to RG1068 were nausea, abdominal pain, and flushing; most were mild.

CONCLUSIONS

Compared with images from MRCP, those from RG1068-stimulated MRCP are improved in many aspects and could aid in diagnosis and clinical decision making for patients with acute, acute recurrent, or chronic pancreatitis. RG1068-enhanced MRCP might also better identify patients in need of therapeutic ERCP (ClinicalTrials.gov, Number: NCT00660335).

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.

Magnetic resonance cholangiopancreatography in the diagnosis of pancreas divisum: a systematic review and meta-analysis

OBJECTIVE

This study aimed to perform a structured meta-analysis of all eligible studies to assess the overall diagnostic use of magnetic resonance cholangiopancreatography (MRCP) alone or with secretin enhancement (secretin-enhanced MRCP [S-MRCP]) in the detection of pancreas divisum.

METHODS

Two authors independently performed a comprehensive search of PubMed, MEDLINE, and the Cochrane Library from inception to September 2013. Studies were included if they allowed construction of 2 × 2 contingency tables of MRCP and/or S-MRCP compared with criterion standard. DerSimonian-Laird random effect models were used to estimate the pooled sensitivity, specificity, specificity, and quantitative receiver operating characteristics.

RESULTS

Of 51 citations, 10 studies with 1474 patients were included. Secretin-enhanced MRCP had a higher overall diagnostic performance than MRCP (S-MRCP: pooled sensitivity, 86% [95% confidence interval (CI), 77%-93%]; specificity, 97% [95% CI, 94%-99%]; and area under the curve, 0.93 ± 0.056 compared with MRCP: sensitivity, 52% [95% CI, 45%-59%]; specificity, 97% [95% CI, 94%-99%]; and area under the curve, 0.76 ± 0.104). Pooled diagnostic odds ratios were 72.19 (95% CI, 5.66-938.8) and 23.39 (95% CI, 7.93-69.02) for S-MRCP and MRCP, respectively. Visual inspection of the funnel plot showed low potential for publication bias.

CONCLUSIONS

Secretin-enhanced MRCP has a much higher diagnostic accuracy than MRCP and should be preferred for diagnosis of pancreas divisum.

Secretin-enhanced MR cholangiopancreatography: spectrum of findings

Magnetic resonance cholangiopancreatography (MRCP) is the most effective, safe, noninvasive magnetic resonance (MR) imaging technique for the evaluation of the pancreaticobiliary ductal system. The MRCP imaging technique has substantially improved during the past 2 decades and is based mainly on the acquisition of heavily T2-weighted MR images, with variants of fast spin-echo sequences. MRCP can also be performed by utilizing the hormone secretin, which stimulates a normal pancreas to secrete a significant amount of fluid while transiently increasing the tone of the sphincter of Oddi. The transient increase in the diameter of the pancreatic duct improves the depiction of the ductal anatomy, which can be useful in patients in whom detailed evaluation of the pancreatic duct is most desired because of a suspicion of pancreatic disease. Improved depiction of the ductal anatomy can be important in (a) the differentiation of side-branch intraductal papillary mucinous neoplasms from other cystic neoplasms and (b) the diagnosis and classification of chronic pancreatitis, the disconnected pancreatic duct syndrome, and ductal anomalies such as anomalous pancreaticobiliary junction and pancreas divisum. In patients examined after pancreatectomy, stimulation with secretin can give information about the patency of the pancreaticoenteric anastomosis. Duodenal filling during the secretin-enhanced phase of the MRCP examination can be used to estimate the excretory reserve of the pancreas. Secretin is well tolerated, and complications are rarely seen. Secretin-enhanced MRCP is most useful in (a) the evaluation of acute and chronic pancreatitis, congenital variants of the pancreaticoduodenal junction, and intraductal papillary mucinous neoplasms and (b) follow-up of patients after pancreatectomy.

Update to the management of pediatric acute pancreatitis: highlighting areas in need of research

Acute pancreatitis is an emerging problem in pediatrics, with an incidence that is rising in the last 2 decades. Data regarding the optimal management and physician practice patterns are lacking. We present a literature review and updates on the management of pediatric pancreatitis. Prospective multicenter studies defining optimal management of pediatric pancreatitis are needed to guide care and improve outcomes for this patient population.

Pancreatic retention cyst: multi-modality imaging findings and review of the literature

PURPOSE

To investigate the multi-modality imaging presentation of the pancreatic retention cyst (PRC) with pathologic correlation.

METHODS

Imaging data including CT, MRI, endoscopic ultrasonography (EUS) and EUS guided fine needle aspiration (EUS-FNA), and endoscopic retrograde cholangiopancreatography (ERCP) in fifteen patients (five males and ten females; mean age, 44.5 years) with pathologically proven PRC were analyzed retrospectively, and imaging features were correlated with pathological findings.

RESULTS

Sixteen PRCs of 15 patients were included in this study. The mean size of PRCs was 4.4 × 4.6 cm (range 0.5 × 0.6-8.1 × 10.1 cm). PRC were round (n = 11), oval (n = 2), or lobular (n = 3). Punctiform calcification of the wall on CT (n = 2), thin septa (n = 4), thin wall (n = 3), and dilation of upstream pancreatic duct (n = 6; mean diameter, 4.3 mm) were detected. Dilation of upstream pancreatic duct was smooth in five PRCs and irregular in one PRC with pancreatic duct with punctiform calcification. Communication of PRCs with pancreatic duct was seen in two patients (one on CT, one on ERCP). Pancreatic inflammation and neoplasm were detected in four and two patients, respectively.

CONCLUSIONS

PRC typically presents as a well-defined, round cystic lesion, and different associated pathologic conditions including pancreatic inflammation and neoplasm may be detected in some patients on the multi-modality imaging examinations. Smooth dilation of upstream pancreatic duct with uncommon communication to the cyst may be helpful for the differentiation. Combination of a variety of imaging modalities could contribute to improve the diagnosis.

Endoscopic approach to the diagnosis and treatment of pancreatic disease

PURPOSE OF REVIEW

The purpose of this review is to examine the recent developments in the use of endoscopic retrograde cholangio-pancreatography (ERCP) and endoscopic ultrasound (EUS) in the management of patients with pancreatic-biliary disease.

RECENT FINDINGS

The use of ERCP to guide selective placement of pancreatic sphincterotomes, stone extraction balloons, and stents enables clinicians to treat pancreatic sphincteric and ductal disorders. Pancreatic stones are a remediable cause of recurrent pancreatitis and small calculi can be easily removed. The gold standard for the diagnosis of pancreas divisum remains ERCP and sphincterotomy is highly effective in the treatment of relapsing pancreatitis. Intraductal papillary mucinous neoplasms are the most common pancreatic malignancy and ERCP, as well as EUS can identify and sample the solid and cystic lesions. Mural nodules can be detected and sampled effectively by EUS-fine needle aspiration (FNA). The sensitivity of EUS-FNA for pancreatic adenocarcinoma is excellent (more than 85%). Although cyst fluid carcinoembryonic antigen is a very good marker for the presence of a mucinous cystic lesion, it is not an indicator of malignancy.

SUMMARY

In summary, ERCP and EUS are important tools for the management of benign and malignant lesions of the pancreas.

Magnetic resonance imaging of the pediatric pancreaticobiliary system

Magnetic resonance cholangiopancreatography (MRCP) is an extremely useful tool for evaluating a wide variety of disorders affecting the pancreaticobiliary system in neonates/infants, children, and adolescents. This imaging technique has numerous distinct advantages over alternative diagnostic modalities, such as endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography, including its noninvasive nature and lack of ionizing radiation. Such advantages make MRCP the preferred first-line method for advanced imaging the pediatric pancreaticobiliary tree, after ultrasonography. This article presents a contemporary review of the use of MRCP in the pediatric population, including techniques, indications, and the imaging appearances of common and uncommon pediatric disorders.

Imaging and Treatment Features of Idiopathic Pancreatitis and Pancreas Divisum in a Young Man: A Case Report

Some patients with pancreas divisum (PD) develop symptoms of recurrent pancreatitis. This is probably caused by insufficient drainage of the pancreatic duct. Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive test reported to be highly accurate in diagnosing PD. Endoscopic minor papilla sphincterotomy is most effective in the treatment of patients with PD and pancreatic stones. We report a case of 17-year-old boy who has suffered from several abdominal pain attacks throughout his childhood without a specific diagnosis. Radiological findings after the first episode of pancreatitis were typical for PD and led to specific treatment and cure.

Sensitivity of endoscopic ultrasound, multidetector computed tomography, and magnetic resonance cholangiopancreatography in the diagnosis of pancreas divisum: a tertiary center experience

OBJECTIVES

There are limited data comparing imaging modalities in the diagnosis of pancreas divisum. We aimed to: (1) evaluate the sensitivity of endoscopic ultrasound (EUS), magnetic resonance cholangiopancreatography (MRCP), and multidetector computed tomography (MDCT) for pancreas divisum; and (2) assess interobserver agreement (IOA) among expert radiologists for detecting pancreas divisum on MDCT and MRCP.

METHODS

For this retrospective cohort study, we identified 45 consecutive patients with pancreaticobiliary symptoms and pancreas divisum established by endoscopic retrograde pancreatography who underwent EUS and cross-sectional imaging. The control group was composed of patients without pancreas divisum who underwent endoscopic retrograde pancreatography and cross-sectional imaging.

RESULTS

The sensitivity of EUS for pancreas divisum was 86.7%, significantly higher than the sensitivity reported in the medical records for MDCT (15.5%) or MRCP (60%) (P < 0.001 for each). On review by expert radiologists, the sensitivity of MDCT increased to 83.3% in cases where the pancreatic duct was visualized, with fair IOA (κ = 0.34). Expert review of MRCPs did not identify any additional cases of pancreas divisum; IOA was moderate (κ = 0.43).

CONCLUSIONS

Endoscopic ultrasound is a sensitive test for diagnosing pancreas divisum and is superior to MDCT and MRCP. Review of MDCT studies by expert radiologists substantially raises its sensitivity for pancreas divisum.

Diagnosis and therapy of pancreas divisum by ERCP: a single center experience

OBJECTIVE

The aim of this study was to determine the diagnosis and endoscopic management of pancreas divisum with results from long-term experience at our institution.

METHODS

A prospectively collected database of all patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) with the diagnosis of pancreas divisum at our institution from January 2001 to April 2010 was retrospectively analyzed.

RESULTS

A total of 45 patients were identified with pancreas divisum with 62 ERCP procedures. The major indication for ERCP included pancreatitis in 33 patients (73.3%), of whom 18 had idiopathic recurrent acute pancreatitis, 8 had recurrent pancreatic-type pain and 7 had chronic pancreatitis. The median size of the incision of sphincterotomy was 5 mm (range 3-8 mm). In all 37 patients (82.2%) underwent placement of stent into the dorsal pancreatic duct, with a median stent size of 5 Fr by 7 cm (range 3-10 Fr by 3-12 cm). The overall response rate was 75.8%.

CONCLUSIONS

The frequency of finding pancreas divisum during ERCP varies among institutions and is low compared with the autopsy series, given that many patients may remain asymptomatic or might not undergo ERCP even if the symptoms develop. Our study is the first to describe specific procedure-related details during therapeutic endoscopy for pancreas divisum.