Comparison of endoscopic retrograde cholangiopancreatography with MR cholangiopancreatography in patients with pancreatitis

Pancreas divisum in a young patient with chronic abdominal pain as per radiological findings: A case report

Key Clinical Message

Pancreas divisum (PD) can be one of the causes of unexplained chronic abdominal pain. In PD, the dominant duct drains the majority of the pancreas via the minor papilla, which can be conveyed in the imaging as crossing duct sign.

Abstract

We report a case a of 16-year-old man who presented with unexplained chronic abdominal pain. Contrast-enhanced computed tomography and magnetic resonance cholangiopancreatography showed a bulky pancreas, but his pancreatic enzymes were normal. The crossing duct sign was prominent in imaging, which confirmed the diagnosis of PD.

Mind the Gap-Disconnected Duct Syndrome: A Review of Current Diagnostic and Management Strategies

ABSTRACT

Disconnected duct syndrome (DDS) is an adverse sequela of acute necrotizing pancreatitis in which there is disruption of the pancreatic duct leading to a failure to deliver pancreatic secretions into the duodenum. Its presentation may range from a persistent external pancreatic fistula to a treatment-resistant pancreatic pseudocyst. The diagnosis is often delayed in the acute setting if there is concurrent necrosis as management is often directed to the associated peripancreatic fluid collection. A combination of imaging modalities may be required to evaluate ductal anatomy. No definitive consensus has been achieved regarding the optimal treatment strategy for DDS, and there is a lack of published level I evidence on the topic. Treatment should be tailored to each individual patient, depending on the anatomy of ductal disruption, the presence of sepsis, the degree of physiological derangement, and the patients' performance status. Patients with DDS represent a specific cohort of patients with complex pancreatic disease that requires the input from a diverse multidisciplinary team to ensure that a good clinical outcome can be achieved.

Approach to management of pancreatic strictures: the gastroenterologist's perspective

Pancreatic strictures represent a complex clinical problem which often requires multidisciplinary management with a team of gastroenterologists, surgeons and radiologists. Dominant strictures are largely due to inflammatory processes of the pancreas like chronic pancreatitis. However, differentiating benign from malignant processes of the pancreas, leading to strictures is imperative and remains a challenge. With advances in endoscopic management, options for therapy include endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound-guided pancreatic drainage (EUS-PD) in situations where ERCP is not feasible or fails. However, endoscopic therapy is suited for a select group of patients and surgery remains key to management in many patients. In this narrative review, we look at the gastroenterologist's perspective and approach to pancreatic ductal strictures, including endoscopic and surgical management.

[Pancreas divisum and pancreatitis]

CLINICAL/METHODOLOGICAL ISSUE

Diagnostic and clinical relevance of pancreas divisum.

STANDARD RADIOLOGICAL METHODS

Ultrasonography (US), magnetic resonance cholangiopancreatography (MRCP), magnetic resonance imaging (MRI), computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP).

PERFORMANCE

Pancreas divisum is an anatomic variation of pancreatic duct system with an incidence in general population of about 10%. It can become symptomatic in approximately 5% of patients. MRI with MRCP is the method of choice to diagnose pancreas divisum.

ACHIEVEMENTS

MRCP is equal to ERCP in diagnosing pancreas divisum in routine clinical practice as it is noninvasive, offers the possibility to evaluate the adjacent tissues and has almost no contraindications.

PRACTICAL RECOMMENDATIONS

It is important to be familiar with the anatomy of the pancreatic duct system in order to plan interventional procedures for symptomatic patients in due time.

Is Cambridge scoring in chronic pancreatitis the same using ERCP and MRCP?: A need for revision of standards

PURPOSE

Grading of chronic pancreatitis (CP) is a clinical and radiologic challenge. Retrograde cholangiopancreatography (ERCP) and magnetic resonance cholangiopancreatography (MRCP) use a version of the Cambridge criteria for ductal evaluation and CP staging, but interchangeability between the modalities lacks validation. This work compares ERCP and MRCP Cambridge scores and evaluates diagnostic performance of MRCP in a large cohort of patients with CP.

METHODS

A large radiology database was searched for CP patients who underwent MRCP between 2003 and 2013. Next, patients who also had an ERCP within 90 days of their MRCP were selected. These were categorized into mild, moderate, and severe CP using the standardized Cambridge classification for ERCP. Radiologists blinded to ERCP findings then rated MRCP with modified Cambridge scores.

RESULTS

The cohort comprised 325 patients (mean age 51 years; 56% female). By ERCP Cambridge classification, 122 had mild CP, 109 moderate CP, and 94 severe CP. MRCP and ERCP showed total agreement of Cambridge score in only 43% of cases. With ERCP as reference, the sensitivity and specificity of MRCP in detecting Cambridge scores 4 + 5 (main-duct predominant) were 75.9% and 64.3%, and for Cambridge score 3 (side-branch predominant) it was 60.0% and 76.9%, respectively.

CONCLUSIONS

There is a lack of strong concordance between ERCP- and MRCP-based grading of CP using the Cambridge criteria. MRCP had moderate to good performance in diagnosing side-branch predominant versus main-duct predominant CP. This suggests an inherent challenge in comparing literature and calls for a revision of the standards.

Low serum trypsinogen levels in chronic pancreatitis: Correlation with parenchymal loss, exocrine pancreatic insufficiency, and diabetes but not CT-based cambridge severity scores for fibrosis

BACKGROUND

Chronic pancreatitis (CP) is a complex inflammatory disorder of the pancreas affecting acinar cells, duct cells, islet cells and inflammatory cells including fibrosis-producing stellate cells. Serum trypsinogen is a biomarkers of acinar cell function.

AIM

To define the degree of correlation between low trypsinogen levels as a marker of acinar cell function and variable features of CP.

METHODS

Serum samples from previously ascertained and well phenotyped case and control subjects from the North American Pancreatitis Study II (NAPS2) were used to measure serum trypsinogen levels in a commercial laboratory. Control samples were used to define normal ranges and compared with levels in CP patients with defined features.

RESULTS

A final cohort of 279 CP patients and 262 controls from the NAPS2 studies were evaluated. In controls trypsinogen had a mean of 34.96 ng/ml and SD = 11.99. Cut-off values for low trypsinogen ranged from <20 to 10 ng/ml and very low trypsinogen at <10 ng/ml. Compared to controls, CP was associated with very low trypsinogen levels (p < 0.0001). Within CP, very low trypsinogen levels correlated with parenchymal loss (pancreatic surgery [p < 0.05]; atrophy with calcifications, [p < 0.001]), EPI (p < 0.01, trend p < 0.001) and diabetes (trend p < 0.01) but not CT-based criteria for fibrosis (pancreatic duct dilation, irregularity, strictures).

CONCLUSIONS

Very low serum trypsinogen levels correlate with measures of acinar cell loss including surgical resection, atrophic-calcific CP, diabetes and functional symptoms EPI but not duct morphology criteria. Serum trypsinogen levels correlate with decreased acinar cell function and therefore have biomarker utility clinical management.

Clinical importance of main pancreatic duct variants and possible correlation with pancreatic diseases

Background: Except for pancreas divisum (PD), the prevalence of anatomic variants of the main pancreatic duct (MPD) seems to be insufficiently investigated. To date, their role in the occurrence of pancreatic exocrine insufficiency (PEI) and morphological changes suggestive of chronic pancreatitis (CP) has remained unclear.Methods: A systematic review was performed, searching MEDLINE and Web of Science, limited to articles published between 1960 and 1 June 2019.Results: Our review included a total number of 3234 subjects. The most common variant of MPD was type 3, followed by type 1, indicating MPD drainage pattern into major papilla (MP) as the most frequent. A sub-variant of type 3, known as 'reverse pancreas divisum' had a prevalence of 2.2%. Type 4 variant- PD, was found in 6.4% of all cases. The most common sub-variant of PD was complete PD, followed by incomplete PD and variant with MPD as only pancreatic duct. Type 5 variant (including ansa pancreatica) was present in 2.9% of subjects. Apart from one study with a significantly higher frequency of morphological changes suggestive of CP in patients with ansa pancreatica, the studies stated no significant association between pancreatic disease and MPD variants. Furthermore, only one study examined the influence of MPD variants on exocrine pancreatic function. Although equivocal, this association is most likely found to be insignificant.Conclusion: To elucidate linkage between MPD variants and the occurrence of chronic pancreatitis and impairment of pancreatic exocrine function, further clinical investigations are warranted.

Inflammatory mimickers of pancreatic adenocarcinoma

Pancreatic ductal adenocarcinoma can be a difficult imaging diagnosis early in its course given its subtle imaging findings such as focal pancreatic duct dilatation, abrupt duct cut-off, and encasement of vasculature. A variety of pancreatitidies have imaging findings that mimic pancreatic ductal adenocarcinoma and lead to mass formation making diagnosis even more difficult on imaging alone. These conditions include acute focal pancreatitis, chronic pancreatitis, autoimmune pancreatitis, and paraduodenal ("groove") pancreatitis. This review will focus on imaging findings that can help differentiate these inflammatory processes from pancreatic ductal adenocarcinoma.

Diagnostic performance of magnetic resonance cholangiopancreatography (MRCP) versus endoscopic retrograde cholangiopancreatography (ERCP) in the pediatric population: a clinical effectiveness study

PURPOSE

To determine the diagnostic performance of magnetic resonance cholangiopancreatography (MRCP) for detecting biliary and pancreatic abnormalities in a pediatric population, using endoscopic retrograde cholangiopancreatography (ERCP) as the reference standard.

MATERIALS AND METHODS

Institutional review board approval with a waiver of informed consent was obtained for this retrospective investigation. Records from the Cincinnati Children's Hospital Medical Center, Division of Gastroenterology and Department of Radiology were used to identify patients aged ≤ 18 years who had undergone both ERCP and MRCP within a 4-week interval between January 2013 and May 2017. Biliary and pancreatic duct findings were documented for each modality to determine the diagnostic performance of MRCP (with 95% confidence intervals), using ERCP as the reference standard.

RESULTS

54 patients met inclusion criteria. Mean patient age at time of ERCP was 10.4 ± 4.9 years, and 25 (46%) were male. Mean interval between ERCP and MRCP was 11.2 ± 9.7 days. For detection of any abnormality (n = 99 ERCP findings), MRCP had a sensitivity of 76.8% (67.5-84.0%) and a positive predictive value (PPV) of 81.7% (72.7-88.3%). MRCP was 75.7% (59.9-86.6%) sensitive, with a PPV of 84.9% (69.1-93.4%) for biliary findings (n = 37) and 73.5% (59.7-83.8%) sensitive, with a PPV of 78.3% (64.4-87.7%) for pancreatic findings (n = 49). For pancreatobiliary abnormalities (n = 13), MRCP had a sensitivity of 92.3% (66.7-99.6%) and a PPV of 85.7% (60.1-97.5%).

CONCLUSION

In clinical practice, MRCP is moderately sensitive for biliary and pancreatic abnormalities, with false-negative and false-positive examinations being relatively common.

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.

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

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.

The clinical value of secretin-enhanced MRCP in the functional and morphological assessment of pancreatic diseases

Secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP) provides a non-invasive way, with which, to evaluate pancreatic duct (PD) anatomy and exocrine pancreatic function. S-MRCP can be added to the routine pancreas MR examination in equivocal cases. Moreover, it can detect subtle PD involvement, allowing diagnosis of early, rather than end-stage, pancreatic diseases. Although S-MRCP is a valuable non-invasive diagnostic method, it is only performed in a few centres due to relative high cost. Furthermore, less familiarity with its indications, the examination technique, and image interpretation also contribute to its limited use. Thus, the purpose of this article is to explain secretin's mechanism of action, the examination technique, the clinically relevant indications, the advantages, and limitations. Finally, we will focus on image analysis and its role in achieving an early and accurate diagnosis of specific pancreatic and PD diseases.

Role of enteral nutrition in pancreaticocolonic fistulas secondary to severe acute pancreatitis: A case report

RATIONALE

Pancreaticocolonic fistula (PCF) is an exceedingly rare complication of severe acute pancreatitis (SAP) and has primarily been treated surgically, but a few reported cases are successfully treated with nonsurgical methods.

PATIENT CONCERNS

A 32-year-old male presented to our hospital with chief complaints of sharp and persistent left upper quadrant abdominal pain radiating to the back.

DIAGNOSES

Computed tomography showed a pancreatic pseudocyst replacing a majority of the pancreatic parenchyma and PCF that formed between the pancreas and the colon. However, the final diagnosis of PCF was confirmed by drainage tube radiograph, which revealed extravasation of contrast from the tail of the pancreas into the colon.

INTERVENTIONS

A therapeutic strategy of enteral nutrition (EN) was applied.

OUTCOMES

The patient responded well to the treatment. No complication and recurrence were reported during 2-year follow-up.

LESSONS

This case highlights the role of EN in the treatment of PCF secondary to SAP. To the best of our knowledge, this is the first case of PCF that treated successfully with EN, rather than surgical or endoscopic intervention.

Secretin-stimulated MRI characterization of pancreatic morphology and function in patients with chronic pancreatitis

BACKGROUND/OBJECTIVES

Chronic pancreatitis (CP) is characterized by abnormal pancreatic morphology and impaired endocrine and exocrine function. However, little is known about the relationship between pancreatic morphology and function, and also the association with the etiology and clinical manifestations of CP. The aim was to explore pancreatic morphology and function with advanced MRI in patients with CP and healthy controls (HC) METHODS: Eighty-two patients with CP and 22 HC were enrolled in the study. Morphological imaging parameters included pancreatic main duct diameter, gland volume, fat signal fraction and apparent diffusion coefficient (ADC) values. Functional secretin-stimulated MRI (s-MRI) parameters included pancreatic secretion (bowel fluid volume) and changes in pancreatic ADC value before and after secretin stimulation. Patients were classified according to the modified Cambridge and M-ANNHEIM classification system and fecal elastase was collected.

RESULTS

All imaging parameters differentiated CP patients from HC; however, correlations between morphological and functional parameters in CP were weak. Patients with alcoholic and non-alcoholic etiology had comparable s-MRI findings. Fecal elastase was positively correlated to pancreatic gland volume (r = 0.68, P = 0.0016) and negatively correlated to Cambridge classification (r = -0.35, P < 0.001). Additionally, gland volume was negatively correlated to the duration of CP (r = -0.39, P < 0.001) and baseline ADC (r = -0.35, P = 0.027). When stratified by clinical stage (M-ANNHEIM), the pancreatic gland volume was significantly decreased in the severe stages of CP (P = 0.001).

CONCLUSIONS

S-MRI provides detailed information about pancreatic morphology and function and represents a promising non-invasive imaging method to characterize pancreatic pathophysiology and may enable monitoring of disease progression in patients with CP.

MRCP Versus ERCP in the Evaluation of Chronic Pancreatitis in Children: Which Is the Better Choice?

OBJECTIVES

To evaluate the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) in the detection of chronic pancreatitis (CP)-specific changes in the pediatric population.

METHODS

The study included 48 children with pancreatic disorders subjected to both endoscopic retrograde cholangiopancreatography (ERCP) and MRCP within a 1- to 4-month interval. The sensitivity, specificity, positive predictive value, and negative predictive value of MRCP in the detection of CP-specific changes were determined using ERCP as a diagnostic standard.

RESULTS

Diagnostic ERCP pancreatograms were obtained in 41 (85.4%) of 48 patients and diagnostic MRCP images in all 48 children. The sensitivity and positive predictive value of MRCP were 77.1% and 90%, respectively, and its specificity and negative predictive value amounted to 50% and 27.3%, respectively. The patients with consistent results of MRCP and ERCP (ie, true-positive and true-negative cases) and individuals with incompatible results of the tests (ie, false-positive and false-negative cases) differed in terms of their median age at MRCP (14.17 vs 10.33 years) and median CP stage according to the Cambridge Scale (4 vs 2).

CONCLUSIONS

Magnetic resonance cholangiopancreatography provides diagnostic information equivalent to ERCP in a large percentage of pediatric patients with CP and should be used as the imaging method of choice, especially if the likelihood of therapeutic intervention is low.

Pancreaticoureteral Fistula: A Rare Complication of Chronic Pancreatitis

Context:

Chronic pancreatitis is an inflammatory condition that may result in progressive parenchymal damage and fibrosis which can ultimately lead to destruction of pancreatic tissue. Fistulas to the pleura, peritoneum, pericardium, and peripancreatic organs may form as a complications of pancreatitis. This case report describes an exceedingly rare complication, pancreaticoureteral fistula (PUF). Only two additional cases of PUF have been reported. However, they evolved following traumatic injury to the ureter or pancreatic duct. No published reports describe PUF as a complication of pancreatitis.

Case Report:

A 69-year-old Hispanic female with a past medical history of cholecystectomy, pancreatic pseudocyst, and recurrent episodes of pancreatitis presented with severe, sharp, and constant abdominal pain. Upon imaging, a fistulous tract was visualized between the left renal pelvis (at the level of an upper pole calyx) and the pancreatic duct and a ureteral stent was placed to facilitate fistula closure. Following the procedure, the patient attained symptomatic relief and oral intake was resumed. A left retrograde pyelogram was repeated 2 months after the initial stent placement and demonstrating no evidence of a persistent fistulous tract.

Conclusion:

Due to PUF's unclear etiology and possible variance of presentation, it is important for physicians to keep this rare complication of pancreatitis in mind, especially, when evaluating a patient with recurrent pancreatitis, urinary symptoms and abnormal imaging within the urinary collecting system and pancreas.

Imaging of pancreas divisum by linear-array endoscopic ultrasonography

Pancreas divisum (PD) is the most common developmental anatomic variant of pancreatic duct. Endoscopic ultrasound (EUS) is often performed to evaluate idiopathic pancreatitis and has been shown to have high accuracy in diagnosis of PD. The different techniques to identify PD by linear EUS have been described differently by different authors. If EUS is done with a proper technique it can be a valuable tool in the diagnosis of PD. The anatomical and technical background of different signs has not been described so far. This article summarizes the different techniques of imaging of pancreatic duct in a suspected case of PD and gives a technical explanation of various signs. The common signs seen during evaluation of pancreatic duct in PD are stack sign of linear EUS, crossed duct sign on linear EUS, the dominant duct and ventral dorsal duct (VD) transition. Few other signs are described which include duct above duct, short ventral duct /absent ventral duct, separate opening of ducts with no communication, separate opening of ducts with filamentous communication, stacking of duct of Santorini and indirect signs like santorinecele. The principles of the sign have been explained on an anatomical basis and the techniques and the principles described in the review will be helpful in technical evaluation of PD during EUS.

Preoperative detection of small pancreatic carcinoma: value of adding diffusion-weighted imaging to conventional MR imaging for improving confidence level

PURPOSE

To evaluate the benefit of adding diffusion-weighted ( DW diffusion weighted ) imaging to conventional magnetic resonance (MR) imaging in the preoperative detection of small pancreatic adenocarcinoma (≤ 3.0 cm).

MATERIALS AND METHODS

The institutional review board approved this retrospective study and waived the requirement for informed consent. This study included 83 patients (56 men, 27 women) with surgically confirmed pancreatic adenocarcinoma of 3.0 cm or smaller and 12 patients (nine men, three women) with histologically proven focal pancreatitis who underwent gadoxetic acid-enhanced MR imaging and DW diffusion weighted imaging at 3.0 T. Two observers reviewed the two image sets, a conventional MR image set and a combined image set including DW diffusion weighted images, to evaluate tumor conspicuity using receiver operating characteristic curve analysis. Contrast ratios between the tumor and proximal or distal pancreas on T1- and T2-weighted images, arterial and portal phase images, and DW diffusion weighted images obtained with a b value of 800 sec/mm(2) were compared by using one-way analysis of variance or Kruskal-Wallis test.

RESULTS

On DW diffusion weighted images, all tumors but two were delineated as completely (32 of 83, 39%) or partially (49 of 83, 59%) hyperintense. Area under the receiver operating characteristic curve values for the two observers were 0.890 and 0.884 for the conventional image set and 0.976 and 0.978 for the combined image set (P = .01 and P = .04), respectively. In regard to tumor detection, the combined image set (98%, 81 of 83 [observer 1]; 96%, 80 of 83 [observer 2]) yielded better sensitivity than the conventional image set (75%, 62 of 83 [observer 1]; 76%, 63 of 83 [observer 2]) (P < .001). Contrast ratios of tumor to proximal or distal pancreas were significantly higher with DW diffusion weighted images than with other images (P < .001).

CONCLUSION

In preoperative evaluation of small pancreatic adenocarcinoma, the addition of DW diffusion weighted imaging to conventional MR imaging improves the sensitivity of cancer detection.

MR imaging of the pancreas

Magnetic resonance (MR) imaging of the pancreas is useful as both a problem-solving tool and an initial imaging examination of choice. With newer imaging sequences such as diffusion-weighted imaging, MR offers improved ability to detect and characterize lesions and identify and stage tumors and inflammation. MR cholangiopancreatography can be used to visualize the pancreatic and biliary ductal system. In this article, the use of MR to evaluate the pancreas, including recent advances, is reviewed and the normal appearance of the pancreas on different imaging sequences, as well as inflammatory diseases, congenital abnormalities, and neoplasms of the pancreas, are discussed.

Pancreatic duct patterns in acute pancreatitis: a MRI study

Objectives

To study the MRI findings of the pancreatic duct in patients with acute pancreatitis.

Materials and Methods

A total of 239 patients with acute pancreatitis and 125 controls were analyzed in this study. The severity of acute pancreatitis was graded using the MR severity index (MRSI) and the Acute Physiology And Chronic Healthy Evaluation II(APACHE II) scoring systems. The number of main pancreatic duct (MPD) segments visualized, and both MPD diameter and pancreatic duct disruption were noted and compared with the severity of acute pancreatitis.

Results

The frequency of MPD segment visualization in the control group was higher than that in the acute pancreatitis group (p<0.05). The number of MPD segments visualized was negatively correlated with the MRSI score (p<0.05) and the APACHE II score (p<0.05). There was no difference in the MPD diameter between the acute pancreatitis and control groups or among the patients with different severities of acute pancreatitis (p>0.05). The prevalence of pancreatic duct disruption was 7.9% in the acute pancreatitis group. The prevalences of pancreatic duct disruption were 4.8% and 15.3% in the mild and severe acute pancreatitis groups based on the APACHE II score, respectively, and were 0%, 5.7% and 43.5% in the mild, moderate and severe acute pancreatitis groups according the MRSI score, respectively. The prevalence of pancreatic duct disruption was correlated with the severity of acute pancreatitis based on the APACHE II score (p<0.05) and MRSI score (p<0.05).

Conclusion

The pancreatic duct in acute pancreatitis patients was of normal diameter. The number of MPD segments visualized and visible pancreatic duct disruption on MRI may be supplementary indicators for determining the severity of acute pancreatitis.

Bilateral pleural fluid caused by a pancreaticopleural fistula requiring surgical treatment

A 53-year-old man developed bilateral pleural effusion with respiratory failure. The amylase level in the pleural effusion was elevated. He had neither abdominal symptoms nor abdominal physical findings. Abdominal computed tomography (CT) also showed no abnormalities. Magnetic resonance cholangiopancreatography (MRCP) was non-diagnostic, but endoscopic retrograde cholangiopancreatography (ERCP) and subsequent CT showed a fistula connecting the pancreatic duct with the right pleural cavity. The pleural effusion was refractory to drug therapy, leading to the need for surgical intervention. The pathological findings revealed chronic pancreatitis without pseudocysts. The elevated pancreatic amylase in the pleural effusion offered an important clue to the correct diagnosis.

Optimizing management of pancreaticopleural fistulas

AIM: To evaluate the management of pancreaticopleural fistulas involving early endoscopic instrumentation of the pancreatic duct.

METHODS: Eight patients with a spontaneous pancreaticopleural fistula underwent endoscopic retrograde cholangiopancreatography (ERCP) with an intention to stent the site of a ductal disruption as the primary treatment. Imaging features and management were evaluated retrospectively and compared with outcome.

RESULTS: In one case, the stent bridged the site of a ductal disruption. The fistula in this patient closed within 3 wk. The main pancreatic duct in this case appeared normal, except for a leak located in the body of the pancreas. In another patient, the papilla of Vater could not be found and cannulation of the pancreatic duct failed. This patient underwent surgical treatment. In the remaining 6 cases, it was impossible to insert a stent into the main pancreatic duct properly so as to cover the site of leakage or traverse a stenosis situated downstream to the fistula. The placement of the stent failed because intraductal stones (n = 2) and ductal strictures (n = 2) precluded its passage or the stent was too short to reach the fistula located in the distal part of the pancreas (n = 2). In 3 out of these 6 patients, the pancreaticopleural fistula closed on further medical treatment. In these cases, the main pancreatic duct was normal or only mildly dilated, and there was a leakage at the body/tail of the pancreas. In one of these 3 patients, additional percutaneous drainage of the peripancreatic fluid collections allowed better control of the leakage and facilitated resolution of the fistula. The remaining 3 patients had a tight stenosis of the main pancreatic duct resistible to dilatation and the stent could not be inserted across the stenosis. Subsequent conservative treatment proved unsuccessful in these patients. After a failed therapeutic ERCP, 3 patients in our series developed superinfection of the pleural or peripancreatic fluid collections. Four out of 8 patients in our series required subsequent surgery due to a failed non-operative treatment. Distal pancreatectomy with splenectomy was performed in 3 cases. In one case, only external drainage of the pancreatic pseudocyst was done because of diffuse peripancreatic inflammatory infiltration precluding safe dissection. There were no perioperative mortalities. There was no recurrence of a pancreaticopleural fistula in any of the patients.

CONCLUSION: Optimal management of pancreaticopleural fistulas requires appropriate patient selection that should be based on the underlying pancreatic duct abnormalities.

A new variant of bile duct duplication with coexistence of distal cholangiocarcinoma

BACKGROUND

A 72-year-old hypertensive woman presented with a 2-month history of right upper quadrant abdominal pain. She had a 15-day history of jaundice, fever with chills and shivering, nausea, vomiting, weight loss and generalized pruritus.

INVESTIGATIONS

Physical examination, laboratory evaluation, transabdominal ultrasonography, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, brush cytology, laparotomy and histopathology.

DIAGNOSIS

Bile duct duplication with coexistence of distal cholangiocarcinoma.

MANAGEMENT

En bloc resection (including the duodenum, pancreatic head and adjacent lymph nodes), hepaticojejunostomy and pylorus-saving Whipple operation.

Role of fat-suppressed t1-weighted magnetic resonance imaging in predicting severity and prognosis of acute pancreatitis: an intraindividual comparison with multidetector computed tomography

OBJECTIVE

To determine the diagnostic value of magnetic resonance (MR) grading focusing on elevated signal on T1-weighted images in the prediction of severity and prognosis of acute pancreatitis as compared with the Balthazar computed tomography (CT) grading.

MATERIALS

Thirty-one patients with acute pancreatitis who underwent CT and MR imaging including fat-suppressed T1-weighted images within a 48-hour interval were included in this study. The severity of pancreatitis was evaluated by 2 observers using the Balthazar CT grading system and an MR grading system that is focused on an elevated signal on T1-weighted images. The MR grading was correlated with the CT grading, and each MR or CT grade was compared with patient outcome parameters, including the duration of hospitalization, local and systemic complications, and clinical outcome grading.

RESULTS

There was a significant correlation between CT and MR gradings for pancreatic or peripancreatic inflammation (r = 0.688, P < 0.01). However, for all of the outcome parameters and outcome grading, a stronger correlation was seen with the MR grading than with the CT grading. No significant correlation was found between CT grading and infected necrosis (r = 0.316, P = 0.083).

CONCLUSIONS

Magnetic resonance imaging including fat-suppressed T1-weighted images is more accurate to predict the severity and prognosis of acute pancreatitis in comparison with CT.

Clinical feasibility of Açai (Euterpe olerácea) pulp as an oral contrast agent for magnetic resonance cholangiopancreatography

BACKGROUND

We evaluate the effectiveness of the Amazonian fruit pulp from Euterpe olerácea (popularly named Açaí) as a negative oral contrast agent applied to clinical routine. The use of such contrasts is particularly important in magnetic resonance cholangiopancreatography (MRCP) to reduce overlapping.

MATERIALS AND METHODS

We administered Açaí pulp to 5 nonsymptomatic subjects and 35 patients submitted to unspecific abdominal MR imaging, intending to set up optimal protocol. In 8 MRCP examinations, contrast and image effects were assessed and graded blindly by 2 independent radiologists. Quantitative analysis was performed by Wilcoxon test as to verify the potential of the Açaí to eliminate overlap signal over the pancreaticobiliary tract. Adverse effects and subject tolerance were also addressed.

RESULTS

The Açaí pulp elicited a local brightness decrease in T2-weighted images. The depiction of gallbladder, common bile duct, ampulla of Vater, and pancreatic duct was markedly improved after Açaí ingestion because of the suppression of the overlapping from bowel loops and gastric content (P < 0.01). All patients considered Açaí palatable, and no side effect was registered.

CONCLUSIONS

The Açaí pulp can be used routinely in MRCP studies as a natural, safe, and inexpensive negative oral contrast agent with high efficacy and patient acceptance.

The effect of prior sphincterotomy on the secretin-stimulated magnetic resonance cholangiopancreatography (s-MRCP)

RATIONALE AND OBJECTIVES

A lack of pancreatic duct compliance and decreased duodenal filling on secretin-stimulated magnetic resonance cholangiopancreatography (s-MRCP) has been noted in patients with chronic pancreatitis. Whether endoscopic sphincterotomy can affect pancreatic duct compliance and duodenal filling on diagnostic s-MRCP is unknown.

MATERIALS AND METHODS

A retrospective review of patients referred to the authors' clinic from December 2006 to December 2007 was performed. Those patients with no evidence of chronic pancreatitis who underwent s-MRCP were studied. Findings on s-MRCP were analyzed, specifically noting change in pancreatic duct diameter size from baseline to maximum dilation and duodenal filling after secretin administration (0.2 microg/kg intravenous dose of human secretin).

RESULTS

Of the 34 patients studied, 12 underwent endoscopic sphincterotomy, and 22 had intact sphincters of Oddi. In the sphincterotomy group, there was a mean change of 0.2 cm (range, 0.0-0.4 cm), while in the nonsphincterotomy group, the mean change was 0.9 cm (range, 0.3-2.0 cm) after secretin administration. The difference was significant (P < .005).

CONCLUSION

Endoscopic sphincterotomy significantly decreases pancreatic duct dilation in response to secretin on s-MRCP. However, further studies are required to determine the effect sphincterotomy has on the amount of duodenal filling and the rate at which duodenal filling occurs.

Can MRCP replace ERCP for the diagnosis of autoimmune pancreatitis?

BACKGROUND

It is of utmost importance that autoimmune pancreatitis (AIP) be differentiated from pancreatic cancer. Irregular narrowing of the main pancreatic duct is a characteristic finding in AIP; it is useful for differentiating AIP from pancreatic cancer stenosis. This study evaluated the usefulness of magnetic resonance cholangiopancreatography (MRCP) for the diagnosis of AIP and assessed whether MRCP could replace endoscopic retrograde cholangiopancreatography (ERCP) for diagnosing AIP.

METHODS

The MRCP and ERCP findings of 20 AIP patients were compared.

RESULTS

On MRCP, the narrowed portion of the main pancreatic duct was not visualized, while the noninvolved segments of the pancreatic duct were visualized. The degree of upstream dilatation of the proximal main pancreatic duct was milder in AIP than in pancreatic cancer patients. In the skipped type, only skipped narrowed lesions were not visualized. After steroid therapy for AIP, the nonvisualized main pancreatic duct became visualized.

CONCLUSIONS

MRCP cannot replace ERCP for the diagnosis of AIP, since narrowing of the main pancreatic duct in AIP was not visualized on MRCP. MRCP findings of segmental or skipped nonvisualized main pancreatic duct accompanied by a less dilated upstream main pancreatic duct may suggest the presence of AIP. MRCP is useful for following AIP patients.

Morphine- and glucagon-augmented magnetic resonance cholangiopancreatography to evaluate living liver donors

The purpose of this study was to investigate the effectiveness of the combined use of intravenous morphine and intramuscular glucagon in improving magnetic resonance cholangiopancreatography (MRCP) image quality in donors for living-related liver transplantation. Sixteen healthy donor candidates underwent an MRCP study. Coronal, single-shot, fast spin-echo, heavily T2-weighted dynamic MRCP images were obtained before and 3 minutes after the intravenous administration of morphine HCl with a dose of 0.04 mg/kg. Thirty minutes after the injection of morphine, intramuscular glucagon was used. Another MRCP image of the same pulse sequence was generated 15 minutes after the injection of glucagon with a dose of 1 mg. The diameter, signal intensity, and number of branches of bile ducts in MRCP images taken immediately before and after the injection of morphine and after the injection of glucagon (plus delayed morphine effects) were compared and analyzed. In all 16 donor candidates, the diameters of the right and left hepatic ducts, common bile duct, and main pancreatic duct were significantly increased (P < 0.05) in the MRCP images taken 3 minutes after the injection of morphine and 15 minutes after the injection of glucagon (plus delayed morphine effects) in comparison with MRCP images taken before any drug administration. The qualitative grading scores of the signal intensity and order of branches of bile ducts revealed improvements in the MRCP images after the injection of glucagon (plus delayed morphine effects; P < 0.05). In conclusion, combining the intravenous administration of low-dose morphine and the intramuscular use of glucagon before MRCP examination improves the visualization of the nondilated biliary ductal anatomy, which is important for the preoperative biliary evaluation of donor candidates for living-related liver transplantation.

Duplication of the extrahepatic bile duct in association with choledocholithiasis as depicted by MDCT

We report here on an extremely rare case of duplicated extrahepatic bile ducts that was associated with choledocholithiasis, and this malady was visualized by employing the minimum intensity projection images with using multi-detector row CT. The presence of duplicated extrahepatic bile ducts with a proximal communication, and the ducts were joined distally and they subsequently formed a single common bile duct, has not been previously reported.

Pancreatitis and the role of US, MRCP and ERCP

Imaging plays a crucial role in the diagnosis of acute and chronic pancreatitis in children. Ultrasound (US) is the primary imaging modality. The US study can be improved by incorporating high resolution imaging, color Doppler, harmonic imaging and panorama view. Computer tomography (CT) is widely used for further evaluation. MR imaging in combination with MR cholangiopancreaticography (MRCP) is emerging as the modality of choice. It is non-invasive and radiation-free. It has high potential to replace endoscopic retrograde cholangiopancreaticography (ERCP), too. The latter is becoming more of an interventional tool. This review discusses the current status and comparative diagnostic potential of US, MRCP and ERCP.

Calibrated magnetic resonance hydrometry to quantify pancreatic juice: a preliminary study

PURPOSE

To investigate the effectiveness of the calibrated MR hydrometry (CMRH) method for accurately measuring pancreatic secretion.

MATERIALS AND METHODS

All studies were performed on a 1.5-T MR system using a fat-suppressed, single-shot half-Fourier fast spin-echo sequence with a standard body coil. A certain volume (20 mL) of saline solution was employed as an extrabody calibrator. The validity of the CMRH method was tested both in vitro and in vivo, and actual and calculated volumes were compared.

RESULTS

The in vitro study yielded a high correlation (r = 0.99; P < 0.0001) between the actual volume of saline solution in the imaging field and the calculated volume. In the in vivo study, for all volunteers, there was a very strong and significant positive correlation between the measured signal intensities or calculated volumes and actual volumes (correlation coefficient range: 0.94-0.99; P < 0.0001).

CONCLUSION

This preliminary study shows that CMRH is an effective tool to measure the amount of pancreatic fluid secretion.

Morphological and functional evaluation of the pancreatic duct with secretin-stimulated magnetic resonance cholangiopancreatography in alcoholic pancreatitis patients

OBJECTIVES

The aim of this investigation was to evaluate the pancreatographic findings and dynamics of pancreatic duct diameter, as determined by secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP), in patients with acute alcoholic pancreatitis or chronic alcoholic pancreatitis and in a control group.

METHODS

S-MRCP was performed in patients with acute alcoholic pancreatitis who did not manifest the functional and radiological (ultrasonography and computed tomography) criteria of chronic pancreatitis (n = 21), in patients with chronic alcoholic pancreatitis (n = 28) and in a control group (n = 16). The diameter of the main pancreatic duct (MPD) was monitored before secretin administration and at 3 and 10 min after secretin administration. Morphological features were also assessed before and after the administration of secretin.

RESULTS

All ductal diameters were significantly larger in chronic alcoholic pancreatitis (P < 0.0001). There were no differences in MPD caliber between patients with acute alcoholic pancreatitis and the control group. The percentage of variation between basal MPD diameter and at 3 min post-secretin administration was lower in patients with chronic (35.5%) pancreatitis than in those with acute alcoholic pancreatitis (52.3%) and the control group (52.5%). There were no significant differences between patients with acute alcoholic pancreatitis and the control group in terms of the frequency of visualization of side branches, ductal narrowing, intraluminal filling defects, and ductal irregularity. One patient with acute alcoholic pancreatitis presented ductal criteria of chronic pancreatitis following the administration of secretin.

CONCLUSIONS

The dynamics of MPD visualized on S-MRCP in patients with acute alcoholic pancreatitis is similar to that observed in the control group and different from that observed in patients with chronic alcoholic pancreatitis. There were no significant differences between patients with acute alcoholic pancreatitis and the control group in terms of morphological pancreatographic features.

Diffusion-weighted MRI of the pancreas: correlation with secretin endoscopic pancreatic function test (ePFT)

RATIONALE AND OBJECTIVES

To evaluate the correlation between apparent diffusion coefficient (ADC) values of the pancreas on diffusion-weighted imaging (DWI) and pancreatic exocrine function determined by HCO(3) concentration in the secretin endoscopic pancreatic function test (ePFT).

MATERIALS AND METHODS

Mean ADC values derived from 10 different points of the pancreatic gland on DWI were reviewed in 14 patients with normal (peak HCO(3) > or = 80 mEq/L) and 14 patients with abnormal (peak HCO(3) < 80 mEq/L) ePFT results. Magnetic resonance cholangiopancreatography (MRCP) images of the same patients were evaluated for the diagnosis of chronic pancreatitis. Correlation between ADC values and HCO(3) concentration as well as Cambridge scores in MRCP was performed using Spearman's correlation test.

RESULTS

Mean ADC value of the pancreas was 1.52 +/- 0.13 x 10(-3) mm(2)/s in patients with abnormal ePFT results and 1.78 +/- 0.07 x 10(-3) mm(2)/s in the normal group. There was a significant statistical difference between the ADC values of the pancreas in the two groups (P < .0001). There was also a statistically significant correlation between HCO(3) level and ADC value of the pancreas in the study patients (r = 0.771, P < .0001). Morphologic changes of the pancreas according to the Cambridge classification were also well correlated with the mean ADC values (r = -0.763, P < .0001).

CONCLUSIONS

Strong correlation between ADC value and pancreatic exocrine function as well as Cambridge score for chronic pancreatitis exists. Further studies are needed to determine the cut off ADC value for chronic pancreatitis.

Suspected chronic pancreatitis with normal MRCP: findings on MRI in correlation with secretin MRCP

PURPOSE

To review pancreatic MRI findings and their relationship with estimated pancreatic exocrine function on secretin-stimulated MR cholangiopancreatography (S-MRCP) in patients with clinically suspected chronic pancreatitis and normal baseline MRCP findings.

MATERIALS AND METHODS

MRI findings of 26 patients with normal pancreatic duct diameter and without side branch ectasia on MRCP were evaluated. A single radiologist assessed pancreatic size, pancreatic signal intensity ratio (SIR), and arterial enhancement ratio (A/V) at head, body, and tail of the pancreas on T(1)-weighted fat-suppressed and serial contrast-enhanced images at a single session. Combined findings were graded with a composite score. Serial S-MRCP was performed at the same session with standard MRI. Correlation and differences between MRI findings and associated grade of duodenal filling (DF) or the degree of pancreatic duct caliber change (PDC) were analyzed.

RESULTS

Seven patients revealed normal and 19 patients abnormal MRI findings. Significant correlation was present between the degree of DF and mean values of pancreatic size (r = 0.748), SIR (r = 0.610), A/V (r = 0.466), composite score (r = 0.833), and PDC (r = 0.554) separately. PDC correlated with SIR (r = 0.413) and composite score (r = 0.452), but not with A/V or pancreatic size. Significant differences were present between normal and abnormal DF grades in terms of mean values of associated findings of size (P = 0.001), SIR (P = 0.008), A/V (P = 0.019), and PDC (P = 0.001).

CONCLUSION

Patients with clinically suspected chronic pancreatitis and normal MRCP findings may have a spectrum of MRI findings that correlate with the estimated pancreatic exocrine insufficiency on S-MRCP with the increasing number of combined findings.

Early endoscopic retrograde cholangiopancreatography versus conservative management in acute biliary pancreatitis without cholangitis: a meta-analysis of randomized trials

BACKGROUND

Early endoscopic retrograde cholangiopancreatography (ERCP) should be performed in all patients with acute biliary pancreatitis (ABP) and coexisting acute cholangitis. In patients without cholangitis and predicted mild ABP it is generally accepted that early ERCP should not be performed. Nevertheless, there is a controversy regarding the role of early ERCP in the treatment of patients with predicted severe ABP without cholangitis. We reviewed randomized trials on early ERCP versus conservative management in patients with ABP without acute cholangitis.

METHODS

Relevant publications in 3 electronic databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials) were systematically reviewed and meta-analyzed.

RESULTS

Seven randomized trials on ERCP in acute pancreatitis were found, of which 3 including a total of 450 patients (230 in the invasive arm and 220 in the control arm) qualified for a meta-analysis according to predefined criteria. In all patients with ABP (predicted mild and severe), early ERCP was associated with a nonsignificant reduction in overall complications [risk ratio (RR) 0.76; 95% confidence interval (CI) 0.41-1.04; P = 0.38] and a nonsignificant increase in mortality (RR 1.13; 95% CI 0.23-5.63; P = 0.88). Subgroup analysis based on predicted severity did not affect these outcomes (overall complications: predicted mild: RR 0.86; 95% CI 0.62-1.19; P = 0.36; predicted severe: RR 0.82; 95% CI 0.32-2.10; P = 0.68; mortality: predicted mild: RR 1.90; 95% CI 0.25-14.55; P = 0.53; predicted severe: RR 1.28; 95% CI 0.20-8.06; P = 0.80).

CONCLUSION

In this meta-analysis, early ERCP in patients with predicted mild and predicted severe ABP without acute cholangitis did not lead to a significant reduction in the risk of overall complications and mortality.

Diagnosis and treatment of pancreatic pseudocysts in chronic pancreatitis

Pancreatic pseudocysts are a well-known complication of acute or chronic pancreatitis, with a higher incidence in the latter. Diagnosis is accomplished most often by computed tomographic scanning, by endoscopic retrograde cholangiopancreatography, or by ultrasound, and a rapid progress in the improvement of diagnostic tools enables detection with high sensitivity and specificity. Different strategies contribute to the treatment of pancreatic pseudocysts: endoscopic transpapillary or transmural drainage, percutaneous catheter drainage, or open surgery. The feasibility of endoscopic drainage is highly dependent on the anatomy and topography of the pseudocyst, but provides high success and low complication rates. Percutaneous drainage is used for infected pseudocysts. However, its usefulness in chronic pancreatitis-associated pseudocysts is questionable. Internal drainage and pseudocyst resection are frequently used as surgical approaches with a good overall outcome, but a somewhat higher morbidity and mortality compared with endoscopic intervention. We therefore conclude that pseudocyst treatment in chronic pancreatitis can be effectively achieved by both endoscopic and surgical means. This review entails publications referring to the classification of pancreatic pseudocysts, epidemiology, diagnostic tools, and therapeutic options for pancreatic pseudocysts. Only full articles were considered for the review. Based on a search in PubMed, the MeSH terms "pancreatic pseudocysts and classification," "diagnosis," and "endoscopic, percutaneous, and surgical treatment" were used either alone or in combination.

Diagnosis of mild chronic pancreatitis (Cambridge classification): Comparative study using secretin injection-magnetic resonance cholangiopancreatography and endoscopic retrograde pancreatography

AIM: To investigate the usefulness of secretin injection-MRCP for the diagnosis of mild chronic pancreatitis.

METHODS: Sixteen patients having mild chronic pancreatitis according to the Cambridge classification and 12 control subjects with no abnormal findings on the pancreatogram were examined for the diagnostic accuracy of secretin injection-MRCP regarding abnormal branch pancreatic ducts associated with mild chronic pancreatitis (Cambridge Classification), using endoscopic retrograde cholangiopancreatography (ERCP) for comparison.

RESULTS: The sensitivity and specificity for abnormal branch pancreatic ducts determined by two reviewers were respectively 55%-63% and 75%-83% in the head, 57%-64% and 82%-83% in the body, and 44%-44% and 72%-76% in the tail of the pancreas. The sensitivity and specificity for mild chronic pancreatitis were 56%-63% and 92%-92%, respectively. Interobserver agreement (κ statistics) concerning the diagnosis of an abnormal branch pancreatic duct and of mild chronic pancreatitis was good to excellent.

CONCLUSION: Secretin injection-MRCP might be useful for the diagnosis of mild chronic pancreatitis.

Chronic pancreatitis: ultrasound, computed tomography, and magnetic resonance imaging features

Chronic pancreatitis is a progressive, irreversible inflammatory and fibrosing disease of the pancreas with clinical manifestations of chronic abdominal pain, weight loss, and permanent pancreatic exocrine and endocrine insufficiency. In the United States, a long history of heavy alcohol consumption is the most common cause of chronic pancreatitis. This review discusses the different modalities such as computed tomography, transabdominal and endoscopic ultrasound, magnetic resonance imaging/magnetic resonance cholangiopancreatography, and endoscopic retrograde cholangiopancreatography available to image chronic pancreatitis, along with their advantages and limitations. In addition, topics such as groove pancreatitis and autoimmune pancreatitis are examined, along with a discussion of distinguishing chronic pancreatitis from pancreatic adenocarcinoma.

Endoscopic ultrasound and IL-8 in pancreatic juice to diagnose chronic pancreatitis

BACKGROUND/AIM

Pancreatic juice (PJ) [IL-8] has been proposed as a marker for pancreatic diseases. We compared the accuracy of PJ [IL-8] and endoscopic ultrasound (EUS) to diagnose chronic pancreatitis (CP).

METHODS

79 patients with symptoms suspicious for CP were enrolled. PJ emptied into the duodenum was collected during an upper endoscopy with IV secretin and [IL-8] was measured. CP was diagnosed when PJ [IL-8] was >20 pg/ml. CP was diagnosed at EUS when >or=4 of the 9 established criteria were present. CP was diagnosed by using composite gold standard: ERCP, histology, CT or MRI, and clinical follow-up (mean 20 months).

RESULTS

38 patients had CP, whereas 41 patients had no pancreatic disease. To diagnose CP, PJ [IL-8] was significantly less sensitive compared to EUS (47 vs. 71%), but equally accurate (71 vs. 80%) and specific (93 vs. 88%). By combining PJ [IL-8] and EUS, sensitivity and specificity significantly increased to 82% (either IL-8 or EUS positive) and 100% (both IL-8 and EUS positive).

CONCLUSIONS

Both PJ [IL-8] and EUS are accurate diagnostic modalities for CP. PJ collection can be performed at the time of EUS. PJ [IL-8] and EUS are complementary with higher sensitivity and specificity when used together.