Diagnostic role of secretin-enhanced MRCP in patients with unsuccessful ERCP

Impact of age on the diagnostic performance of pancreatic ductal diameters in detecting chronic pancreatitis

PURPOSE

In the diagnosis of chronic pancreatitis (CP), definition of main pancreatic duct (MPD) dilation is challenging due to lack of commonly accepted normal values. This study assessed the diagnostic performance of MPD diameters to detect CP including the impact of age.

METHODS

274 patients with ERCP-verified CP and 262 healthy controls were included. All had magnetic resonance cholangiopancreatography (MRCP) with measurement of MPD diameters in the pancreatic head, body, and tail. CP disease stage was defined as patients with and without functional (exocrine and/or endocrine) impairment. Diagnostic performance of MPD diameter and corresponding cut-offs values to diagnose CP were determined, including an age-stratified analysis.

RESULTS

In healthy controls, an effect of age on MPD diameters was seen for the pancreatic head (P < 0.001), body (P = 0.006), and tail (P = 0.03). Patients with CP had increased MPD diameter compared to controls (all segments P < 0.001). Increased pancreatic head MPD diameter was seen in patients with functional pancreatic impairment compared to patients without (P = 0.03). The diagnostic performance of MPD diameter to detect CP was high (all segments ROC-AUC > 0.92). The optimal pancreatic MPD diameter cut-off values for diagnosing CP were: < 40 years: 2.0(head) and 1.8(body) mm; 40-60 years: 2.4(head) and 2.1(body) mm; > 60 years: 2.7(head) and 2.1(body) mm.

CONCLUSION

Age is an important factor when evaluating the diameter of the pancreatic ductal system. Our findings challenge the existing reported thresholds for defining an abnormal duct diameter and point at age-stratified assessments as an integrated part of future imaging-based diagnostic and grading systems for CP.

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.

Endoscopic characteristics and usefulness of endoscopic dilatation of anastomotic stricture following pancreaticojejunostomy: case series and a review of the literature

The incidence of pancreatitis induced by anastomotic stricture following pancreaticodigestive tract anastomosis as a late-onset adverse event has been reported to be 3% or lower, but some cases repeatedly relapse and are difficult to treat. Endoscopic identification and treatment of the anastomotic site are considered to be difficult, and only a small number of cases have been reported. We present three cases with recurrent pancreatitis induced by anastomotic stricture following pancreaticojejunostomy applied after pancreaticoduodenectomy. We successfully identified the anastomotic site and performed endoscopic dilatation of the anastomotic stricture, and pancreatitis has not recurred. We characterized endoscopic features of the anastomotic site, understanding of which is essential to identify the site, and investigated useful techniques to identify the site and perform cannulation for pancreatography. Furthermore, we showed the safety and usefulness of endoscopic dilatation for anastomotic stricture following pancreaticojejunostomy according to our three cases and a review of the literature.

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.

The physiological roles of secretin and its receptor

Secretin is secreted by S cells in the small intestine and affects the function of a number of organ systems. Secretin receptors (SR) are expressed in the basolateral domain of several cell types. In addition to regulating the secretion of a number of epithelia (e.g., in the pancreas and biliary epithelium in the liver), secretin exerts trophic effects in several cell types. In this article, we will provide a comprehensive review on the multiple roles of secretin and SR signaling in the regulation of epithelial functions in various organ systems with particular emphasis in the liver. We will discuss the role of secretin and its receptor in health and biliary disease pathogenesis. Finally, we propose future areas of research for the further evaluation of the secretin/secretin receptor axis in liver pathophysiology.

Role of secretin-enhanced magnetic resonance cholangiopancreatography in the evaluation of patients following pancreatojejunostomy

Objective:

This study was conducted to assess the role of secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP) in the evaluation of patients following pancreatico-jejunal anatomosis.

Materials and Methods:

S-MRCP studies (n = 83) performed at Brigham and Women's Hospital between 1/2005 and 7/2005 were retrospectively reviewed. Among these, there were 13 patients (10 females, 3 males; mean age = 45 years, range = 18-74 years) who were evaluated with S-MRCP following pancreatojejunal anatomosis. Single-shot fast spin-echo T2-weighted thick slab dynamic MRCP images obtained before and every minute (for 10 min) after IV injection of secretin (2 mcg/kg body weight of SecreFloTM IV over 1 min) were reviewed retrospectively and independently by 3 readers. Image analysis included measurement of the main pancreatic duct (MPD) diameter and subjective assessment of the grade of visualization of the MPD remnant. The amount of jejunal fluid and visualization of the pancreatico-jejunal anatomosis pre-and post-secretin were also documented. Direct correlation with endoscopic retrograde cholangiopancreatography (ERCP) finding was available in six of the 13 cases.

Results:

The MPD diameter and MPD remnant visualization improved post-secretin for 1/3 readers. The number of pancreatico-jejunal anastomoses and the amount of jejunal fillings pre-and post-secretin was seen to improve significantly for 1 of the 3 readers. For Reader 1, the mean MPD diameter in the body of the pancreas, on the pre-and post-secretin image, was 3.2 ± 1.3 mm and 3.8 ± 1.9 mm, respectively. There was no statistical difference in the values pre- and post-secretin in the MPD diameter (P = 0.07), MPD visualization (P = 0.16) and the number of pancreatico-jejunal anastomoses seen (P = 0.125 5/13 pre- and 9/13 post-secretin). Statistical significance was seen in the amount of jejunal filling (P = 0.01) after secretin. For Reader 2, the MPD diameter pre-and post-secretin was 4 ± 2 and 3.9 ± 2.1 mm, respectively (P = 0.89). The MPD visualization (P = 0.19) and degree of jejunal filling (P = 0.7) did not improve significantly. There were 3/13 pancreatico-jejunostomy anastomoses seen pre- and 8/13 seen post-secretin (P = 0.06). The values for Reader 3 reached a statistical significance for the measurement of MPD (P = 0.032). In addition, MPD visualization (P = 0.038), the number of anastomoses seen (P = 0.016) and jejunal filling (P = 0.006) were also significantly improved.

Conclusion:

The addition of intravenous secretin to an MRCP study in the evaluation of patients following pancreatojejunal anastomosis does not significantly impact the visualization of the pancreatic duct. However, secretin may improve the assessment of the pancreatico-jejunal anastomosis.

Magnetic resonance cholangiopancreatography reports in the evaluation of chronic pancreatitis: a need for quality improvement

BACKGROUND

Numerous publications from academic centers suggest that magnetic resonance cholangiopancreatography (MRCP) can diagnose early chronic pancreatitis (CP) and assess pancreatic secretory reserve/function. However, the rigorous composite interpretation methods and quantitative secretory dynamics reported in these studies are not routinely measured in clinical practice. Therefore, the utility of routine MRCP reports in the clinical setting is unknown.

STUDY DESIGN

Cross-sectional study of patients referred to a tertiary center who underwent both MRCP and endoscopic pancreas function testing (ePFT) for assessment of chronic pancreatitis and abdominal pain.

AIMS

To compare MRCP and sMRCP reports to a reference standard pancreas function test for diagnosis of chronic pancreatitis.

METHODS

Source population: patients seen within a pancreas clinic at a tertiary referral center. MRCP and sMRCP reports were reviewed to record pancreas duct (dilation, side-branch changes), parenchyma enhancement (T(1), T(2) signal) and physiologic response (duodenal filling, pancreas duct response) to secretin. ePFT was categorized based on previously published data (normal peak bicarbonate >80 mEq/l). Referent values were calculated for MRCP and sMRCP using secretin ePFT as gold standard.

RESULTS

A total of 69 patients were identified (mean age 43.5 +/- 12; 65.2% female). 28 (40.6%) patients had abnormal ePFT based on their peak bicarbonate level. The mean bicarbonate values in the abnormal PFT and normal PFT groups were 59 +/- 13.9 and 95.3 +/- 12.6 mEq/l, respectively. Peak bicarbonate decreased with severity of chronic pancreatitis on MRCP (p = 0.0016). There was fair agreement of MRCP and ePFT (kappa 0.335 [0.113, 0.557]). The pre-stimulation pancreas duct changes reported were found to be the only predictor of abnormal pancreas function (p = 0.002). The post-stimulation findings of duodenal filling (p = 0.47), T(2)enhancement (p = 0.21) or change in pancreas duct caliber (p = 0.3) reported did not improve MRCP agreement with ePFT. Overall diagnostic accuracy, sensitivity and specificity were 70, 85 and 46%, respectively, for MRCP reports using ePFT as the gold standard.

CONCLUSIONS

Pancreas ductal features described on routine MRCP reports correlate with abnormal pancreas function. Current MRCP reports should be standardized to include all radiologic information available in hopes of predicting early chronic pancreatitis.

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.

Surgical approaches to chronic pancreatitis

Chronic pancreatitis (CP), a benign, inflammatory process of the pancreas, can cause severe pain, diabetes mellitus, steatorrhoea, and weight loss and often leads to a significant reduction in the quality of life. In the past decade our knowledge of the pathophysiology of CP has increased together with the number and quality of treatment options available for this disease. In addition to pharmacological and endoscopic treatment modalities, surgical drainage and resection procedures have become increasingly important since they have the potential to provide superior long-term results in patients with CP. The classical and pylorus-preserving pancreaticoduodenectomy, once the standard operations for patients with CP, have been replaced by organ-sparing procedures like the duodenum preserving pancreatic head resection and its variants. The latter allow better preservation of the exocrine and endocrine pancreatic function, and provide adequate pain relieve and improvement in the quality of life of CP patients.

Prospective comparison of secretin-stimulated magnetic resonance cholangiopancreatography with manometry in the diagnosis of sphincter of Oddi dysfunction types II and III

BACKGROUND

In sphincter of Oddi dysfunction (SOD), sphincter of Oddi manometry (SOM) predicts the response to sphincterotomy, but is invasive and associated with complications.

AIM

To evaluate the role of secretin-stimulated magnetic resonance cholangiopancreatography (ss-MRCP) in predicting the results of SOM in patients with suspected type II or III SOD.

METHODS

MRCP was performed at baseline and at 1, 3, 5 and 7 min after intravenous secretin. SOD was diagnosed when the mean basal sphincter pressure at SOM was >40 mm Hg. Long-term outcome after SOM, with or without endoscopic sphincterotomy, was assessed using an 11-point (0-10) Likert scale.

RESULTS

Of 47 patients (male/female 9/38; mean age 46 years; range 27-69 years) referred for SOM, 27 (57%) had SOD and underwent biliary and/or pancreatic sphincterotomy. ss-MRCP was abnormal in 10/16 (63%) type II and 0/11 type III SOD cases. The diagnostic accuracy of ss-MRCP for SOD types II and III was 73% and 46%, respectively. During a mean follow-up of 31.6 (range 17-44) months, patients with normal SOM and SOD type II experienced a significant reduction in symptoms (mean Likert score 8 vs 4; p = 0.03, and 9 vs 1.6; p = 0.0002, respectively), whereas in patients with SOD type III, there was no improvement in pain scores. All patients with SOD and an abnormal ss-MRCP (n = 12) reported long-term symptom improvement (mean Likert score 9.2 v 1.2, p<0.001).

CONCLUSIONS

ss-MRCP is insensitive in predicting abnormal manometry in patients with suspected type III SOD, but is useful in selecting patients with suspected SOD II who are most likely to benefit from endotherapy.

Diagnóstico y estadificación del carcinoma de páncreas (I)

Carcinoma of the pancreas is a neoplasm with a poor prognosis that is diagnosed in the advanced stages in most patients. Given that surgical resection is the only potentially curative treatment for this disease, it is of the utmost importance to appropriately select the group of patients with initial stage pancreatic tumors that have not extended and can therefore be resected. Several different imaging techniques can be used for this purpose: ultrasonography (US), computed tomography (CT), magnetic resonance (MR), as well as the recent additions of endoscopic ultrasonography (EUS) and positron emission tomography (PET). Other techniques, such as laparoscopy and laparoscopic ultrasonography, also play a role in the diagnosis and staging of these patients. Continual technological developments in each of the above-mentioned techniques have led to reiterated updates in the scientific literature throughout the last two decades. This review aims to evaluate each of these techniques and present diagnostic algorithms reflected in the literature in order to achieve the greatest diagnostic accuracy in determining the extent of the disease so that unnecessary surgery can be avoided in cases not susceptible to resection.

Morphology of biliary tree displayed by endoscopic retrograde cholangiopancreatography in patients with pancreaticobiliary diseas

AIM: To explore the rule of pancreaticobiliary disease displayed by endoscopic retrograde cholangiapancreatography (ERCP).

METHODS: Retrospective analysis of 190 patients underwent ERCP from May 1 to August 30, 2004 was performed at Changhai hospital. Three contents including amorphology of the biliary tree, influential factors for dilated biliary tree and the correlations with pancreaticobiliary disease were studied.

RESULTS: Of the 190 patients, examination was not completed in 4 cases, and 38 were found without intact bile tree and 148 with intact one. All the 148 patients were classified into 7 groups: Normal bile tree was observed in 18 patients with chronic pancreatitis or without biliopancreatic disease; Hibernated bile tree was found in 15 patients with choledocholithiasis, in whom the mean values of common bile duct (CBD) and stones were 1.41 ± 0.25 and 0.69 ± 0.22 cm in diameter, respectively; Willow-like bile tree was found in 56 patients with choloedocholithiasis, in whom the mean values of CBD and stones were 1.69 ± 0.39 and 1.32 ± 0.44 cm in diameter, respectively; Sapless bile tree was found in 36 patients with choledocholithiasis, in whom the mean values of CBD and stones diameter were 1.80 ± 0.47 and 1.33 ± 0.46 cm in diameter, respectively; Vine-like bile tree was detected in 17 patients with endobiliary cholangiocarcinoma of CBD and carcinoma of pancreatic head, in whom the mean values of CBD diameter was 2.35 ± 0.62 cm; Irregular bile tree was in 6 patients without dominant disease.

CONCLUSION: The morphology of bile tree is associated with biliopancreatic disease and its features. The degrees of dilated CBD were resulted from the location and nature of the disease.

Systematic review: sphincter of Oddi dysfunction--non-invasive diagnostic methods and long-term outcome after endoscopic sphincterotomy

BACKGROUND

Sphincter of Oddi dysfunction is a benign, functional gastrointestinal disorder for which invasive endoscopic therapy with potential complications is often recommended.

AIMS

To review the available evidence regarding the diagnostic accuracy of non-invasive methods that have been used to establish the diagnosis and to estimate the long-term outcome after endoscopic sphincterotomy.

METHODS

A systematic review of English language articles and abstracts containing relevant terms was performed.

RESULTS

Non-invasive diagnostic methods are limited by their low sensitivity and specificity, especially in patients with Type III sphincter of Oddi dysfunction. Secretin-stimulated magnetic resonance cholangiopancreatography appears to be useful in excluding other potential causes of symptoms, and morphine-provocated hepatobiliary scintigraphy also warrants further study. Approximately 85%, 69% and 37%, of patients with biliary Types I, II and III sphincter of Oddi dysfunction, respectively, experience sustained benefit after endoscopic sphincterotomy. In pancreatic sphincter of Oddi dysfunction, approximately 75% of patients report symptomatic improvement after pancreatic sphincterotomy, but the studies have been non-controlled and heterogeneous.

CONCLUSIONS

Patients with suspected sphincter of Oddi dysfunction, particularly those with biliary Type III, should be carefully evaluated before considering sphincter of Oddi manometry and endoscopic sphincterotomy. Further controlled trials are needed to justify the invasive management of patients with biliary Type III and pancreatic sphincter of Oddi dysfunction.

Chronic pancreatitis

PURPOSE OF REVIEW

As in our previous reviews, we endeavor to review important new observations in chronic pancreatitis made in the past year. We included articles, including review articles, only if they contained new observations or readdressed old questions and provided new insights into old and new concepts.

RECENT FINDINGS

Important observations include the following: (1) Strong association between cystic fibrosis transmembrane regulator dysfunction/mutations and 'recurrent acute pancreatitis', particularly in patients with pancreas divisum (2) Pancreas divisum may be incidental finding in recurrent acute pancreatitis (3) Smoking increases risk of chronic pancreatitis (4) Coxsackie B virus may increase severity of alcoholic chronic pancreatitis (5) CD4+ T cells and an immune reaction against amylase may play a role in pathogenesis of autoimmune pancreatitis (6) 2-(18F)-Fluro-2-deoxy-D-glucose positron emission tomography might be useful to detect pancreatic cancer in chronic pancreatitis patients at risk for developing pancreatic cancer, but contrast-enhanced Doppler ultrasound or endosonography may be as sensitive and better than contrast enhanced computed tomography (7) Superiority of surgery vs endotherapy for long term pain relief and weight gain in painful chronic pancreatitis (8) Early treatment of pain and malabsorption may improve life quality (9) Antifibrogenesis and fibrolytic agents as potential therapies.

SUMMARY

Ongoing basic and clinical research this past year has further characterized genetic, molecular and clinical aspects of chronic pancreatitis. The advent of predictable and lasting treatments of chronic pancreatitis is most likely to appear on the wings of carefully conducted studies targeting genetic and molecular mechanisms of chronic pancreatitis, particularly pancreatic fibrogenesis.