Evidence-based clinical practice guidelines for chronic pancreatitis 2021

BACKGROUND

Chronic pancreatitis (CP) is defined according to the recently proposed mechanistic definition as a pathological fibro-inflammatory syndrome of the pancreas in individuals with genetic, environmental, and/or other risk factors who develop persistent pathological responses to parenchymal injury or stress.

METHODS

The clinical practice guidelines for CP in Japan were revised in 2021 based on the 2019 Japanese clinical diagnostic criteria for CP, which incorporate the concept of a pathogenic fibro-inflammatory syndrome in the pancreas. In this third edition, clinical questions are reclassified into clinical questions, background questions, and future research questions.

RESULTS

Based on analysis of newly accumulated evidence, the strength of evidence and recommendations for each clinical question is described in terms of treatment selection, lifestyle guidance, pain control, treatment of exocrine and endocrine insufficiency, and treatment of complications. A flowchart outlining indications, treatment selection, and policies for cases in which treatment is ineffective is provided. For pain control, pharmacological treatment and the indications and timing for endoscopic and surgical treatment have been updated in the revised edition.

CONCLUSIONS

These updated guidelines provide clinicians with useful information to assist in the diagnosis and treatment of CP.

Nationwide epidemiological survey of chronic pancreatitis in Japan: introduction and validation of the new Japanese diagnostic criteria 2019

OBJECTIVES

To provide updated clinico-epidemiological information on chronic pancreatitis (CP) in Japan.

METHODS

We conducted a two-stage nationwide epidemiological survey; the number of CP patients was estimated in the first-stage survey, and their clinical features were examined in the second-stage survey. We surveyed patients with CP who had visited hospitals in 2016 and were diagnosed according to the Japanese diagnostic criteria 2009 (DC2009). Furthermore, we validated the new Japanese diagnostic criteria (DC2019) in patients with early CP diagnosed according to DC2009.

RESULTS

The number of patients with definite/probable CP in 2016 was 56,520 (prevalence, 44.5 per 100,000 persons), and that of early CP was 4470 (prevalence, 3.5 per 100,000 persons). We obtained detailed clinical information of 2150 patients with definite/probable CP and 249 patients with early CP. Compared with the early CP cases, the definite/probable CP cases had higher proportions of male (4.8 vs. 1.3), alcohol-related etiology (72.0% vs. 45.8%), smoking history (69.6% vs. 41.0%), diabetes mellitus (42.3% vs. 19.3%), and past history of acute pancreatitis (AP) (50.4% vs. 22.1%). Among the patients with early CP diagnosed according to DC2009, 93 (37.3%) were diagnosed with early CP according to DC2019, but the diagnosis of the remaining 156 (62.7%) patients was downgraded. Alcohol-related etiology, smoking history, early disease onset, and past history of AP were associated with the maintenance of early CP diagnosis in DC2019.

CONCLUSION

We clarified the current status of CP in Japan. Further validation studies are warranted to clarify the diagnostic utility of DC2019.

Evaluation and Management of Suspected Early Chronic Pancreatitis (ECP)

PURPOSE OF REVIEW

Chronic pancreatitis in the advanced stages leads to significant health care utilization because of the associated complications. Early-stage diagnosis could prevent the development of these complications by appropriate management. In this article, we reviewed the recent evidence pertaining to the diagnosis and management of early chronic pancreatitis (ECP).

RECENT FINDINGS

The working group for the International Consensus Guidelines for Chronic Pancreatitis has published consensus-based statements to streamline the diagnosis of ECP. There is no international consensus on the definition and diagnosis of ECP. The Revised Japanese Diagnostic Criteria for ECP based on clinical features and endoscopic ultrasound findings have been proposed. Large prospective cohort studies are needed to develop and validate internationally acceptable diagnostic criteria. ECP is recognized as a distinct stage in the development and progression of CP. Consensus-based definitions and diagnostic criteria need to be developed.

Endoscopic Ultrasound-Guided Management of Chronic Pancreatitis

PURPOSE OF REVIEW

The purpose of this review is to discuss the role of endoscopic ultrasound (EUS) in the diagnosis and treatment of chronic pancreatitis (CP).

RECENT FINDINGS

EUS has evolved and become invaluable in diagnosing early CP with the use of elastography and contrast enhancement. Lumen-apposing metal stents have allowed for easier transmural drainage and necrosectomy for pancreatic pseudocyst and walled of necrosis. EUS-guided pancreatic duct drainage is being utilized for pancreatic duct complications including stenosis, stones, and duct disruptions that are not amendable to endoscopic retrograde cholangiopancreatography. EUS is an effective tool that assists with the diagnosis and treatment of CP. The technology continues to evolve allowing for diagnosis of CP in earlier stages, which enables more effective therapy. The development of new EUS-guided tools and techniques has improved the treatment of complications from CP.

Magnetic resonance cholangiopancreatography findings in early chronic pancreatitis diagnosed according to the Japanese Diagnostic Criteria

OBJECTIVES

It is important for diagnosing early chronic pancreatitis (CP), which may be improved by therapeutic intervention. We aimed to examine the pancreatic ductal changes on magnetic resonance cholangiopancreatography (MRCP) in patients with early CP defined by the Japanese Diagnostic Criteria.

METHODS

This retrospective study included patients suspected early CP and performed both endoscopic ultrasonography (EUS) and MRCP from January 2010 to August 2018. We assessed the diameter of the main pancreatic duct (MPD) and the number of irregularly dilated duct branches using MRCP imaging in early CP.

RESULTS

We enrolled 165 patients and 25 patients (15%) fulfilled the diagnostic criteria for early CP. Irregular dilatation of ≥ 3 duct branches on MRCP was more often observed in early CP compared to non-early CP (P = 0.004), although MPD diameter was comparable (2.06 mm in early CP vs. 1.96 in non-early CP, P = 0.698). The sensitivity and specificity were 45% and 74%, respectively. The prevalence of positive MRCP findings in patients with ≥ 2 positive EUS findings was higher than that in patients with 1 positive EUS finding (P = 0.08) and in patients without an EUS finding (P < 0.001). There was no difference in the average diameter of MPD.

CONCLUSION

Patients with early CP often exhibit alteration in duct branches and not in MPD in addition to parenchymal alteration. Both pancreatic parenchyma and duct branches might need to be evaluated by EUS and MRCP.

Comparison of Duodenal Mucosal Chromogranin-A Expression in Non-Alcoholic Fatty Pancreas Dyspeptic Patients with and without Endosonography-Diagnosed Early Chronic Pancreatitis: A Case Series Study

Nonalcoholic fatty pancreas (NAFP) is hypothetically related to progressive fibro-inflammation of the pancreas whose exocrine function is controlled by enteroendocrine cells (EEC). There is little evidence of pancreatic fibrosis in fatty pancreas and of whether there are quantitative differences for EEC. This study aimed to prove the coexistence of NAFP and pancreatic fibrosis or early chronic pancreatitis (ECP) using acoustic radiation force impulse (ARFI) and endosonography. Besides, the expression of duodenal mucosal chromogranin-A, a surrogate for EEC, was analyzed. Dyspeptic patients were surveyed at the digestive clinic and received abdominal sonography, endosonography, and serology tests. Cases with organic causes of dyspepsia were excluded. Pancreatic fibrosis was defined as an ARFI value ≥1.3 m/s. ECP was defined by at least 2 scores of the Japan Pancreas Society endosonographic criteria. During endosonography, 4 biopsy samples of mucosa in the duodenal first part were obtained for analysis of chromogranin-A expression by Western blot. Mucosal biopsy was also performed at the gastric antrum for surveillance of Helicobacter pylori. Between January and June 2018, a total of 24 patients with NAFP were enrolled among 48 candidates and divided into 2 groups based on whether they had pancreatic fibrosis or not. In the pancreatic fibrosis group (n = 11, pancreatic ARFI: 1.76 ± 0.34 m/s), there was a higher endosonographic criteria score (2.45 vs. 1.61, p = 0.002), increased expression of chromogranin-A (p = 0.001), and more severe fatty pancreas that was defined by pancreatic duct blurring on abdominal sonography (91 vs. 46%, p = 0.062) as compared to the non-pancreatic fibrosis group (n = 13, pancreatic ARFI: 1.11 ± 0.09 m/s). A total of 54 endosonographic abnormalities of ECP was present in these 24 patients in the head (52%), body (31%), and tail (17%), an anatomic pattern similar to pancreatic adenocarcinoma. In conclusion, among dyspeptic patients with NAFP, the duodenal mucosa chromogranin-A showed increased expression in those with pancreatic fibrosis and endosonography-diagnosed ECP.

The diagnostic value of Rosemont and Japanese diagnostic criteria for 'indeterminate', 'suggestive', 'possible' and 'early' chronic pancreatitis

BACKGROUND

Longitudinal data are lacking to support consensus criteria for diagnosing early chronic pancreatitis.

METHODS

Retrospective single centre study of the initial evidence for chronic pancreatitis (CP), with reassessment after follow-up (January 2003-November 2016).

RESULTS

807 patients were previously diagnosed with chronic pancreatitis. This diagnosis was rejected in 118 patients: 52 had another pathology altogether, the remaining 66 patients formed the study population. 38 patients with 'normal' imaging were reclassified as chronic abdominal pain syndrome (CAPS), and 28 patients had minimal change features of CP on EUS (MCEUS) but never progressed. Strict application of the Japanese diagnostic criteria would diagnose only two patients with early CP and eleven as possible CP. Patients were more likely to have MCEUS if the EUS was performed within 12 months of an attack of acute pancreatitis. 40 patients with MCEUS were identified, including an additional 12 who progressed to definite CP after a median of 30 (18.75-36.5) months. Those continuing to consume excess alcohol and/or continued smoking were significantly more likely to progress. Those who progressed were more likely to develop pancreatic exocrine insufficiency, require pancreatic surgery and had higher mortality.

CONCLUSION

There needs to be more stringent application of the systems used for diagnosing chronic pancreatitis with revision of the current terminology 'indeterminate', 'suggestive', 'possible', and 'early' chronic pancreatitis. All patients with MCEUS features of CP require ongoing clinical follow up of at least 30 months and all patients with these features should be strongly counselled regarding smoking cessation and abstinence from alcohol.