American Pancreatic Association Practice Guidelines in Chronic Pancreatitis

Abstract

The diagnosis of chronic pancreatitis remains challenging in early stages of the disease. This report defines the diagnostic criteria useful in the assessment of patients with suspected and established chronic pancreatitis. All current diagnostic procedures are reviewed and evidence based statements are provided about their utility and limitations. Diagnostic criteria for chronic pancreatitis are classified as definitive, probable or insufficient evidence. A diagnostic (STEP-wise; S-survey, T-tomography, E-endoscopy and P-pancreas function testing) algorithm is proposed that proceeds from a non-invasive to a more invasive approach. This algorithm maximizes specificity (low false positive rate) in subjects with chronic abdominal pain and equivocal imaging changes. Futhermore, a nomenclature is suggested to further characterize patients with established chronic pancreatitis based on TIGAR-O (T-toxic, I-idiopathic, G-genetic, A- autoimmune, R-recurrent and O-obstructive) etiology, gland morphology (Cambridge criteria) and physiologic state (exocrine, endocrine function) for uniformity across future multi-center research collaborations. This guideline will serve as a baseline manuscript that will be modified as new evidence becomes available and our knowledge of chronic pancreatitis improves.

Good Agreement Between Transabdominal and Endoscopic Ultrasound of the Pancreas in Chronic Pancreatitis

“…4b) yielded diagnostic accuracies of US in weighted and unweighted scores for diagnosing CP as presented in ▶ Table 4. The cut-offs calculated by Youden-index in our study were different from those suggested by earlier EUS studies [1,2,19,20].…”

“…There was a trend for better accuracy in the weighted score, but the difference was not significant. The superiority of a weighted score has not been demonstrated in EUS [1,2,20]. From analysis of the agreement for the single criteria, we identified calcifications as the most reliable criteria demonstrated by US.…”

Good Agreement Between Transabdominal and Endoscopic Ultrasound of the Pancreas in Chronic Pancreatitis

“…4b) yielded diagnostic accuracies of US in weighted and unweighted scores for diagnosing CP as presented in ▶ Table 4. The cut-offs calculated by Youden-index in our study were different from those suggested by earlier EUS studies [1,2,19,20].…”

“…There was a trend for better accuracy in the weighted score, but the difference was not significant. The superiority of a weighted score has not been demonstrated in EUS [1,2,20]. From analysis of the agreement for the single criteria, we identified calcifications as the most reliable criteria demonstrated by US.…”

A Bi-national Analysis of 252 Pancreatic Resections for Chronic Pancreatitis with Regard to Incidental Carcinoma Sequence and Overall Postoperative Outcome

“…The diagnosis of CP is usually confirmed by imaging technologies. From our observations, endosonography, computed tomography and magnetic resonance imaging were the preferred diagnostic modalities for assessing morphological abnormalities of the pancreas, which is in line with recommendations from recent guidelines (17). While ERCP has the highest diagnostic sensitivity of all imaging modalities for detection of CP, ERCP is an invasive technique, with the risk of procedure-associated complications, such as post-ERCP pancreatitis (10).…”

Diagnostic Accuracy of Transabdominal Ultrasound in Chronic Pancreatitis

“…The German clinical practice guideline for CP (Mayerle et al 2013) describes the specificity of US as good (70%-97%), whereas the method has pitfalls with respect to sensitivity (60%-81%). Reports evaluating transabdominal US of the pancreas in CP after the substantial improvement in US and imaging technology during the last two decades have been requested (Conwell et al 2014). Our results confirm that dedicated transabdominal US of the pancreas has good specificity under adequate scanning conditions and that the overall accuracy has improved compared with most of the existing studies.…”

Good Agreement Between Transabdominal and Endoscopic Ultrasound of the Pancreas in Chronic Pancreatitis

“…4b) yielded diagnostic accuracies of US in weighted and unweighted scores for diagnosing CP as presented in ▶ Table 4. The cut-offs calculated by Youden-index in our study were different from those suggested by earlier EUS studies [1,2,19,20].…”

“…There was a trend for better accuracy in the weighted score, but the difference was not significant. The superiority of a weighted score has not been demonstrated in EUS [1,2,20]. From analysis of the agreement for the single criteria, we identified calcifications as the most reliable criteria demonstrated by US.…”

A Bi-national Analysis of 252 Pancreatic Resections for Chronic Pancreatitis with Regard to Incidental Carcinoma Sequence and Overall Postoperative Outcome

“…The diagnosis of CP is usually confirmed by imaging technologies. From our observations, endosonography, computed tomography and magnetic resonance imaging were the preferred diagnostic modalities for assessing morphological abnormalities of the pancreas, which is in line with recommendations from recent guidelines (17). While ERCP has the highest diagnostic sensitivity of all imaging modalities for detection of CP, ERCP is an invasive technique, with the risk of procedure-associated complications, such as post-ERCP pancreatitis (10).…”

Diagnostic Accuracy of Transabdominal Ultrasound in Chronic Pancreatitis

“…The German clinical practice guideline for CP (Mayerle et al 2013) describes the specificity of US as good (70%-97%), whereas the method has pitfalls with respect to sensitivity (60%-81%). Reports evaluating transabdominal US of the pancreas in CP after the substantial improvement in US and imaging technology during the last two decades have been requested (Conwell et al 2014). Our results confirm that dedicated transabdominal US of the pancreas has good specificity under adequate scanning conditions and that the overall accuracy has improved compared with most of the existing studies.…”

Good Agreement Between Transabdominal and Endoscopic Ultrasound of the Pancreas in Chronic Pancreatitis

“…4b) yielded diagnostic accuracies of US in weighted and unweighted scores for diagnosing CP as presented in ▶ Table 4. The cut-offs calculated by Youden-index in our study were different from those suggested by earlier EUS studies [1,2,19,20].…”

“…There was a trend for better accuracy in the weighted score, but the difference was not significant. The superiority of a weighted score has not been demonstrated in EUS [1,2,20]. From analysis of the agreement for the single criteria, we identified calcifications as the most reliable criteria demonstrated by US.…”

A Bi-national Analysis of 252 Pancreatic Resections for Chronic Pancreatitis with Regard to Incidental Carcinoma Sequence and Overall Postoperative Outcome

“…The diagnosis of CP is usually confirmed by imaging technologies. From our observations, endosonography, computed tomography and magnetic resonance imaging were the preferred diagnostic modalities for assessing morphological abnormalities of the pancreas, which is in line with recommendations from recent guidelines (17). While ERCP has the highest diagnostic sensitivity of all imaging modalities for detection of CP, ERCP is an invasive technique, with the risk of procedure-associated complications, such as post-ERCP pancreatitis (10).…”

Diagnostic Accuracy of Transabdominal Ultrasound in Chronic Pancreatitis

“…The German clinical practice guideline for CP (Mayerle et al 2013) describes the specificity of US as good (70%-97%), whereas the method has pitfalls with respect to sensitivity (60%-81%). Reports evaluating transabdominal US of the pancreas in CP after the substantial improvement in US and imaging technology during the last two decades have been requested (Conwell et al 2014). Our results confirm that dedicated transabdominal US of the pancreas has good specificity under adequate scanning conditions and that the overall accuracy has improved compared with most of the existing studies.…”