Endoscopic ultrasound‐based multimodal evaluation of the pancreas in patients with suspected early chronic pancreatitis

Abstract

Background Diagnosis of early chronic pancreatitis is a clinical challenge and hindered by the lack of a gold standard. Endoscopic ultrasound (EUS) and the endoscopic pancreatic function test (ePFT) are the most sensitive morphological and functional methods in this setting. EUS-elastography allows for the quantification (strain ratio) of pancreatic fibrosis, and the dynamic evaluation of the main pancreatic duct compliance provides additional information. We developed a multimodal EUS-based approach for the evaluation of the pancreas by integrating these four methods in a single procedure. Objective We aim to describe morphological and functional pancreatic abnormalities in patients with clinical suspicion of chronic pancreatitis and inconclusive EUS findings by using the multimodal EUS-based approach. Methods This was a prospective, cross-sectional, observational study of patients with clinically suspected chronic pancreatitis and indeterminate EUS criteria of the disease. EUS criteria of chronic pancreatitis, quantitative pancreatic elastography, ePFT and compliance of the main pancreatic duct were evaluated in a single procedure. Results In total, 53 patients with 3–4 EUS criteria of chronic pancreatitis were included (mean age 39.7 years, 29 male). Strain ratio was abnormally high in all patients. Peak bicarbonate concentration was decreased in 43 patients (81.1%) and the main pancreatic duct compliance was reduced in 41 patients (77.3%). Some 34 patients (64.1%) had abnormal results at EUS, elastography, ePFT and compliance of the main pancreatic duct. Conclusions A multimodal EUS-based test for the morphological and functional evaluation of the pancreas is presented, which allows detecting mild pancreatic abnormalities in patients with suspected early chronic pancreatitis. The presence of abnormal morphological and functional evaluation of the pancreas could support the clinical suspicion of early chronic pancreatitis in the appropriate clinical setting.

Early chronic pancreatitis: a challenge not so far to be met

“…Indeed, there is ongoing debate regarding the most accurate elastographic technique. In the present study by Dominguez-Munoz and colleagues 4 it was the SR technique that gives a 'relative' stiffness measure. In SR the strain of a region of interest (ROI) is compared with the strain of a region in normal surrounding reference tissue.…”

“…9 EUS-EG is undoubtedly a technique that can really help to reach a diagnosis of CO and, most of all, ECP. To date few papers have been published on the diagnostic capacity of SR (fundamentally used in Spain 4 and Japan) 10 or SH. In the future comparative prospective studies about these two techniques could suggest which one should be used in the diagnosis of CP, especially ECP.…”

“…For these reasons, the article by Dominguez‐Munoz and colleagues 4 published in the August issue of the journal is of utmost interest: in that prospective, cross‐sectional, observational study 53 patients with clinically suspected ECP were included and a multimodal EUS‐based approach using four parameters (EUS criteria of CP, quantitative pancreatic elastography, endoscopic pancreatic function test (ePFT) and compliance of the main pancreatic duct after secretin stimulation) was adopted. This approach permits the evaluation in the same exam of more ECP features at once: morphological alterations with B‐mode EUS, the parenchymal fibrosis through the stiffness measured by endoscopic ultrasound‐elastography (EUS‐EG), secretory functionality of the pancreas with ePFT and the compliance of the ducts after secretin administration.…”

Pancreatic Fibrosis (Early Chronic Pancreatitis) as Emerging Diagnosis in Structural Causes of Dyspepsia: Evidence from Endoscopic Ultrasonography and Shear Wave Elastography

“…A prospective study using EUS to diagnose alcoholic early chronic pancreatitis was published in 2002 [ 13 ]. In the past two decades, early chronic pancreatitis has mostly been diagnosed by EUS in studies [ 14 , 15 , 21 , 40 , 41 , 42 , 43 , 44 , 45 ]. By definition, early chronic pancreatitis is a syndrome requiring symptoms, risk factors, biomarkers, and image diagnosis, according to an international consensus [ 19 ].…”

Comprehensive review of diagnostic modalities for early chronic pancreatitis

“…EUS findings such as hyperechoic foci and strands, parenchymal lobularity, and a hyperechoic ductal wall are considered to be signs of pancreatic fibrosis[ 51 ]. A study conducted in 2016 using a quantitative receiver operating characteristic (ROC) curve analysis to evaluate the accuracy of EUS features revealed that four or more standard EUS features achieved the best balance of sensitivity (61%; 95%CI: 46.8-73.5) and specificity (75%; 95%CI: 42.8-94.2) (AUC = 0.68) for predicting abnormal pancreatic histopathology alterations of non-calcific pancreatitis.…”