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Salgado D, Kang J, Costa AF. Mimics of pancreatic neoplasms at cross-sectional imaging: Pearls for characterization and diagnostic work-up. Curr Probl Diagn Radiol 2025; 54:382-391. [PMID: 39701879 DOI: 10.1067/j.cpradiol.2024.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 11/13/2024] [Accepted: 12/09/2024] [Indexed: 12/21/2024]
Abstract
Interpreting imaging examinations of the pancreas can be a challenge. Several different entities can mimic or mask pancreatic neoplasms, including normal anatomic variants, non-pancreatic lesions, and both acute and chronic pancreatitis. It is important to distinguish these entities from pancreatic neoplasms, as the management and prognosis of a pancreatic neoplasm, particularly adenocarcinoma, have considerable impact on patients. Normal pancreatic variants that mimic a focal lesion include focal fatty atrophy, annular pancreas, and ectopic pancreas. Extra-pancreatic lesions that can mimic a primary pancreatic neoplasm include vascular lesions, such as arteriovenous malformations and pseudoaneurysms, duodenal diverticula, and intra-pancreatic accessory spleen. Both acute and chronic pancreatitis can mimic or mask a pancreatic neoplasm and are also associated with pancreatic ductal adenocarcinoma. Awareness of these entities and their imaging features will enable the radiologist to narrow the differential diagnosis, provide recommendations that expedite diagnosis and avoid unnecessary work-up or delays in patient care.
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Affiliation(s)
- David Salgado
- Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University. Victoria General Building, 3rd floor, 1276 South Park Street, Halifax, Nova Scotia B3H 2Y9, Canada.
| | - Jessie Kang
- Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University. Victoria General Building, 3rd floor, 1276 South Park Street, Halifax, Nova Scotia B3H 2Y9, Canada.
| | - Andreu F Costa
- Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University. Victoria General Building, 3rd floor, 1276 South Park Street, Halifax, Nova Scotia B3H 2Y9, Canada.
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Yoon DW, Kim DK, Kim T, Lee KC. Detection Rate of Small Pancreas Cysts and Intrareader Reliability of the Cysts Size Measurements on Transabdominal Ultrasonography. Ultrasound Q 2024; 40:132-135. [PMID: 38470608 DOI: 10.1097/ruq.0000000000000657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
ABSTRACT This study aimed to assess the detection rate of small (<10 mm) pancreas cyst and intrareader reliability for cyst size measurements on transabdominal ultrasonography (US). From 2020 to 2022, 194 pancreas cysts in 173 patients, incidentally detected on computed tomography or magnetic resonance imaging, were evaluated on US by 1 of 2 radiologists (readers 1 and 2). Intrareader agreements of cyst size measurements on US were assessed by intraclass correlation coefficient (ICC). Bland-Altman plot was used to visualize the differences between the first and second size measurements in each reader. In this study, readers 1 and 2 evaluated 86 cysts in 76 patients and 108 cysts in 97 patients, respectively. Most of the cysts (191 of 194) were located in the nontail portion of the pancreas. Overall detection rate of pancreas cysts by US was 92.3% (179 of 194). The mean size of measured 179 pancreas cysts was 4.7 ± 1.5 mm. The readers showed excellent intrareader agreements (ICC = 0.925 and 0.960) for cyst size measurements, except for the cysts with size ≤5 mm, where both readers showed good intrareader agreements (ICC = 0.848 and 0.873). The 95% limits of agreement of readers 1 and 2 were 13.8% and 14.9% of the mean, respectively. Therefore, transabdominal US could be a reliable follow-up imaging modality for small (<10 mm) nontail pancreas cysts incidentally detected on computed tomography or magnetic resonance imaging, especially for the cysts with size between 5 and 10 mm. Size changes of the pancreas cysts approximately less than 15% may be within the measurement error.
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Affiliation(s)
- Do Won Yoon
- Department of Radiology, the Armed Forces Capital Hospital, Seongnam
| | - Dong Kyu Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Taeho Kim
- Department of Radiology, the Armed Forces Capital Hospital, Seongnam
| | - Kyu-Chong Lee
- Department of Radiology, the Armed Forces Capital Hospital, Seongnam
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Hosaka M, Kubo T, Matsuoka T, Hasegawa T. Severe Acute Pancreatitis Rapidly Developed Into Pulmonary Edema and Diffuse Alveolar Hemorrhage Leading to Respiratory Failure: An Autopsy Case. Cureus 2023; 15:e46560. [PMID: 37933351 PMCID: PMC10625659 DOI: 10.7759/cureus.46560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2023] [Indexed: 11/08/2023] Open
Abstract
Acute pancreatitis often results in life-threatening situations, making a prompt and accurate diagnosis cardinally important. To achieve these, it is crucial to correctly identify characteristic symptoms and test findings. However, when patients do not exhibit distinctive symptoms during a physician's examination, in addition to limited resources, these can become challenging. In this manuscript, we present an instructive case. A male in his twenties, who complained of generalized malaise, was admitted to our hospital. Unfortunately, however, he passed away within two days prior to undergoing detailed examinations or receiving therapeutic interventions. We performed an autopsy in order to ascertain the reasons for this outcome. The findings revealed that pulmonary edema and diffuse alveolar hemorrhage were the causative factors of his demise, with acute pancreatitis observed in the background. The occurrence of acute pancreatitis leading to death in youths is infrequent. Where could we have intervened to halt such an unfortunate course in a young individual? This patient probably had diabetic ketoacidosis and hyperlipidemia, both of which are known to be closely associated with acute pancreatitis. In retrospect, we should have noticed this point. In this case, the condition progressed too rapidly for appropriate therapeutic interventions. We believe that this case would provide educational instruction for similar situations that could arise in the future.
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Affiliation(s)
- Michiko Hosaka
- Department of Surgical Pathology, Sapporo Medical University, Sapporo, JPN
| | - Terufumi Kubo
- Department of Pathology, Sapporo Medical University, Sapporo, JPN
| | | | - Tadashi Hasegawa
- Department of Surgical Pathology, Sapporo Medical University, Sapporo, JPN
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Rho S, Martin S, Nigogosyan Z, Kushnir V, Mintz AJ, Hu ZI. Pancreatic tail cancer in the setting of pancreatitis with a review of the literature: A case report. Clin Case Rep 2023; 11:e8023. [PMID: 37830064 PMCID: PMC10565090 DOI: 10.1002/ccr3.8023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/26/2023] [Accepted: 09/25/2023] [Indexed: 10/14/2023] Open
Abstract
Environmental risk factors for pancreatic cancer include acute and chronic pancreatitis, obesity, and tobacco use. Differentiating a pancreatic neoplasm in a patient with pancreatitis can be challenging due to their similar presentations. A 57-year-old African American man with a history of congestive heart failure, pancreatitis, and incomplete pancreas divisum presented with an epigastric abdominal pain that radiated to his back. Imaging showed necrotizing pancreatitis, a developing splenic infarct, and a mass at the pancreas tail. The patient was discharged with pain medications and was recommended follow-up imaging after resolution of his pancreatitis. He was readmitted to the emergency department 2 weeks later with recurrent acute abdominal pain. Computed tomography scan of abdomen and pelvis followed by magnetic resonance imaging and endoscopic ultrasound revealed an infiltrative pancreatic tail mass. Biopsy of the mass confirmed a locally advanced pancreatic tail adenocarcinoma. Chronic pancreatitis is associated with pancreatic cancer. Practitioners should be aware of the co-existence of chronic pancreatitis and pancreatic cancer, and the initial steps to evaluate a malignancy in chronic pancreatitis.
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Affiliation(s)
- Shinji Rho
- School of MedicineWashington University School of MedicineSt. LouisMissouriUSA
| | - Sooyoung Martin
- Department of RadiologyWashington University School of MedicineSt. LouisMissouriUSA
| | - Zack Nigogosyan
- Department of RadiologyWashington University School of MedicineSt. LouisMissouriUSA
| | - Vladimir Kushnir
- Department of GastroenterologyWashington University School of MedicineSt. LouisMissouriUSA
| | - Aaron J. Mintz
- Department of RadiologyWashington University School of MedicineSt. LouisMissouriUSA
| | - Zishuo Ian Hu
- Department of Medicine, Division of Oncology, Section of Medical OncologyWashington University School of MedicineSt. LouisMissouriUSA
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Zhang H, Meng Y, Li Q, Yu J, Liu F, Fang X, Li J, Feng X, Zhou J, Zhu M, Li N, Lu J, Shao C, Bian Y. Two nomograms for differentiating mass-forming chronic pancreatitis from pancreatic ductal adenocarcinoma in patients with chronic pancreatitis. Eur Radiol 2022; 32:6336-6347. [PMID: 35394185 DOI: 10.1007/s00330-022-08698-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 02/16/2022] [Accepted: 02/25/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To develop and validate a CT nomogram and a radiomics nomogram to differentiate mass-forming chronic pancreatitis (MFCP) from pancreatic ductal adenocarcinoma (PDAC) in patients with chronic pancreatitis (CP). METHODS In this retrospective study, the data of 138 patients with histopathologically diagnosed MFCP or PDAC treated at our institution were retrospectively analyzed. Two radiologists analyzed the original cross-sectional CT images based on predefined criteria. Image segmentation, feature extraction, and feature reduction and selection were used to create the radiomics model. The CT and radiomics models were developed using data from a training cohort of 103 consecutive patients. The models were validated in 35 consecutive patients. Multivariable logistic regression analysis was conducted to develop a model for the differential diagnosis of MFCP and PDAC and visualized as a nomogram. The nomograms' performances were determined based on their differentiating ability and clinical utility. RESULTS The mean age of patients was 53.7 years, 75.4% were male. The CT nomogram showed good differentiation between the two entities in the training (area under the curve [AUC], 0.87) and validation (AUC, 0.94) cohorts. The radiomics nomogram showed good differentiation in the training (AUC, 0.91) and validation (AUC, 0.93) cohorts. Decision curve analysis showed that patients could benefit from the CT and radiomics nomograms, if the threshold probability was 0.05-0.85 and > 0.05, respectively. CONCLUSIONS The two nomograms reasonably accurately differentiated MFCP from PDAC in patients with CP and hold potential for refining the management of pancreatic masses in CP patients. KEY POINTS • A CT nomogram and a computed tomography-based radiomics nomogram reasonably accurately differentiated mass-forming chronic pancreatitis from pancreatic ductal adenocarcinoma in patients with chronic pancreatitis (CP). • The two nomograms can monitor the cancer risk in patients with CP and hold promise to optimize the management of pancreatic masses in patients with CP.
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Affiliation(s)
- Hao Zhang
- Department of Radiology, Changhai Hospital, Naval Medical University, Changhai Road 168, Shanghai, 200434, China
| | - Yinghao Meng
- Department of Radiology, Changhai Hospital, Naval Medical University, Changhai Road 168, Shanghai, 200434, China
- Department of Radiology, No. 971 Hospital of Navy, Qingdao, 266071, Shandong, China
| | - Qi Li
- Department of Radiology, Changhai Hospital, Naval Medical University, Changhai Road 168, Shanghai, 200434, China
| | - Jieyu Yu
- Department of Radiology, Changhai Hospital, Naval Medical University, Changhai Road 168, Shanghai, 200434, China
| | - Fang Liu
- Department of Radiology, Changhai Hospital, Naval Medical University, Changhai Road 168, Shanghai, 200434, China
| | - Xu Fang
- Department of Radiology, Changhai Hospital, Naval Medical University, Changhai Road 168, Shanghai, 200434, China
| | - Jing Li
- Department of Radiology, Changhai Hospital, Naval Medical University, Changhai Road 168, Shanghai, 200434, China
| | - Xiaochen Feng
- Department of Radiology, Changhai Hospital, Naval Medical University, Changhai Road 168, Shanghai, 200434, China
| | - Jian Zhou
- Department of Radiology, Changhai Hospital, Naval Medical University, Changhai Road 168, Shanghai, 200434, China
| | - Mengmeng Zhu
- Department of Radiology, Changhai Hospital, Naval Medical University, Changhai Road 168, Shanghai, 200434, China
| | - Na Li
- Department of Radiology, Changhai Hospital, Naval Medical University, Changhai Road 168, Shanghai, 200434, China
| | - Jianping Lu
- Department of Radiology, Changhai Hospital, Naval Medical University, Changhai Road 168, Shanghai, 200434, China
| | - Chengwei Shao
- Department of Radiology, Changhai Hospital, Naval Medical University, Changhai Road 168, Shanghai, 200434, China.
| | - Yun Bian
- Department of Radiology, Changhai Hospital, Naval Medical University, Changhai Road 168, Shanghai, 200434, China.
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Inciarte DJ, Ramon D. Diseases of the Pancreas. Fam Med 2022. [DOI: 10.1007/978-3-030-54441-6_175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Immune Checkpoint Inhibitor-Induced Pancreatic Injury: Imaging Findings and Literature Review. Target Oncol 2021; 15:25-35. [PMID: 31925647 DOI: 10.1007/s11523-019-00694-w] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The immunotherapy revolution in cancer treatment involves a variety of specialists, not only oncologists, but also internal medicine physicians, endocrinologists, dermatologists, gastroenterologists, rheumatologists, and radiologists, introducing new scenarios and novel challenges in the diagnosis and management of a number of novel immune-related adverse events. Among these, immune checkpoint inhibitor-induced pancreatic injury has been described (occurring in up to 4% of patients) and has been reported to be responsible for visits to the emergency departments in up to 1.9% of patients treated with immune checkpoint inhibitors. This side effect can be symptomatic or non-symptomatic, and can be associated with the development of long-term damage to the pancreas, requiring the involvement of different specialists, including radiologists and gastroenterologists in the multidisciplinary team that manages these patients. The aim of this narrative review is to provide a summary of the available literature related to immune checkpoint inhibitor-induced pancreatic injury including the epidemiology, the clinical findings, and the management algorithm for diagnosis with a detailed analysis of the differential diagnosis at imaging, and treatment. A more in-depth focus is dedicated to symptomatic acute pancreatitis with its peculiar findings at imaging (ultrasound, computed tomography, and magnetic resonance imaging).
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8
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Inciarte DJ, Ramon D. Diseases of the Pancreas. Fam Med 2021. [DOI: 10.1007/978-1-4939-0779-3_175-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Tirkes T, Shah ZK, Takahashi N, Grajo JR, Chang ST, Wachsman AM, Mawad K, Farinas CA, Li L, Appana SN, Conwell DL, Yadav D, Dasyam AK. Inter-observer variability of radiologists for Cambridge classification of chronic pancreatitis using CT and MRCP: results from a large multi-center study. Abdom Radiol (NY) 2020; 45:1481-1487. [PMID: 32285180 DOI: 10.1007/s00261-020-02521-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE Determine inter-observer variability among radiologists in assigning Cambridge Classification (CC) of chronic pancreatitis (CP) based on magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography (MRCP) and contrast-enhanced CT (CECT). METHODS Among 422 eligible subjects enrolled into the PROCEED study between 6/2017 and 8/2018, 39 were selected randomly for this study (chronic abdominal pain (n = 8; CC of 0), suspected CP (n = 22; CC of 0, 1 or 2) or definite CP (n = 9; CC of 3 or 4). Each imaging was scored by the local radiologist (LRs) and three of five central radiologists (CRs) at other consortium sites. The CRs were blinded to clinical data and site information of the participants. We compared the CC score assigned by the LR with the consensus CC score assigned by the CRs. The weighted kappa statistic (K) was used to estimate the inter-observer agreement. RESULTS For the majority of subjects (34/39), the group assignment by LR agreed with the consensus composite CT/MRCP score by the CRs (concordance ranging from 75 to 89% depending on cohort group). There was moderate agreement (63% and 67% agreed, respectively) between CRs and LRs in both the CT score (weighted Kappa [95% CI] = 0.56 [0.34, 0.78]; p-value = 0.57) and the MR score (weighted Kappa [95% CI] = 0.68 [0.49, 0.86]; p-value = 0.72). The composite CT/MR score showed moderate agreement (weighted Kappa [95% CI] = 0.62 [0.43, 0.81]; p-value = 0.80). CONCLUSION There is a high degree of concordance among radiologists for assignment of CC using MRI and CT.
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Affiliation(s)
- Temel Tirkes
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N. University Blvd. Suite 0663, Indianapolis, IN, 46202, USA.
| | - Zarine K Shah
- Department of Radiology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Joseph R Grajo
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Stephanie T Chang
- Department of Radiology and Division of Body MRI, Stanford University School of Medicine, Stanford, CA, USA
| | - Ashley M Wachsman
- Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kareem Mawad
- Department of Radiology, South San Francisco Medical Center, The Permanente Medical Group, South San Francisco, CA, USA
| | - Carlos A Farinas
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Liang Li
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Savitri N Appana
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Darwin L Conwell
- Division of Gastroenterology, Department of Medicine, Ohio State University Wexner Medical Center, Hepatology & Nutrition, Columbus, OH, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anil K Dasyam
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Narita M, Hata H, Matsusue R, Yamaguchi T, Otani T, Ikai I. Is the remnant pancreas still working over a year after surgery in patients undergoing pancreaticoduodenectomy with reconstruction by pancreaticogastrostomy? Pancreatology 2020; 20:217-222. [PMID: 31862231 DOI: 10.1016/j.pan.2019.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/11/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreaticogastrostomy (PG) has been widely used as an alternative to pancreatojejunostomy (PJ) in patients undergoing pancreaticoduodenectomy (PD), but its long-term exocrine function remains unclear. The present study aimed to measure the secretion of pancreatic α-amylase (p-AMY) into the gastric cavity in patients who underwent PG reconstruction after PD over 1 year after surgery and to evaluate the relationship between gastric p-AMY level and clinically available indirect tests. METHODS Clinical records of 39 patients who underwent PG reconstruction after PD were reviewed. Pancreatic exocrine function was evaluated over 1 year after surgery using the following methods: 1) Measurement of p-AMY level in gastric fluids (gastric p-AMY level) during routine gastrointestinal endoscopy, 2) Qualitative faecal fat determination by Sudan III staining on faeces and 3) Pancreatic function diagnostic (PFD) test using oral administration of N-benzoyl-l-tyrosyl-p-aminobenzoic acid. RESULTS Gastric p-AMY level was detectable in 31 of 39 patients (79%), and 12 patients (30.8%) had steatorrhea over a year after surgery. Patients with steatorrhea had significantly lower gastric p-AMY level, larger diameter of remnant main pancreatic duct (MPD) and larger pancreatic duct to parenchymal thickness ratio than those without steatorrhea (84 IU/L vs 7979 IU/L, respectively; P < 0.001, 5.3 mm vs 3.2 mm, respectively; P = 0.001, and 0.38 vs 0.23, respectively; P = 0.007). Receiver operating characteristic analysis showed that the cut-off value of the diameter of the remnant MPD to predict steatorrhea was 3.5 mm (sensitivity, 92.3%; specificity, 70.4%). PFD test was not associated with any clinical data. CONCLUSIONS Pancreatic enzyme was detected in 79% of patients having PG reconstruction. Diameter of remnant MPD >3.5 mm and pancreatic parenchymal atrophy may be surrogate markers of postoperative exocrine insufficiency following PD.
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Affiliation(s)
- Masato Narita
- Department of Surgery, National Hospital Organisation, Kyoto Medical Centre,1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan.
| | - Hiroaki Hata
- Department of Surgery, National Hospital Organisation, Kyoto Medical Centre,1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Ryo Matsusue
- Department of Surgery, National Hospital Organisation, Kyoto Medical Centre,1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Takashi Yamaguchi
- Department of Surgery, National Hospital Organisation, Kyoto Medical Centre,1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Tetsushi Otani
- Department of Surgery, National Hospital Organisation, Kyoto Medical Centre,1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Iwao Ikai
- Department of Surgery, National Hospital Organisation, Kyoto Medical Centre,1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
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CT and MR features that can help to differentiate between focal chronic pancreatitis and pancreatic cancer. Radiol Med 2020; 125:356-364. [PMID: 31933064 DOI: 10.1007/s11547-019-01132-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 12/27/2019] [Indexed: 02/07/2023]
Abstract
Diagnosis of a focal pancreatic mass in routine clinical practice can be a challenge because patients with chronic pancreatitis may present with symptoms and imaging findings that can be difficult to distinguish from pancreatic cancer. Markers, such as cancer antigen 19-9 and carcinoembryonic antigen, are helpful if abnormal, but normal values do not rule out pancreatic cancer. One of the strongest complicating factors is that chronic pancreatitis is a risk factor for pancreatic cancer. Transition of chronic pancreatitis to pancreatic cancer is relatively rare, but it normally has a poor prognosis because diagnosis is often delayed. From a radiologic diagnosis perspective, the classic so-called double-duct sign is helpful. This sign is considered a hallmark sign of pancreatic cancer on magnetic resonance cholangiopancreatography, but it can also be identified in patients with chronic pancreatitis or with other conditions. A number of additional imaging findings or signs are, therefore, necessary. The aim of this article was to describe the strong CT and MR imaging features or integrated imaging features that can help to differentiate between pancreatic cancer and focal chronic pancreatitis.
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Mahalingam S, Langdon J, Muniraj T, Do A, Guo Y, Spektor M, Mathur M. Endoscopic Retrograde Cholangiopancreatography: Deciphering the Black and White. Curr Probl Diagn Radiol 2020; 50:74-84. [PMID: 32063296 DOI: 10.1067/j.cpradiol.2020.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 01/01/2020] [Accepted: 01/06/2020] [Indexed: 12/12/2022]
Abstract
Endoscopic Retrograde Cholangiopancreatography (ERCP) remains the conventional method of imaging the pancreatic and biliary tree and is performed by direct injection of iodinated contrast material via the major papilla. This diagnostic procedure gained popularity in the 1970s and subsequently paved way for ERCP guided interventions such as sphincterotomy, stone retrieval and stent placement. Currently, therapeutic ERCP is more widespread than diagnostic ERCP primarily due to the availability of noninvasive imaging. Nevertheless, more than half a million ERCPs are performed annually in the United States and radiologists need to be comfortable interpreting them. The following review will familiarize the reader with the imaging appearances of biliary and pancreatic disorders on conventional ERCP, and elaborate on therapeutic ERCP with illustrative examples.
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Affiliation(s)
- Sowmya Mahalingam
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT.
| | - Jonathan Langdon
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT
| | | | - Albert Do
- Yale University School of Medicine, Section of Digestive Diseases, New Haven, CT
| | - Yang Guo
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT; Brigham and Women's Hospital, Brookline, MA
| | - Michael Spektor
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT
| | - Mahan Mathur
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT
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13
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Wolske KM, Ponnatapura J, Kolokythas O, Burke LMB, Tappouni R, Lalwani N. Chronic Pancreatitis or Pancreatic Tumor? A Problem-solving Approach. Radiographics 2019; 39:1965-1982. [PMID: 31584860 DOI: 10.1148/rg.2019190011] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Certain inflammatory pancreatic abnormalities may mimic pancreatic ductal adenocarcinoma at imaging, which precludes accurate preoperative diagnosis and may lead to unnecessary surgery. Inflammatory conditions that may appear masslike include mass-forming chronic pancreatitis, focal autoimmune pancreatitis, and paraduodenal pancreatitis or "groove pancreatitis." In addition, obstructive chronic pancreatitis can mimic an obstructing ampullary mass or main duct intraductal papillary mucinous neoplasm. Secondary imaging features such as the duct-penetrating sign, biliary or main pancreatic duct skip strictures, a capsulelike rim, the pancreatic duct-to-parenchyma ratio, displaced calcifications in patients with chronic calcific pancreatitis, the "double duct" sign, and vessel encasement or displacement can help to suggest the possibility of an inflammatory mass or a neoplastic process. An awareness of the secondary signs that favor a diagnosis of malignant or inflammatory lesions in the pancreas can help the radiologist to perform the differential diagnosis and determine the degree of suspicion for malignancy. Repeat biopsy or surgical resection may be necessary to achieve an accurate diagnosis and prevent unnecessary surgery for inflammatory conditions. Online supplemental material and DICOM image stacks are available for this article. ©RSNA, 2019.
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Affiliation(s)
- Kristy Marie Wolske
- From the Departments of Radiology of Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 (K.M.W., J.P., R.T., N.L.); University of Washington, Seattle, Wash (O.K.); and University of North Carolina at Chapel Hill, Chapel Hill, NC (L.M.B.B.)
| | - Janardhana Ponnatapura
- From the Departments of Radiology of Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 (K.M.W., J.P., R.T., N.L.); University of Washington, Seattle, Wash (O.K.); and University of North Carolina at Chapel Hill, Chapel Hill, NC (L.M.B.B.)
| | - Orpheus Kolokythas
- From the Departments of Radiology of Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 (K.M.W., J.P., R.T., N.L.); University of Washington, Seattle, Wash (O.K.); and University of North Carolina at Chapel Hill, Chapel Hill, NC (L.M.B.B.)
| | - Lauren M B Burke
- From the Departments of Radiology of Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 (K.M.W., J.P., R.T., N.L.); University of Washington, Seattle, Wash (O.K.); and University of North Carolina at Chapel Hill, Chapel Hill, NC (L.M.B.B.)
| | - Rafel Tappouni
- From the Departments of Radiology of Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 (K.M.W., J.P., R.T., N.L.); University of Washington, Seattle, Wash (O.K.); and University of North Carolina at Chapel Hill, Chapel Hill, NC (L.M.B.B.)
| | - Neeraj Lalwani
- From the Departments of Radiology of Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 (K.M.W., J.P., R.T., N.L.); University of Washington, Seattle, Wash (O.K.); and University of North Carolina at Chapel Hill, Chapel Hill, NC (L.M.B.B.)
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14
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Singh KR, Muktesh G, Gunjan D, Kochhar R, Singh V, Das A, Siddappa P, Singh K. Patterns of alcohol consumption and nutrition intake in patients with alcoholic liver disease and alcoholic pancreatitis in North Indian men. JGH OPEN 2019; 3:316-321. [PMID: 31406925 PMCID: PMC6684506 DOI: 10.1002/jgh3.12165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 01/05/2019] [Accepted: 01/31/2019] [Indexed: 11/09/2022]
Abstract
Background and Aim Chronic alcoholism and nutrition play an important role in liver and pancreatic diseases. To compare drinking habits and nutritional data in patients with alcoholic liver disease (ALD) and alcoholic pancreatitis (ALP). Methods Clinical, anthropometric, dietary intake, laboratory, and imaging data were recorded in consecutive patients of ALD and ALP. Results In 150 patients of ALP (n = 76) and ALD (n = 74), the age of starting alcohol consumption (19.03 ± 3.78 vs 18.0 ± 2.59 years) and the mean amount of alcohol consumed per day (165.63 ± 87.99 vs 185.50 ± 113.54 g; P = 0.230) were similar. Patients with ALD consumed alcohol on a daily basis more frequently (90.5 vs 72.3%; P = 0.003) and had a longer duration of alcohol intake (21.6 + 0.2 vs 14.5 + 6.9 years; P < 0.0001) than patients in the ALP group. Binge drinking was more common in patients with ALP compared to patients with ALD (60.5 vs 20.3%); P < 0.0001). Patients with ALP had a lower body mass index (19.9 ± 3.49 vs 22.64 ± 4.88 kg/m2; P = 0.001) and more frequent decrease in mid arm circumference (57.9 vs 44.6%; P = 0.042) and triceps skin fold thickness (67.1 vs 52.7%; P = 0.072) compared to patients with ALD. Conclusion There was no difference in the age of starting alcohol consumption and mean amount of alcohol consumption per day between the groups. Patients with ALD were more likely to be daily drinkers with a longer duration of alcohol intake. However, binge drinking and malnourishment was more common in the ALP group.
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Affiliation(s)
- Karam R Singh
- Unit of Gastroenterology Regional Institute of Medical Sciences Imphal India
| | - Gaurav Muktesh
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Deepak Gunjan
- Department of Gastroenterology All India Institute of Medical Sciences Delhi India
| | - Rakesh Kochhar
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Virendra Singh
- Department of Hepatology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Ashim Das
- Department of Histopathology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Pradeep Siddappa
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Kartar Singh
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
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15
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Abstract
Chronic pancreatitis (CP) is an important gastrointestinal cause of morbidity worldwide. It can severely impair the quality of life besides life-threatening acute and long-term complications. Pain and pancreatic exocrine insufficiency (leading to malnutrition) impact the quality of life. Acute complications include pseudocysts, pancreatic ascites, and vascular complications. Long-term complications are diabetes mellitus and pancreatic cancer. Early diagnosis of CP is crucial to alter the natural course of the disease. However, majority of the cases are diagnosed in the advanced stage. The role of various imaging techniques in the diagnosis of CP is discussed in this review.
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Affiliation(s)
- Rohan Kamat
- Department of Radiodiagnosis and Imaging, PGIMER, Chandigarh, India
| | - Pankaj Gupta
- Department of Gastroenterology, PGIMER, Chandigarh, India
- Correspondence: Dr. Pankaj Gupta, Department of Gastroenterology, Section of Radiology, PGIMER, Chandigarh, India. E-mail:
| | - Surinder Rana
- Department of Gastroenterology, PGIMER, Chandigarh, India
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16
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Kwon CI, Cho JH, Choi SH, Ko KH, Tirkes T, Gromski MA, Lehman GA. Recent advances in the diagnosis and management of chronic pancreatitis. Korean J Intern Med 2019; 34:242-260. [PMID: 30840807 PMCID: PMC6406102 DOI: 10.3904/kjim.2019.051] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 02/13/2019] [Indexed: 02/06/2023] Open
Abstract
Chronic pancreatitis is a chronic condition characterized by pancreatic inflammation that causes fibrosis and the destruction of exocrine and endocrine tissues. Chronic pancreatitis is a progressive disease, and no physiological treatment is available to reverse its course. However, with advances in medical technology, the existing diagnostic and treatment methods for chronic pancreatitis are evolving. Managing patients with chronic pancreatitis is challenging and necessitates a multidisciplinary approach. In this review, we discuss the recent advances in the diagnosis and management of chronic pancreatitis and introduce future alternative modalities.
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Affiliation(s)
- Chang-Il Kwon
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Jae Hee Cho
- Division of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Sung Hoon Choi
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Kwang Hyun Ko
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Temel Tirkes
- Department of Radiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark A. Gromski
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Glen A. Lehman
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
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17
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Tirkes T. Chronic Pancreatitis: What the Clinician Wants to Know from MR Imaging. Magn Reson Imaging Clin N Am 2019; 26:451-461. [PMID: 30376981 DOI: 10.1016/j.mric.2018.03.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Diagnosis of chronic pancreatitis requires a complete medical history and clinical investigations, including imaging technologies and function tests. MR imaging/magnetic resonance cholangiopancreatography is the preferred diagnostic tool for detection of ductal and parenchymal changes in patients with chronic pancreatitis. Ductal changes may not be present in the initial phase of chronic pancreatitis. Therefore, early diagnosis remains challenging.
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Affiliation(s)
- Temel Tirkes
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, IU Health University Hospital, 550 North University Boulevard, UH0663, Indianapolis, IN 46202, USA.
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18
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Hafezi-Nejad N, Singh VK, Faghih M, Kamel IR, Zaheer A. Jejunal response to secretin is independent of the pancreatic response in secretin-enhanced magnetic resonance cholangiopancreatography. Eur J Radiol 2019; 112:7-13. [PMID: 30777222 DOI: 10.1016/j.ejrad.2018.12.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 12/14/2018] [Accepted: 12/31/2018] [Indexed: 12/12/2022]
Abstract
PURPOSE To investigate whether jejunal secretions are independent of the pancreatic response to secretin in secretin-enhanced Magnetic Resonance Cholangiopancreatography (s-MRCP) examination of subjects with and without chronic pancreatitis (CP). METHODS Patients were identified through a search of s-MRCP examinations performed between 2014-2016 (n = 513) as well as the multidisciplinary pancreatitis clinic registry (n = 586). Fifty cases with CP (based on M-ANNHEIM criteria) and 50 matched controls were selected. Signal intensity changes after secretin administration (˜1-5 min' post-secretin response) in three locations were assessed: second portion of the duodenum (D2), third/fourth portions of the duodenum (D3-4), and the jejunum. The post-secretin response was compared between (cases vs. controls) and within the study groups. RESULTS There was a significantly lower 1-5 min' post-secretin response among CP patients in D2 (all p-values <0.01). However, no significant difference in 1-5 min' post-secretin response was detected in the jejunum. Minute-by-minute analysis of the post-secretin response showed a significant increase up to the 5th minute only in D2 of the control group. The post-secretin response in the jejunum was significant after 1 min but was similar among patients with CP and controls. CP was a significant determinant of post-secretin response in D2 but not in the jejunum. CONCLUSIONS Early post-secretin response at jejunum is independent of the pancreatic response that can be detected at D2, and should not be misinterpreted as a rapid pancreatic response. Therefore, pancreatic function on s-MRCP should be assessed by the presence of fluid in D2 and not jejunum.
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Affiliation(s)
- Nima Hafezi-Nejad
- Russell H. Morgan Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD, United States.
| | - Vikesh K Singh
- Pancreatitis Center, Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, United States.
| | - Mahya Faghih
- Pancreatitis Center, Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, United States.
| | - Ihab R Kamel
- Russell H. Morgan Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD, United States.
| | - Atif Zaheer
- Russell H. Morgan Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD, United States; Pancreatitis Center, Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, United States.
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19
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Obaitan I, Hayat U, Hashmi H, Trikudanathan G. Imaging in pancreatitis: current status and recent advances. Expert Opin Orphan Drugs 2018. [DOI: 10.1080/21678707.2018.1536539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Itegbemie Obaitan
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Umar Hayat
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN, USA
| | - Hiba Hashmi
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN, USA
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN, USA
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20
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Abstract
OBJECTIVE The purpose of this article is to discuss the advances in CT acquisition and image postprocessing as they apply to imaging the pancreas and to conceptualize the role of radiogenomics and machine learning in pancreatic imaging. CONCLUSION CT is the preferred imaging modality for assessment of pancreatic diseases. Recent advances in CT (dual-energy CT, CT perfusion, CT volumetry, and radiogenomics) and emerging computational algorithms (machine learning) have the potential to further increase the value of CT in pancreatic imaging.
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21
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Morphological and functional changes of chronic pancreatitis in patients with dyspepsia: A prospective, observational, cross-sectional study. Pancreatology 2018; 18:280-285. [PMID: 29496438 DOI: 10.1016/j.pan.2018.02.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 02/03/2018] [Accepted: 02/08/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Whether chronic pancreatitis (CP) may present with dyspepsia is controversial. We aimed at evaluating the frequency and risk factors of changes of CP in patients presenting with epigastric pain syndrome (EPS)-like symptoms. DESIGN A prospective, observational, cross-sectional study was carried out in patients with EPS-like symptoms. Patients underwent endoscopic ultrasound (EUS) evaluation of the pancreas, and changes of CP were defined as the presence of five or more EUS criteria of the disease. In patients with 3 or 4 EUS criteria, magnetic resonance dynamic evaluation of the pancreas (MRI/sMRCP) and endoscopic pancreatic function test (ePFT) were carried out to confirm or exclude the presence of changes of CP. A multivariate logistic regression analysis was performed to evaluate factors associated with CP findings, and results are shown as odds ratio (OR) and 95% confidence interval (CI). RESULTS 213 patients were included. Changes of CP were confirmed by EUS (≥5 criteria) in 18 patients (8.4%). Thirty-four patients had 3-4 EUS criteria, and changes of CP were confirmed in 27 of them by MRI/sMRCP and ePFT (12.7%). Morphological and functional findings of CP were then present in 45 patients (21.1%). Male gender (OR 2.97; 95%CI 1.39-6.37) and alcohol and tobacco consumption (OR 6.56; 95%CI 1.97-21.85) were associated with the presence of changes of CP. CONCLUSION Morphological and functional changes of CP are frequent in patients with EPS-like symptoms. Whether these pancreatic changes explain EPS-like symptoms requires further investigation.
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22
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Dhar VK, Xia BT, Ahmad SA. The Surgeon's Role in Treating Chronic Pancreatitis and Incidentally Discovered Pancreatic Lesions. J Gastrointest Surg 2017; 21:2110-2118. [PMID: 28808857 DOI: 10.1007/s11605-017-3534-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 08/01/2017] [Indexed: 01/31/2023]
Abstract
Chronic pancreatitis and incidentally discovered pancreatic lesions present significant diagnostic and therapeutic challenges for surgeons. While both decompressive and resection procedures have been described for treatment of chronic pancreatitis, optimal management must be tailored to each patient's individual disease characteristics, parenchymal morphology, and ductal anatomy. Surgeons should strive to achieve long-lasting pain relief while preserving native pancreatic function. For patients with incidentally discovered pancreatic lesions, differentiating benign, pre-malignant, and malignant lesions is critical as earlier treatment is thought to result in improved survival. The purpose of this evidence-based manuscript is to review the presentation, workup, surgical management, and associated outcomes for patients with chronic pancreatitis or incidentally discovered solid and cystic lesions of the pancreas.
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Affiliation(s)
- Vikrom K Dhar
- Division of Surgical Oncology, Department of Surgery, College of Medicine, University of Cincinnati, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Brent T Xia
- Division of Surgical Oncology, Department of Surgery, College of Medicine, University of Cincinnati, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Syed A Ahmad
- Division of Surgical Oncology, Department of Surgery, College of Medicine, University of Cincinnati, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA.
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23
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The Impact of Risk Factors of Chronic Pancreatitis on Secretin Pancreatic Function Testing: Results of a 20-Year Study. Pancreas 2017; 46:887-890. [PMID: 28697128 DOI: 10.1097/mpa.0000000000000871] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The aim of this study was to determine the effect of established risk factors on the outcome of secretin pancreatic function testing (sPFT) in patients undergoing work-up for suspected chronic pancreatitis. METHODS We completed a retrospective review of patients who underwent sPFT for suspected chronic pancreatitis over 20 years. We compared peak bicarbonate concentrations between groups and completed univariate and multivariate analyses to determine associations between risk factors and positive sPFT results (peak bicarbonate <80 mEq/L). RESULTS Forty-three of 162 patients had positive sPFT results. There were significant differences in peak bicarbonate concentrations in patients with and without recurrent acute pancreatitis (RAP) and with local complications from acute pancreatitis (AP) (P ≤ 0.05). The bicarbonate concentration in patients with and without other risk factors such as tobacco use, alcohol use, and family history of pancreatitis was not significantly different. Female sex, a history of AP, and a history of RAP were associated with positive sPFT results on univariate analysis (P ≤ 0.05). On multivariate analysis, sex and RAP remained significant. CONCLUSIONS Our study demonstrates that female sex, history of AP and RAP, and AP with local complications are associated with positive sPFT results or lower peak bicarbonate concentration. However, other risk factors do not impact the results of sPFT.
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24
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Comparison of Combined Endoscopic Ultrasonography and Endoscopic Secretin Testing With the Traditional Secretin Pancreatic Function Test in Patients With Suspected Chronic Pancreatitis: A Prospective Crossover Study. Pancreas 2017; 46:770-775. [PMID: 28609365 DOI: 10.1097/mpa.0000000000000829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE We aimed to determine the feasibility and accuracy of a combined endoscopic ultrasonography (EUS) with a shortened pancreatic function testing (sEUS) for structural and functional assessment using a single instrument in patients with suspected chronic pancreatitis (CP). METHODS We completed a prospective crossover study, enrolling patients with suspected CP. Patients who underwent both traditional 1-hour secretin pancreatic function test (sPFT) and sEUS were included in the analysis. We compared study results for test concordance and for correlation of peak bicarbonate concentrations. RESULTS Eleven (64.7%) of 17 patients had concordant sPFT and sEUS findings when the cutoff for peak bicarbonate was 80 mEq/L. Six patients had discordant findings with a negative sPFT and positive sEUS. This poor concordance suggests that sEUS is an unreliable functional test. Lowering the sEUS cutoff to 70 mEq/L resulted in improved concordance (64.7% vs 70.6%). Finally, there was no significant correlation between peak bicarbonate concentrations (r = 0.47; 95% confidence interval, -0.02 to 0.79) in these 2 functional tests. CONCLUSIONS We demonstrate poor concordance between sPFT and sEUS suggesting that a combined shortened functional and structural test using a single instrument may not be a feasible test for diagnosis of suspected CP when a cutoff of 80 mEq/L is used.
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25
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Lee JW, Kim HG, Lee DW, Han J, Kwon HY, Seo CJ, Oh JH, Lee JH, Jung JT, Kwon JG, Kim EY. Association between Smoking and the Progression of Computed Tomography Findings in Chronic Pancreatitis. Gut Liver 2017; 10:464-9. [PMID: 26601825 PMCID: PMC4849701 DOI: 10.5009/gnl14289] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background/Aims Smoking and alcohol intake are two well-known risk factors for chronic pancreatitis. However, there are few studies examining the association between smoking and changes in computed tomography (CT) findings in chronic pancreatitis. The authors evaluated associations between smoking, drinking and the progression of calcification on CT in chronic pancreatitis. Methods In this retrospective study, 59 patients with chronic pancreatitis who had undergone initial and follow-up CT between January 2002 and September 2010 were included. Progression of calcification among CT findings was compared according to the amount of alcohol intake and smoking. Results The median duration of follow-up was 51.6 months (range, 17.1 to 112.7 months). At initial CT findings, there was pancreatic calcification in 35 patients (59.3%). In the follow-up CT, progression of calcification was observed in 37 patients (62.7%). Progression of calcification was more common in smokers according to the multivariate analysis (odds ratio [OR], 9.987; p=0.006). The amount of smoking was a significant predictor for progression of calcification in the multivariate analysis (OR, 6.051 in less than 1 pack per day smokers; OR, 36.562 in more than 1 pack per day smokers; p=0.008). Conclusions Continued smoking accelerates pancreatic calcification, and the amount of smoking is associated with the progression of calcification in chronic pancreatitis.
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Affiliation(s)
- Jeong Woo Lee
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Ho Gak Kim
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Dong Wook Lee
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jimin Han
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Hyuk Yong Kwon
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Chang Jin Seo
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Ji Hye Oh
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Joo Hyoung Lee
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jin Tae Jung
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Joong Goo Kwon
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Eun Young Kim
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
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Abstract
Pancreatic diseases, chronic pancreatitis, pancreatic cancer and diabetes mellitus, taken together, occur in >10% of the world population. Pancreatic diseases, as with other diseases, benefit from early intervention and appropriate diagnosis. Although imaging technologies have given clinicians an unprecedented toolbox to aid in clinical decision-making, advances in these technologies and development of molecular-based diagnostic tools could enable physicians to identify diseases at an even earlier stage and, thereby, improve patient outcomes. In this Review, we discuss and identify gaps in the use of imaging techniques for the early detection and appropriate treatment stratification of various pancreatic diseases, including diabetes mellitus, acute and chronic pancreatitis and pancreatic cancer. Imaging techniques discussed are MRI, CT, PET and ultrasonography. Additionally, the identification of new molecular targets for imaging and the development of contrast agents that are able to give molecular information in noninvasive radionuclear imaging and ultrasonography are emerging areas of innovation that could lead to increased diagnostic accuracy and improved patient outcomes.
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Affiliation(s)
- Julien Dimastromatteo
- Department of Biomedical Engineering, University of Virginia, 415 Lane Road, Building MR5, Charlottesville, Virginia 22903, USA
| | - Teresa Brentnall
- Division of Gastroenterology, Digestive Diseases Center, 1959 Northeast Pacific Street, Seattle, Washington 98195, USA
| | - Kimberly A Kelly
- Department of Biomedical Engineering, University of Virginia, 415 Lane Road, Building MR5, Charlottesville, Virginia 22903, USA
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Diseases of the Pancreas. Fam Med 2017. [DOI: 10.1007/978-3-319-04414-9_96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Adibelli ZH, Adatepe M, Imamoglu C, Esen OS, Erkan N, Yildirim M. Anatomic variations of the pancreatic duct and their relevance with the Cambridge classification system: MRCP findings of 1158 consecutive patients. Radiol Oncol 2016; 50:370-377. [PMID: 27904444 PMCID: PMC5120578 DOI: 10.1515/raon-2016-0041] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 06/06/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The study was conducted to evaluate the frequencies of the anatomic variations and the gender distributions of these variations of the pancreatic duct and their relevance with the Cambridge classification system as morphological sign of chronic pancreatitis using magnetic resonance cholangiopancreatography (MRCP). PATIENTS AND METHODS We retrospectively reviewed 1312 consecutive patients who referred to our department for MRCP between January 2013 and August 2015. We excluded 154 patients from the study because of less than optimal results due to imaging limitations or a history of surgery on pancreas. Finally a total of 1158 patients were included in the study. RESULTS Among the 1158 patients included in the study, 54 (4.6%) patients showed pancreas divisum, 13 patients (1.2%) were defined as ansa pancreatica. When we evaluated the course of the pancreatic duct, we found the prevalence 62.5% for descending, 30% for sigmoid, 5.5% for vertical and 2% for loop. The most commonly observed pancreatic duct configuration was Type 3 in 528 patients (45.6%) where 521 patients (45%) had Type 1 configuration. CONCLUSIONS Vertical course (p = 0.004) and Type 2 (p = 0.03) configuration of pancreatic duct were more frequent in females than males. There were no statistically significant differences between the gender for the other pancreatic duct variations such as pancreas divisium, ansa pancreatica and course types other than vertical course (p > 0.05 for all). Variants of pancreas divisum and normal pancreatic duct variants were not associated with morphologic findings of chronic pancreatitis by using the Cambridge classification system. The ansa pancreatica is a rare type of anatomical variation of the pancreatic duct, which might be considered as a predisposing factor to the onset of idiopathic pancreatitis.
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Affiliation(s)
| | - Mustafa Adatepe
- Department of Radiology, Urfa Balõklõgol State Hospital, Urfa, Turkey
| | - Cetin Imamoglu
- Department of Radiology, Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Ozgur Sipahi Esen
- Department of Radiology, Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Nazif Erkan
- Department of Surgery, Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Mehmet Yildirim
- Department of Surgery, Bozyaka Training and Research Hospital, Izmir, Turkey
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Secretin-Stimulated Magnetic Resonance Imaging Assessment of the Benign Pancreatic Disorders: Systematic Review and Proposal for a Standardized Protocol. Pancreas 2016; 45:1092-103. [PMID: 27171509 DOI: 10.1097/mpa.0000000000000606] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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30
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New advances in the diagnosis of canine and feline liver and pancreatic disease. Vet J 2016; 215:87-95. [DOI: 10.1016/j.tvjl.2016.02.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/04/2016] [Accepted: 02/12/2016] [Indexed: 12/20/2022]
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Katabathina VS, Flaherty EM, Dasyam AK, Menias CO, Riddle ND, Lath N, Kozaka K, Matsui O, Nakanuma Y, Prasad SR. "Biliary Diseases with Pancreatic Counterparts": Cross-sectional Imaging Findings. Radiographics 2016; 36:374-92. [PMID: 26824512 DOI: 10.1148/rg.2016150071] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
On the basis of the similarities in the histopathologic findings and the clinical-biologic behaviors of select biliary and pancreatic conditions, a new disease concept, "biliary diseases with pancreatic counterparts," has been proposed. Both nonneoplastic and neoplastic pathologic conditions of the biliary tract have their counterparts in the pancreas. Immunoglobulin G4 (IgG4)-related sclerosing cholangitis is the biliary manifestation of IgG4-related sclerosing disease, and type 1 autoimmune pancreatitis is its pancreatic counterpart. People with chronic alcoholism can develop peribiliary cysts and fibrosis as well as pancreatic fibrosis and chronic pancreatitis simultaneously. Pancreatic ductal adenocarcinoma, intraductal papillary mucinous neoplasm, and mucinous cystic neoplasm are considered pancreatic counterparts for the biliary neoplasms of extrahepatic cholangiocarcinoma, intraductal papillary neoplasm of the biliary tract, and hepatic mucinous cystic neoplasm, respectively. The anatomic proximity of the biliary tract and the pancreas, the nearly simultaneous development of both organs from the endoderm of the foregut, and the presence of pancreatic exocrine acini within the peribiliary glands surrounding the extrahepatic bile ducts are suggested as causative factors for these similarities. Interestingly, these diseases show "nearly" identical findings at cross-sectional imaging, an observation that further supports this new disease concept. New information obtained with regard to biliary diseases can be used for evaluation of pancreatic abnormalities, and vice versa. In addition, combined genetic and molecular studies may be performed to develop novel therapeutic targets. For both biliary and pancreatic diseases, imaging plays a pivotal role in initial diagnosis, evaluation of treatment response, efficacy testing of novel drugs, and long-term surveillance.
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Affiliation(s)
- Venkata S Katabathina
- From the Departments of Radiology (V.S.K., E.M.F.) and Pathology (N.D.R.), University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229; Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.K.D.); Department of Radiology, Mayo Clinic at Scottsdale, Scottsdale, Ariz (C.O.M.); Department of Radiology, Singapore General Hospital, Singapore (N.L.); Department of Radiology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan (K.K., O.M.); Department of Pathology, Shizuoka Cancer Center, Shizuoka, Japan (Y.N.); and Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (S.R.P.)
| | - Erin M Flaherty
- From the Departments of Radiology (V.S.K., E.M.F.) and Pathology (N.D.R.), University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229; Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.K.D.); Department of Radiology, Mayo Clinic at Scottsdale, Scottsdale, Ariz (C.O.M.); Department of Radiology, Singapore General Hospital, Singapore (N.L.); Department of Radiology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan (K.K., O.M.); Department of Pathology, Shizuoka Cancer Center, Shizuoka, Japan (Y.N.); and Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (S.R.P.)
| | - Anil K Dasyam
- From the Departments of Radiology (V.S.K., E.M.F.) and Pathology (N.D.R.), University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229; Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.K.D.); Department of Radiology, Mayo Clinic at Scottsdale, Scottsdale, Ariz (C.O.M.); Department of Radiology, Singapore General Hospital, Singapore (N.L.); Department of Radiology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan (K.K., O.M.); Department of Pathology, Shizuoka Cancer Center, Shizuoka, Japan (Y.N.); and Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (S.R.P.)
| | - Christine O Menias
- From the Departments of Radiology (V.S.K., E.M.F.) and Pathology (N.D.R.), University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229; Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.K.D.); Department of Radiology, Mayo Clinic at Scottsdale, Scottsdale, Ariz (C.O.M.); Department of Radiology, Singapore General Hospital, Singapore (N.L.); Department of Radiology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan (K.K., O.M.); Department of Pathology, Shizuoka Cancer Center, Shizuoka, Japan (Y.N.); and Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (S.R.P.)
| | - Nicole D Riddle
- From the Departments of Radiology (V.S.K., E.M.F.) and Pathology (N.D.R.), University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229; Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.K.D.); Department of Radiology, Mayo Clinic at Scottsdale, Scottsdale, Ariz (C.O.M.); Department of Radiology, Singapore General Hospital, Singapore (N.L.); Department of Radiology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan (K.K., O.M.); Department of Pathology, Shizuoka Cancer Center, Shizuoka, Japan (Y.N.); and Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (S.R.P.)
| | - Narayan Lath
- From the Departments of Radiology (V.S.K., E.M.F.) and Pathology (N.D.R.), University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229; Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.K.D.); Department of Radiology, Mayo Clinic at Scottsdale, Scottsdale, Ariz (C.O.M.); Department of Radiology, Singapore General Hospital, Singapore (N.L.); Department of Radiology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan (K.K., O.M.); Department of Pathology, Shizuoka Cancer Center, Shizuoka, Japan (Y.N.); and Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (S.R.P.)
| | - Kazuto Kozaka
- From the Departments of Radiology (V.S.K., E.M.F.) and Pathology (N.D.R.), University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229; Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.K.D.); Department of Radiology, Mayo Clinic at Scottsdale, Scottsdale, Ariz (C.O.M.); Department of Radiology, Singapore General Hospital, Singapore (N.L.); Department of Radiology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan (K.K., O.M.); Department of Pathology, Shizuoka Cancer Center, Shizuoka, Japan (Y.N.); and Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (S.R.P.)
| | - Osamu Matsui
- From the Departments of Radiology (V.S.K., E.M.F.) and Pathology (N.D.R.), University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229; Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.K.D.); Department of Radiology, Mayo Clinic at Scottsdale, Scottsdale, Ariz (C.O.M.); Department of Radiology, Singapore General Hospital, Singapore (N.L.); Department of Radiology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan (K.K., O.M.); Department of Pathology, Shizuoka Cancer Center, Shizuoka, Japan (Y.N.); and Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (S.R.P.)
| | - Yasuni Nakanuma
- From the Departments of Radiology (V.S.K., E.M.F.) and Pathology (N.D.R.), University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229; Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.K.D.); Department of Radiology, Mayo Clinic at Scottsdale, Scottsdale, Ariz (C.O.M.); Department of Radiology, Singapore General Hospital, Singapore (N.L.); Department of Radiology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan (K.K., O.M.); Department of Pathology, Shizuoka Cancer Center, Shizuoka, Japan (Y.N.); and Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (S.R.P.)
| | - Srinivasa R Prasad
- From the Departments of Radiology (V.S.K., E.M.F.) and Pathology (N.D.R.), University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229; Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pa (A.K.D.); Department of Radiology, Mayo Clinic at Scottsdale, Scottsdale, Ariz (C.O.M.); Department of Radiology, Singapore General Hospital, Singapore (N.L.); Department of Radiology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan (K.K., O.M.); Department of Pathology, Shizuoka Cancer Center, Shizuoka, Japan (Y.N.); and Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (S.R.P.)
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Domínguez Muñoz JE, Lucendo Villarín AJ, Carballo Álvarez LF, Tenías JM, Iglesias García J. Spanish multicenter study to estimate the incidence of chronic pancreatitis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 108:411-6. [DOI: 10.17235/reed.2016.4056/2015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Anderson MA, Akshintala V, Albers KM, Amann ST, Belfer I, Brand R, Chari S, Cote G, Davis BM, Frulloni L, Gelrud A, Guda N, Humar A, Liddle RA, Slivka A, Gupta RS, Szigethy E, Talluri J, Wassef W, Wilcox CM, Windsor J, Yadav D, Whitcomb DC. Mechanism, assessment and management of pain in chronic pancreatitis: Recommendations of a multidisciplinary study group. Pancreatology 2016; 16:83-94. [PMID: 26620965 PMCID: PMC4761301 DOI: 10.1016/j.pan.2015.10.015] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 10/29/2015] [Accepted: 10/31/2015] [Indexed: 12/11/2022]
Abstract
DESCRIPTION Pain in patients with chronic pancreatitis (CP) remains the primary clinical complaint and source of poor quality of life. However, clear guidance on evaluation and treatment is lacking. METHODS Pancreatic Pain working groups reviewed information on pain mechanisms, clinical pain assessment and pain treatment in CP. Levels of evidence were assigned using the Oxford system, and consensus was based on GRADE. A consensus meeting was held during PancreasFest 2012 with substantial post-meeting discussion, debate, and manuscript refinement. RESULTS Twelve discussion questions and proposed guidance statements were presented. Conference participates concluded: Disease Mechanism: Pain etiology is multifactorial, but data are lacking to effectively link symptoms with pathologic feature and molecular subtypes. Assessment of Pain: Pain should be assessed at each clinical visit, but evidence to support an optimal approach to assessing pain character, frequency and severity is lacking. MANAGEMENT There was general agreement on the roles for endoscopic and surgical therapies, but less agreement on optimal patient selection for medical, psychological, endoscopic, surgical and other therapies. CONCLUSIONS Progress is occurring in pain biology and treatment options, but pain in patients with CP remains a major problem that is inadequately understood, measured and managed. The growing body of information needs to be translated into more effective clinical care.
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Affiliation(s)
| | | | - Kathryn M Albers
- Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Inna Belfer
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Randall Brand
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Suresh Chari
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Greg Cote
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Brian M Davis
- Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Luca Frulloni
- Department of Medicine, University of Verona, Verona, Italy
| | - Andres Gelrud
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Nalini Guda
- Department of Gastroenterology, Aurora St. Luke's Medical Center, Milwaukee, WI, USA
| | - Abhinav Humar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Adam Slivka
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Eva Szigethy
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jyothsna Talluri
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wahid Wassef
- Department of Medicine, University of Massachusetts, Worcester, MA, USA
| | - C Mel Wilcox
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John Windsor
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Dhiraj Yadav
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - David C Whitcomb
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Cell Biology & Molecular Physiology, University of Pittsburgh, Pittsburgh, PA, USA; Department of Human Genetics, University of Pittsburgh, Pittsburgh, PA, USA.
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Diagnostic Performance of Contrast-Enhanced MRI With Secretin-Stimulated MRCP for Non-Calcific Chronic Pancreatitis: A Comparison With Histopathology. Am J Gastroenterol 2015; 110:1598-606. [PMID: 26372506 DOI: 10.1038/ajg.2015.297] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 07/22/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Diagnosis of non-calcific chronic pancreatitis (NCCP) in patients presenting with chronic abdominal pain is challenging and controversial. Contrast-enhanced magnetic resonance imaging (MRI) with secretin-stimulated MRCP (sMRCP) offers a safe and noninvasive modality to diagnose mild CP, but its findings have not been correlated with histopathology. We aimed to assess the correlation of a spectrum of MRI/sMRCP findings with surgical histopathology in a cohort of NCCP patients undergoing total pancreatectomy with islet autotransplantation (TPIAT). METHODS Adult patients undergoing TPIAT for NCCP between 2008 and 2013 were identified from our institution's surgery database and were included if they had MRI/sMRCP within a year before surgery. Histology was obtained from resected pancreas at the time of TPIAT by wedge biopsy of head, body, and tail, and was graded by a gastrointestinal pathologist who was blinded to the imaging features. A fibrosis score (FS) of 2 or more was considered as abnormal, with FS ≥6 as severe fibrosis. A multivariate regression analysis was performed for MRI features predicting fibrosis, after taking age, sex, smoking, alcohol, and body mass index (BMI) into consideration. A quantitative receiver operating characteristic (ROC) curve analysis was performed and Spearman rank correlation coefficient (r) was calculated. RESULTS Fifty-seven patients (females=49, males=8) with NCCP and MRI/sMRCP were identified. ROC curve analysis showed that two or more MRI/sMRCP features provided the best balance of sensitivity (65%), specificity (89%), and accuracy (68%) to differentiate abnormal (FS≥2) from normal pancreatic tissue. Two or more features provided the best cutoff (sensitivity 88%, specificity 78%) for predicting severe fibrosis (FS≥6). There was a significant correlation between the number of features and severity of fibrosis (r=0.6, P<0.0001). A linear regression after taking age, smoking, and BMI into consideration showed that main pancreatic duct irregularity, T1-weighted signal intensity ratio between pancreas and paraspinal muscle, and duodenal filling after secretin injection to be significant independent predictors of fibrosis. CONCLUSIONS A strong correlation exists between MRI/sMRCP findings and histopathology of NCCP.
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Pancreatic ductal adenocarcinoma and chronic mass-forming pancreatitis: Differentiation with dual-energy MDCT in spectral imaging mode. Eur J Radiol 2015; 84:2470-6. [PMID: 26481480 DOI: 10.1016/j.ejrad.2015.09.023] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 09/01/2015] [Accepted: 09/27/2015] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To investigate the value of dual-energy MDCT in spectral imaging in the differential diagnosis of chronic mass-forming chronic pancreatitis (CMFP) and pancreatic ductal adenocarcinoma (PDAC) during the arterial phase (AP) and the pancreatic parenchymal phase (PP). MATERIALS AND METHODS Thirty five consecutive patients with CMFP (n=15) or PDAC (n=20) underwent dual-energy MDCT in spectral imaging during AP and PP. Iodine concentrations were derived from iodine-based material-decomposition CT images and normalized to the iodine concentration in the aorta. The difference in iodine concentration between the AP and PP, contrast-to-noise ratio (CNR) and the slope K of the spectrum curve were calculated. RESULTS Normalized iodine concentrations (NICs) in patients with CMFP differed significantly from those in patients with PDAC during two double phases (mean NIC, 0.26±0.04 mg/mL vs. 0.53±0.02 mg/mL, p=0.0001; 0.07±0.02 mg/mL vs. 0.28±0.04 mg/mL, p=0.0002, respectively). There were significant differences in the value of the slope K of the spectrum curve in two groups during AP and PP (K(CMFP)=3.27±0.70 vs. K(PDAC)=1.35±0.41, P=0.001, and K(CMFP)=3.70±0.17 vs. K(PDAC)=2.16±0.70, p=0.003, respectively). CNRs at low energy levels (40-70 keV) were higher than those at high energy levels (80-40 keV). CONCLUSION Individual patient CNR-optimized energy level images and the NIC can be used to improve the sensitivity and the specificity for differentiating CMFP from PDAC by use of dual-energy MDCT in spectral imaging with fast tube voltage switching.
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Bor R, Madácsy L, Fábián A, Szepes A, Szepes Z. Endoscopic retrograde pancreatography: When should we do it? World J Gastrointest Endosc 2015; 7:1023-1031. [PMID: 26322155 PMCID: PMC4549659 DOI: 10.4253/wjge.v7.i11.1023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 06/30/2015] [Accepted: 08/14/2015] [Indexed: 02/05/2023] Open
Abstract
Endoscopic retrograde pancreatography (ERP) is an accurate imaging modality in the diagnosis of pancreatobiliary diseases. However, its use has been substantially reduced due to the invasiveness of procedure, the risk of complications and the widespread availability of non-invasive cross-section imaging techniques (computed tomography, magnetic resonance imaging, and endoscopic ultrasound). Since the introduction of endoscopic sphincterotomy, ERP has transformed from diagnostic method to an almost exclusively therapeutic procedure. Pancreatic duct injection substantially increased the risk of post-ERP pancreatitis (1.6%-15.7%); therefore, according to international guidelines ERP is recommended only in cases where biliary intervention is required. However, the role of ERP in the management of pancreatic diseases is currently not clearly defined, but in some cases the filling of pancreatic duct may provide essential information complementing the results of non-invasive imaging techniques. The aim of this publication is to systematically summarize the literature dealing with the diagnostic yield of ERP. We would like to define the precise indications of ERP and overview a diagnostic protocol of pancreatic diseases depending on international guidelines and the opinion of Hungarian experts, because it may improve the diagnostic accuracy, minimize of burden of patients and reduce the risk of procedure related complications.
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Diseases of the Pancreas. Fam Med 2015. [DOI: 10.1007/978-1-4939-0779-3_96-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lévy P, Domínguez-Muñoz E, Imrie C, Löhr M, Maisonneuve P. Epidemiology of chronic pancreatitis: burden of the disease and consequences. United European Gastroenterol J 2014; 2:345-54. [PMID: 25360312 DOI: 10.1177/2050640614548208] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 07/23/2014] [Indexed: 12/13/2022] Open
Abstract
The epidemiology of chronic pancreatitis (CP) is incompletely understood. A number of difficulties exist in estimating the prevalence and incidence of CP. Long-term follow-up is often problematic, especially in chronic alcoholics, and obtaining a formal and standardised diagnosis can take years. The available studies are reasonably consistent in their estimation of the incidence of CP but few studies have attempted to estimate prevalence. Although life expectancy in CP is diminished compared with control populations, median survival lies in the range of 15-20 years. Such a survival would suggest a prevalence of CP rather higher than that determined from the survey studies. A recent epidemiological study in France found an annual incidence of 7.8 per 100,000. Assuming a survival of 15-20 years, the annual prevalence should be between 120 to 143 per 100,000. Overall, our understanding of the epidemiology of CP is poor compared with other illnesses. We consider that both prevalence and the rate of pancreatic insufficiency and of CP are currently underestimated. There is a distinct need for more studies to remedy this lack of knowledge.
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Affiliation(s)
- Philippe Lévy
- Service de Pancréatologie-Gastroentérologie, Pôle des Maladies de l'Appareil Digestif, DHU UNITY, Hôpital Beaujon, Faculté Denis Diderot, Clichy Cedex, France
| | | | - Clem Imrie
- University of Glasgow, Glasgow, United Kingdom
| | - Matthias Löhr
- Karolinska University Hospital & Karolinska Institutet, Stockholm, Sweden
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Manikkavasakar S, AlObaidy M, Busireddy KK, Ramalho M, Nilmini V, Alagiyawanna M, Semelka RC. Magnetic resonance imaging of pancreatitis: An update. World J Gastroenterol 2014; 20:14760-14777. [PMID: 25356038 PMCID: PMC4209541 DOI: 10.3748/wjg.v20.i40.14760] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Revised: 06/02/2014] [Accepted: 06/17/2014] [Indexed: 02/06/2023] Open
Abstract
Magnetic resonance (MR) imaging plays an important role in the diagnosis and staging of acute and chronic pancreatitis and may represent the best imaging technique in the setting of pancreatitis due to its unmatched soft tissue contrast resolution as well as non-ionizing nature and higher safety profile of intravascular contrast media, making it particularly valuable in radiosensitive populations such as pregnant patients, and patients with recurrent pancreatitis requiring multiple follow-up examinations. Additional advantages include the ability to detect early forms of chronic pancreatitis and to better differentiate adenocarcinoma from focal chronic pancreatitis. This review addresses new trends in clinical pancreatic MR imaging emphasizing its role in imaging all types of acute and chronic pancreatitis, pancreatitis complications and other important differential diagnoses that mimic pancreatitis.
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Adrian AM, Twedt DC, Kraft SL, Marolf AJ. Computed tomographic angiography under sedation in the diagnosis of suspected canine pancreatitis: a pilot study. J Vet Intern Med 2014; 29:97-103. [PMID: 25273956 PMCID: PMC4858079 DOI: 10.1111/jvim.12467] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Revised: 07/17/2014] [Accepted: 08/27/2014] [Indexed: 12/31/2022] Open
Abstract
Background Computed tomography (CT) is highly accurate for diagnosing pancreatitis in humans. The diagnosis of pancreatitis in dogs is based on clinical signs, laboratory findings, and ultrasonographic (US) changes. There are, however, inherent limitations in relying on laboratory and ultrasound findings for the clinical diagnosis of pancreatitis in dogs. Hypothesis/Objectives We hypothesized that CT angiography would be a rapid and reliable method to confirm pancreatitis in dogs compared to ultrasonography. The aim was to describe the CT characteristics and compare them to ultrasound findings and correlate the CT appearance to the severity of the patients' clinical course. Animals A prospective pilot case series; 10 dogs with pancreatitis were enrolled if the history, clinical signs, laboratory, and ultrasonographic findings were indicative of pancreatitis. Methods A 3‐phase angiographic CT was performed under sedation. Afterward, each dog had US‐guided aspirates of the pancreas collected and blood drawn for cPLi assay. Images were evaluated for portion of visible pancreas, pancreatic size and margin, pancreatic parenchyma, presence of peripancreatic changes and contrast enhancement pattern. The results were compared with outcome. Results An enlarged, homogeneously to heterogeneously attenuating and contrast‐enhancing pancreas with ill‐defined borders was identified in all dogs. CT identified more features characterizing pancreatic abnormalities compared to US. Thrombi were found in 3/10 dogs. Three dogs with heterogeneous contrast enhancement had an overall poorer outcome than those with homogenous enhancement. Conclusions and Clinical Importance CT angiography under sedation was used in dogs to confirm clinically suspected pancreatitis and identified clinically relevant and potentially prognostic features of pancreatitis in dogs.
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Affiliation(s)
- A M Adrian
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO
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Busireddy KK, AlObaidy M, Ramalho M, Kalubowila J, Baodong L, Santagostino I, Semelka RC. Pancreatitis-imaging approach. World J Gastrointest Pathophysiol 2014; 5:252-270. [PMID: 25133027 PMCID: PMC4133524 DOI: 10.4291/wjgp.v5.i3.252] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 02/13/2014] [Accepted: 05/16/2014] [Indexed: 02/06/2023] Open
Abstract
Pancreatitis is defined as the inflammation of the pancreas and considered the most common pancreatic disease in children and adults. Imaging plays a significant role in the diagnosis, severity assessment, recognition of complications and guiding therapeutic interventions. In the setting of pancreatitis, wider availability and good image quality make multi-detector contrast-enhanced computed tomography (MD-CECT) the most used imaging technique. However, magnetic resonance imaging (MRI) offers diagnostic capabilities similar to those of CT, with additional intrinsic advantages including lack of ionizing radiation and exquisite soft tissue characterization. This article reviews the proposed definitions of revised Atlanta classification for acute pancreatitis, illustrates a wide range of morphologic pancreatic parenchymal and associated peripancreatic changes for different types of acute pancreatitis. It also describes the spectrum of early and late chronic pancreatitis imaging findings and illustrates some of the less common types of chronic pancreatitis, with special emphasis on the role of CT and MRI.
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Graziani R, Mautone S, Ambrosetti MC, Manfredi R, Re TJ, Calculli L, Frulloni L, Pozzi Mucelli R. Autoimmune pancreatitis: multidetector-row computed tomography (MDCT) and magnetic resonance (MR) findings in the Italian experience. Radiol Med 2014; 119:558-71. [PMID: 24638911 DOI: 10.1007/s11547-013-0373-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 07/30/2013] [Indexed: 12/17/2022]
Abstract
Multidetector-row computed tomography (MDCT) and magnetic resonance (MR) imaging are currently the most frequently performed imaging modalities for the study of pancreatic disease. In cases of suspected autoimmune pancreatitis (AIP), a dynamic quadriphasic (precontrast, contrast-enhanced pancreatic, venous and late phases) study is recommended in both techniques. In the diffuse form of autoimmune pancreatitis (DAIP), the pancreatic parenchyma shows diffuse enlargement and appears, during the MDCT and MR contrast-enhanced pancreatic phase, diffusely hypodense and hypointense, respectively, compared to the spleen because of lymphoplasmacytic infiltration and pancreatic fibrosis. During the venous phase of MDCT and MR imaging, the parenchyma appears hyperdense and hyperintense, respectively, in comparison to the pancreatic phase. In the delayed phase of both imaging modalities, it shows retention of contrast media. A "capsule-like rim" may be recognised as a peripancreatic MDCT hyperdense and MR hypointense halo in the T2-weighted images, compared to the parenchyma. DAIP must be differentiated from non-necrotizing acute pancreatitis (NNAP) and lymphoma since both diseases show diffuse enlargement of the pancreatic parenchyma. The differential diagnosis is clinically difficult, and dynamic contrast-enhanced MDCT has an important role. In the focal form of autoimmune pancreatitis (FAIP), the parenchyma shows segmental enlargement involving the head, the body-tail or the tail, with the same contrast pattern as the diffuse form on both modalities. FAIP needs to be differentiated from pancreatic adenocarcinoma to avoid unnecessary surgical procedures, since both diseases have similar clinical and imaging presentation. The differential diagnosis is clinically difficult, and dynamic contrast-enhanced MDCT and MR imaging both have an important role. MR cholangiopancreatography helps in the differential diagnosis. Furthermore, MDCT and MR imaging can identify the extrapancreatic manifestations of AIP, most commonly biliary, renal and retroperitoneal. Finally, in all cases of uncertain diagnosis, MDCT and/or MR follow-up after short-term treatment (2-3 weeks) with high-dose steroids can identify a significant reduction in size of the pancreatic parenchyma and, in FAIP, normalisation of the calibre of the upstream main pancreatic duct.
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Affiliation(s)
- Rossella Graziani
- Department of Radiology, "G.B. Rossi" Hospital, University of Verona, P.le L.A. Scuro 11, 37134, Verona, Italy,
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Nikkola J, Rinta-Kiikka I, Räty S, Laukkarinen J, Lappalainen-Lehto R, Järvinen S, Seppänen H, Nordback I, Sand J. Pancreatic morphological changes in long-term follow-up after initial episode of acute alcoholic pancreatitis. J Gastrointest Surg 2014; 18:164-70; discussion 170-1. [PMID: 24002755 DOI: 10.1007/s11605-013-2279-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 06/24/2013] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The long-term morphological changes induced by a single episode of alcoholic pancreatitis are not known. Our aim was to study these morphological changes in secretin-stimulated magnetic resonance cholangiopancreatography (S-MRCP) after the first episode of alcohol-associated acute pancreatitis and to evaluate the risk factors and possible protective factors potentially associated with later chronic findings. We have previously reported 2-year follow-up results in pancreatic morphology. This study extends the follow-up to 9 years. PATIENTS AND METHODS In this prospective follow-up study, S-MRCP imaging was performed for 44 (41 M, 3 F; mean age, 46 (25-68) years) patients after their first episode of alcohol-associated pancreatitis. Pancreatic morphology was evaluated at 3 months and at 2, 7, and 9 years after hospitalization. Recurrent attacks of pancreatitis were studied and pancreatic function was monitored by laboratory tests. Patients' alcohol consumption was evaluated with questionnaires, laboratory markers, and self-estimated alcohol consumption via interview. Smoking and body mass index were annually recorded. RESULTS At 3 months, 32 % of the patients had normal findings in S-MRCP, 52 % had acute, and 16 % had chronic changes. At 7 years, S-MRCP was performed on 36 patients with normal findings in 53 %, the rest (47 %) having chronic findings. Pancreatic cyst was present in 36 %, parenchymal changes in 28 %, and atrophy in 28 % of the cases. There were no new changes in the pancreas in the attending patients between 7 and 9 years (18 patients). Of the patients with only acute findings at 3 months, 60 % resolved to normal in 7 years, but the rest (40 %) showed chronic changes later on. The initial attack was mild in 65 %, moderate in 25 %, and severe in 10 % of the patients. Patients with mild first attack had fewer chronic changes at 7 years compared to patients with moderate or moderate and severe together (p = 0.03, p = 0.01). Of the patients in the seventh year of S-MRCP, 22 % had suffered a recurrent episode of acute pancreatitis (mean, 22 (2-60) months) and 11 % had a clinical diagnosis of chronic pancreatitis. At 7 years, 88 % of the patients with recurrences had chronic findings in S-MRCP versus 36 % with nonrecurrent pancreatitis (p = 0.02). Six (17 %) patients abstained from alcohol throughout follow-up (mean, 8.7 (7-9.1) years), but even one of these developed pancreatic atrophy. Out of the non-abstinent patients who did not suffer recurrences, 4/22 (18 %) had developed new findings during at follow-up S-MRCP (NS). In univariate analysis, heavy smoking showed no correlation with increased chronic changes compared to nonsmoking. CONCLUSIONS Morphological pancreatic changes increase with recurrent episodes of acute pancreatitis. Patients with mild first attack have fewer chronic changes in the pancreas in the long term. However, even a single episode of acute alcoholic pancreatitis may induce chronic morphological changes in long-term follow-up.
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Affiliation(s)
- Jussi Nikkola
- School of Medicine, University of Tampere, Tampere, Finland
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Hansen TM, Nilsson M, Gram M, Frøkjær JB. Morphological and functional evaluation of chronic pancreatitis with magnetic resonance imaging. World J Gastroenterol 2013; 19:7241-7246. [PMID: 24259954 PMCID: PMC3831205 DOI: 10.3748/wjg.v19.i42.7241] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 07/13/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023] Open
Abstract
Magnetic resonance imaging (MRI) techniques for assessment of morphology and function of the pancreas have been improved dramatically the recent years and MRI is very often used in diagnosing and follow-up of chronic pancreatitis (CP) patients. Standard MRI including fat-suppressed T1-weighted and T2-weighted imaging techniques reveal decreased signal and glandular atrophy of the pancreas in CP. In contrast-enhanced MRI of the pancreas in CP the pancreatic signal is usually reduced and delayed due to decreased perfusion as a result of chronic inflammation and fibrosis. Thus, morphological changes of the ductal system can be assessed by magnetic resonance cholangiopancreatography (MRCP). Furthermore, secretin-stimulated MRCP is a valuable technique to evaluate side branch pathology and the exocrine function of the pancreas and diffusion weighted imaging can be used to quantify both parenchymal fibrotic changes and the exocrine function of the pancreas. These standard and advanced MRI techniques are supplementary techniques to reveal morphological and functional changes of the pancreas in CP. Recently, spectroscopy has been used for assessment of metabolite concentrations in-vivo in different tissues and may have the potential to offer better tissue characterization of the pancreas. Hence, the purpose of the present review is to provide an update on standard and advanced MRI techniques of the pancreas in CP.
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Foygel K, Wang H, Machtaler S, Lutz AM, Chen R, Pysz M, Lowe AW, Tian L, Carrigan T, Brentnall TA, Willmann JK. Detection of pancreatic ductal adenocarcinoma in mice by ultrasound imaging of thymocyte differentiation antigen 1. Gastroenterology 2013; 145:885-894.e3. [PMID: 23791701 PMCID: PMC3783557 DOI: 10.1053/j.gastro.2013.06.011] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2012] [Revised: 05/14/2013] [Accepted: 06/14/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS Early detection of pancreatic ductal adenocarcinoma (PDAC) allows for surgical resection and increases patient survival times. Imaging agents that bind and amplify the signal of neovascular proteins in neoplasms can be detected by ultrasound, enabling accurate detection of small lesions. We searched for new markers of neovasculature in PDAC and assessed their potential for tumor detection by ultrasound molecular imaging. METHODS Thymocyte differentiation antigen 1 (Thy1) was identified as a specific biomarker of PDAC neovasculature by proteomic analysis. Up-regulation in PDAC was validated by immunohistochemical analysis of pancreatic tissue samples from 28 healthy individuals, 15 with primary chronic pancreatitis tissues, and 196 with PDAC. Binding of Thy1-targeted contrast microbubbles was assessed in cultured cells, in mice with orthotopic PDAC xenograft tumors expressing human Thy1 on the neovasculature, and on the neovasculature of a genetic mouse model of PDAC. RESULTS Based on immunohistochemical analyses, levels of Thy1 were significantly higher in the vascular of human PDAC than chronic pancreatitis (P = .007) or normal tissue samples (P < .0001). In mice, ultrasound imaging accurately detected human Thy1-positive PDAC xenografts, as well as PDACs that express endogenous Thy1 in genetic mouse models of PDAC. CONCLUSIONS We have identified and validated Thy1 as a marker of PDAC that can be detected by ultrasound molecular imaging in mice. The development of a specific imaging agent and identification of Thy1 as a new biomarker could aid in the diagnosis of this cancer and management of patients.
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Affiliation(s)
- Kira Foygel
- Department of Radiology, Molecular Imaging Program at Stanford (MIPS); Stanford University, Stanford, California, USA
| | - Huaijun Wang
- Department of Radiology, Molecular Imaging Program at Stanford (MIPS); Stanford University, Stanford, California, USA
| | - Steven Machtaler
- Department of Radiology, Molecular Imaging Program at Stanford (MIPS); Stanford University, Stanford, California, USA
| | - Amelie M. Lutz
- Department of Radiology, Molecular Imaging Program at Stanford (MIPS); Stanford University, Stanford, California, USA
| | - Ru Chen
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Marybeth Pysz
- Department of Radiology, Molecular Imaging Program at Stanford (MIPS); Stanford University, Stanford, California, USA
| | - Anson W. Lowe
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Lu Tian
- Department of Health, Research & Policy, Stanford University, Stanford, California, USA
| | - Tricia Carrigan
- Translational Diagnostics, Ventana Medical Systems, INC, Tucson, Arizona, USA
| | | | - Jürgen K. Willmann
- Department of Radiology, Molecular Imaging Program at Stanford (MIPS); Stanford University, Stanford, California, USA
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Defining the accuracy of secretin pancreatic function testing in patients with suspected early chronic pancreatitis. Am J Gastroenterol 2013; 108:1360-6. [PMID: 23711627 PMCID: PMC5388854 DOI: 10.1038/ajg.2013.148] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Accepted: 04/08/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The diagnosis of chronic pancreatitis in patients with characteristic symptoms but normal pancreatic imaging is challenging. Assessment of pancreatic function through secretin pancreatic function testing (SPFT) has been advocated in this setting, but its diagnostic accuracy is not fully known. METHODS This was a retrospective review of patients who received SPFT at our tertiary care institution between January 1995 and December 2008 for suspected chronic pancreatitis. For all patients, medical records were reviewed for evidence of subsequent development of chronic pancreatitis by imaging and/or pathology. Patients were then categorized as "true positive" or "true negative" for chronic pancreatitis based on follow-up imaging or histologic evidence. RESULTS In all, 116 patients underwent SPFT. Of the 27 patients who tested positive, 7 were lost to follow-up. Of the remaining 20 SPFT-positive patients, 9 (45%) developed radiologic or histologic evidence of chronic pancreatitis after a median of 4 years (1-11 years). Of the 89 patients who had negative SPFT testing, 19 were lost to follow-up. Of the remaining 70 patients, 2 were eventually diagnosed with chronic pancreatitis based on subsequent imaging/histology after a median follow-up period of 7 years (3-11 years). The sensitivity of the SPFT in diagnosing chronic pancreatitis was 82% with a specificity of 86%. The positive predictive value (PPV) of chronic pancreatitis was 45% with a negative predictive value (NPV) of 97%. CONCLUSIONS In patients with suspected early chronic pancreatitis and normal pancreatic imaging, SPFT is highly accurate at ruling out early chronic pancreatitis with a NPV of 97%.
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Martínez J, Abad-González Á, Aparicio JR, Aparisi L, Boadas J, Boix E, de las Heras G, Domínguez-Muñoz E, Farré A, Fernández-Cruz L, Gómez L, Iglesias-García J, García-Malpartida K, Guarner L, Lariño-Noia J, Lluís F, López A, Molero X, Moreno-Pérez Ó, Navarro S, Palazón JM, Pérez-Mateo M, Sabater L, Sastre Y, Vaquero EC, De-Madaria E. Recomendaciones del Club Español Pancreático para el diagnóstico y tratamiento de la pancreatitis crónica: parte 1 (diagnóstico). GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36:326-39. [DOI: 10.1016/j.gastrohep.2012.12.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 12/14/2012] [Accepted: 12/27/2012] [Indexed: 12/20/2022]
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Marolf AJ, Kraft SL, Dunphy TR, Twedt DC. Magnetic resonance (MR) imaging and MR cholangiopancreatography findings in cats with cholangitis and pancreatitis. J Feline Med Surg 2013; 15:285-94. [PMID: 23143839 PMCID: PMC10816759 DOI: 10.1177/1098612x12466084] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Cholangiohepatitis/cholangitis is second only to hepatic lipidosis as the most common liver disease in cats and is often associated with concurrent pancreatitis. Magnetic resonance imaging (MRI) and MR cholangiopancreatography (MRCP) have developed into an accurate, highly sensitive and specific imaging tool for the diagnosis of biliary and pancreatic duct disorders in humans. In this prospective case series, 10 cats with suspected cholangitis and/or pancreatitis were enrolled based on clinical history, physical examination and appropriate diagnostic test results. MRI and MRCP sequences with secretin stimulation of the cranial abdomen were performed, and sonography and laparoscopic biopsies for histologic diagnosis were obtained for comparison. MRI detected pancreatic abnormalities in cats suspected of pancreatitis, including T1 pre-contrast hypointense and T2 hyperintense pancreatic parenchyma and a dilated pancreatic duct. The MRI findings of the liver were non-specific. Nine of 10 cats had biliary abnormalities, including gall bladder wall thickening, gall bladder wall moderate contrast enhancement and/or gall bladder debris. Eight of 10 cats had histologic evidence of pancreatitis, as well as hepatitis or cholangitis, with one cat diagnosed with hepatic lymphoma. The advantages of MRI/MRCP over sonography of these cats included the striking pancreatic signal changes associated with pancreatitis and the ability to comprehensibly assess and measure the pancreas and hepatobiliary structures without operator dependence or interference from bowel gas. MRI/MRCP imaging of the feline abdomen may be beneficial in cases with equivocal ultrasound imaging findings.
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Affiliation(s)
- Angela J Marolf
- Colorado State University, Veterinary Medical Center, Fort Collins, CO 80523, USA.
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Martínez J, Abad-González A, Aparicio JR, Aparisi L, Boadas J, Boix E, de Las Heras G, Domínguez-Muñoz E, Farré A, Fernández-Cruz L, Gómez L, Iglesias-García J, García-Malpartida K, Guarner L, Lariño-Noia J, Lluís F, López A, Molero X, Moreno-Pérez O, Navarro S, Palazón JM, Pérez-Mateo M, Sabater L, Sastre Y, Vaquero E, de-Madaria E. The Spanish Pancreatic Club recommendations for the diagnosis and treatment of chronic pancreatitis: part 1 (diagnosis). Pancreatology 2012; 13:8-17. [PMID: 23395564 DOI: 10.1016/j.pan.2012.11.309] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2012] [Revised: 11/13/2012] [Accepted: 11/18/2012] [Indexed: 12/11/2022]
Abstract
Chronic pancreatitis (CP) is a relatively uncommon, complex and heterogeneous disease. The absence of a gold standard applicable to the initial phases of CP makes its early diagnosis difficult. Some of its complications, particularly chronic pain, can be difficult to manage. There is much variability in the diagnosis and treatment of CP and its complications amongst centers and professionals. The Spanish Pancreatic Club has developed a consensus on the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. A list of questions was drafted, and two experts reviewed each question. Then, a draft was produced and shared with the entire panel of experts and discussed in a face-to-face meeting. This first part of the consensus addresses the diagnosis of CP and its complications.
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Affiliation(s)
- J Martínez
- Pancreatic Unit, University General Hospital of Alicante, Spain.
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Enrique Domínguez-Muñoz J, Iglesias-García J. Últimos avances en pancreatitis crónica. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 35 Suppl 1:86-90. [DOI: 10.1016/s0210-5705(12)70039-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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