Chronic pancreatitis

US & EUS diagnosis & treatment

Adrian Săftoiu
Gastroenterology & Hepatology Department
Elias Emergency University Hospital Bucharest, RO
University of Medicine and Pharmacy Carol Davila Bucharest, RO
Definition and classification
 Definition
– Recurrent inflammation > Interstitial fibrosis
– Ireversible destruction of pancreatic parenchyma
– Changes of pancreatic ducts
– Relative conservation of endocrine pancreas
 Classification
– Chronic calcifying pancreatitis
– Chronic obstructive pancreatitis
– Autoimmune pancreatitis
– Groove pancreatitis

Sarles H, Sahel J, Laugier R. Rev Prat 1991, 41: 1289-1295.

Diagnosis
Positive diagnosis
 Diagnosis is established via high quality imaging:
– Increased density of the parenchyma
– Atrophy of the gland
– Calcifications (intraparenchymal / intraductal)
– Pseudocysts
– Irregularities main pancreatic duct / side branches
 Usual tests
– Morfological
 Xray < US < CT < MRCP< EUS
– Functional
 Steatorrhea

Lohr MJ et al. UEG Journal (HaPanEU) 2017, 5: 153-199.

Positive diagnosis
 Guidelines for diagnostic imaging

Frokjaer JB et al. Pancreatology 2018; 18: 764-773.

Best imaging modality
 EUS, MRI, and CT are the best imaging
methods for establishing diagnosis
– GRADE 1C, strong agreement
– EUS outperforms other imaging tests
 Most sensitive imaging test
– Parenchymal criteria
– Ductal criteria
 Specificity increases with increasing diagnostic criteria
– GRADE 1B, strong agreement

Lohr MJ et al. UEG Journal (HaPanEU) 2017, 5: 153-199.

Criteria for diagnosis
 Parenchymal
– hyperechoic foci or lines
– cysts Clear diagnosis - 5 criteria
– lobularity No diagnosis < 2 criteria

 Ductal
– dilated pancreatic duct
 >3 mm head, >2 mm body, > 1 mm tail
– dilated secondary ducts
– hyperechoic Wirsung duct walls
– irregular Wirsung duct
– hyperechoic intraductal foci
International Working Group for Minimum Standard Terminology
for Gastrointestinal Endosonography
Aabaken L. Eur J Ultrasound 1999, 10: 179-183.
Advanced chronic pancreatitis
 Abdominal Xray
– L1-L2 calcifications
 High specificity
 Very low sensitivity
Advanced chronic pancreatitis
 Transabdominal ultrasound
– Can only be used to diagnose advanced chronic pancreatitis
 GRADE 1A, strong agreement
– 1st imaging modality
 Lower sensitivity/specificity as compared with CT/EUS
Advanced chronic pancreatitis
 Transabdominal ultrasound
– Can be used to detect complications
– Disadvantages > obscured visualisation
 Air
 Obesity
Chronic pseudotumoral pancreatitis
 Contrast-enhanced ultrasound (CEUS)
– Hyper- or iso-enhanced
 dependent on the degree of fibrosis
 differential diagnosis of focal solid pancreatic masses
– CEUS can increase diagnostic accuracy for solid lesions
 GRADE 1C, strong agreement
Pancreatic adenocarcinoma
 Typically hypoenhanced in all phases
– size and margins better detected by CEUS
– relationship with peripancreatic arteries and veins
– CEUS can increase diagnostic accuracy for solid lesions
 GRADE 1C, strong agreement
Pseudocysts
 Differentiation with cystic pancreatic tumors
– non-vascular inclusions (debris)
 vascular mural nodules
– avascular wall
– CEUS can increase diagnostic accuracy for cystic lesions
 GRADE 1C, strong agreement
Advanced chronic pancreatitis
 Spiral CT with pancreas protocol
– most appropriate method for identifying pancreatic
calcifications
– for very small calcifications non-enhanced CT is preferred
 GRADE 2C, strong agreement
Advanced chronic pancreatitis
 MR with MRCP
– The presence of typical imaging findings with MRI/MRCP is
sufficient for diagnosis
– normal MRI/MRCP cannot exclude
mild forms of the disease
 GRADE 1C, strong agreement
Early chronic pancreatitis
 Subset of chronic pancreatitis patients
– History (alcohol)
– Symptoms Up to 40 %
– Normal usual imaging tests
 Transabdominal US
 Computer tomography
 Magnetic resonance

Forsmark CE. Gastrointestinal Endoscopy 1999, 52:293-297.

Early chronic pancreatitis
 Diagnosis steps
– Morfological
 EUS
 ERCP
– Functional
 Secretin testing
 Gold standard not available
– Pathology
 Biopsy ? – Focal chronic pancreatitis
– Natural history

Draganov P, Toskes PP. Curr Opin Gastroenterol 2002, 18: 558-562.

Normal pancreas
 Normal parenchyma
– Homogenous, finely granular
 Ductal system
– Linear MPD, regular margins, < 3 mm

Sahai AV. Gastrointestinal Endoscopy 2002; 56: S76-S81.

Diagnostic criteria - EUS
 Parenchyma
– Low echogenicity and inhomogeneity
– Atrophy
– Hyperechoic bands and foci
– Lobularity (“honeycomb” appearance)
– Cysts / pseudocysts
– Parenchymal calcifications
 Ductal system
– Ductal dilatation
  3 mm head,  2 mm body,  1 mm tail
– Hyperechoic margins and irregular MPD
– Visible side branches
– Intraductal stones

Wallace MB, Hawes RH. Pancreas 2001; 23: 26-35.

Diagnostic criteria - EUS
 Prospective study – 9 EUS criteria
– Normal EUS  2 criteria
 ERCP and secretin testing normal
– EUS abnormal  5 criteria
 ERCP and secretin testing abnormal
– EUS slightly abnormal  3, 4 criteria
 Frequently, ERCP and secretin testing normal
 It is not clear whether the patients have early CP
 ROC (receiver operating curve) analysis ( 3 criteria)
– Sensitivity > 80%
– Specificity > 70%

Sahai AV et al. Gastrointestinal Endoscopy 1998; 48: 18-25.

Need of standardisation
 EUS criteria – parenchymal and ductal
 Major A  Minor
1. Hyperechoic foci with 1. Cysts
shadowing 2. Dilated MPD (> 3.5 mm)
2. Main pancreatic duct (MPD) 3. Irregular MPD contour
calculi 4. Dilated side branch (> 1 mm)
5. Hyperechoic MPD wall
 Major B 6. Strands
1. Lobularity (honeycombing) 7. Hyperechoic foci (non-
shadowing)
8. Lobularity (single)

Conference of EUS diagnosis of CP, Rosemont, Illinois, 2007.

Need of standardisation
 EUS diagnosis of chronic pancreatitis
 Definite  Suggestive  Indeterminate
 1 Major A + >  1 Major A + < 3  > 2 Minor
3 Minor Minor  < 5 Minor
 1 Major A +  Major B +> 3  Major B + < 3
Major B Minor Minor
 2 Major A  > 5 Minor
 Normal
 < 2 Minor

Conference of EUS diagnosis of CP, Rosemont, Illinois, 2007.

Advanced chronic pancreatitis
 Endoscopic ultrasound
– most sensitive imaging
technique for the diagnosis
– specificity increases
with increasing diagnostic criteria
– GRADE 1B, strong agreement
Early chronic pancreatitis
 Endoscopic ultrasound slightly abnormal
– Hyperechoic bands and foci
– Irregular & dilated MPD, with hyperechoic margins
Early chronic pancreatitis
 Normal ERCP and modified EUS
EUS FNA ?!
 Limited role for cytology diagnosis
– Comparative EUS vs ERCP EUS FNA vs ERCP
 Sensitivity 97% 100%
 Specificity 60% 67%
 PPV 94% 96%
 NPV 75% 100%
– Chronic inflammation
 Lymphocytes / macrophages
 Hyperplasic epithelial cells
 Necrosis / cell debris
 Protein plugs / calcifications

Hollerbach S et al. Endoscopy 2001; 33: 824-831.

Complications
Focal lesions in chronic pancreatitis
 Which imaging method allows a clear
differentiation?
 CT
 EUS
 EUS-FNA
Chronic pseudotumoral pancreatitis
 Extremely difficult to differentiate
– Increased vascularisation
Contrast-enhanced EUS
 CE-EUS  Hyper or iso-enhanced
– dependent on the degree of fibrosis
 pseudocysts can be easily visualised
– Contrast enhanced EUS needs to be assessed further
 GRADE 2C, strong disagreement
EUS elastography
 Different SH/SR can quantify degree of fibrosis
– EUS-guided elastography needs to be assessed further
 GRADE 2C, strong disagreement
Pancreatic adenocarcinoma
 Chronic pancreatitis > increased risk of carcinoma
– Imaging methods cannot differentiate all cases
– EUS FNA vs. ERP brush cytology
EUS FNA ERP brush cytology
– Sensitivity 85-95% 60%
– Specificity 100% 98%

Chang KJ. Gastrointest Endosc 2002; 56: S28-S34.

Confirmation of diagnosis
 Different methods of tissue diagnosis
– Brush cytology
– Transpapillary biopsies
– EUS-guided FNA
Pancreatic adenocarcinoma
 Most of them are hypoenhanced
– Over 90-95%
 Vessels indicate
poor differentiation
Cytology and microhistology
 Maximum accuracy > 90%
– Giemsa + Papanicolau stains
– Immunocytochemical stains

Vimentină

AE1 / AE3
Pseudocysts
 Endoscopic ultrasound (diagnosis)
– Method of choice for initial evaluation
 Distance lumen – pseudocysts content < 1 cm
 Detection of vessels: color sau power Doppler
– Digestive wall: gastric / duodenal varices
– Pseudocyst - wall: peripancreatic collaterals and vessels
 Content
– Anechoic  single stenting
– Hypoechoic (necrosis)  multiple stenting / nasocystic drainage
 Characterization of the wall
– Smooth, regular  pseudocysts
– Focal thickening  cystic tumors EUS-FNA

Fockens P. Gastrointest Endosc 2002; 56: S93-S97.

Pancreatic head pseudocyst
 Male 54 years old, chronic pancreatitis
– Simple pseudocyst with smooth wall
Pancreatic head pseudocyst
 Male 48 years old, chronic pancreatitis
– Echogenic content
 hydatid cyst ?!  infected pseudocyst  peritonitis
Differential diagnosis
 Cystic lesions
– serous cystadenoma
– mucinous cystadenoma
 clinical decision making
Clinical impact
 High clinical impact of EUS
– Change of tratament in 25%
C1 Transpapilary drainage
 Pancreatic head pseudocyst
– Communication with MPD (~ 60%)
C2 Transduodenal drainage
 Direct EUS & endoscopic control
C3 Transgastric drainage
 Direct EUS & endoscopic control
C4 Transesophageal drainage
 Real-time guidance
– Heart / major vessels !
C4 Transesophageal drainage
 Favourable evolution
– Complet drainage
Pancreatic pseudoaneurysm
 Doppler US + CT
Other vascular complications
 Splenic vein stenosis
– inflammatory changes in the pancreas
– turbulent flow in the splenic vein
– compression of the celiac trunk
Other vascular complications
 Splenic vein thrombosis
Specific types
Autoimmune pancreatitis
 Diagnostic criteria
Contrast EUS

Cho M. Gut Liver 2018

EUS-FNA/FNB
 Non-inferiority trial
– MOSE versus ROSE
Groove pancreatitis
 Diagnostic criteria
– type of chronic pancreatitis that affects the area between the
pancreatic head, the duodenum and the common bile duct
and can simulate, mask or coexist with pancreatic
carcinoma.
 severe chronic alcoholism
 heavy smoking
– Symptoms and signs
 severe abdominal pain, nausea, vomiting, and, in rare cases, acute
gastric outlet obstruction
 jaundice (as a result of distal common bile duct narrowing and
strictures)
 chronic weight loss
Groove pancreatitis
 TUS
– acute changes
 duodenal groove
 pancreatic head
– cystic spaces
– thick walls
– obstruction
Groove pancreatitis
 EUS
– acute changes
 duodenal groove
 pancreatic head
– calcifications
– cystic spaces
– thick walls
– increased vascularity
 EUS-FNA / EUS-FNB
to exclude malignancy
Conclusions
 Both transabdominal and endoscopic ultrasound have
a major role in the diagnosis of chronic pancreatitis,
even in the context of rapid improvement of other
imaging tests (CT / MR)

 EUS-guided FNA become an essential method to

obtain a tissue diagnosis of malignancy

 Interventional EUS enhanced the spectrum of

therapeutic procedures, with several applications
currently under evaluation
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