-
J Gastroint Dig Syst Gastrointestinal Endoscopy ISSN: 2161-069X,
an open access journal
Journal of Gastrointestinal & Digestive System
Yamabe et al,. J Gastroint Dig Syst 2013, S2 DOI:
10.4172/2161-069X.S2-005
Review Article Open Access
Endosonographic Diagnosis of Chronic PancreatitisAkane Yamabe,
Athushi Irisawa*, Goro Shibukawa, Yoko Abe, Akiko Nikaido, Ko Inbe
and Koki HoshiDepartment of Gastroenterology, Fukushima Medical
University Aizu Medical Center, Japan
AbstractChronic pancreatitis (CP) is characterized by
irreversible damage that engenders fibrosis and necrosis of
pancreatic tissue, with the consequent loss of endocrine and
exocrine function of the pancreas. The clinical course of CP
engenders a high rate of morbidity and mortality over a 20-25-year
period. In view of this fact, current efforts emphasize the
establishment of early diagnosis to commence intervention that can
positively affect the natural course of the disease. Endoscopic
ultrasonography (EUS) is a well-established and less-invasive
modality for CP diagnosis. The higher imaging resolution provided
by EUS enables detection of subtle pancreatic abnormalities, not
only parenchymal but also ductal changes, that are undetectable
using other modalities. This review presents an overview of the
endosonographic diagnosis of chronic pancreatitis.
*Corresponding author: Athushi Irisawa, Department of
Gastroenterology, Fuku-shima Medical University Aizu Medical
Center, 21-2, Maeda, Yazawa, Kawahigashi, Aizuwakamatsu, 969-3492,
Japan, Tel: 81-0242-75-2100; E-mail: [email protected]
Received May 09, 2013; Accepted May 30, 2013; Published June 01,
2013
Citation: Yamabe A, Irisawa A, Shibukawa G, Abe Y, Nikaido A, et
al. (2013) Endosonographic Diagnosis of Chronic Pancreatitis. J
Gastroint Dig Syst S2: 005. doi:10.4172/2161-069X.S2-005
Copyright: © 2013 Yamabe A, et al. This is an open-access
article distributed under the terms of the Creative Commons
Attribution License, which permits unrestricted use, distribution,
and reproduction in any medium, provided the original author and
source are credited.
Keywords: Chronic pancreatitis; EUS; Early chronic
pancreatitis;ERP
IntroductionChronic pancreatitis (CP) is characterized by
irreversible damage
that engenders fibrosis and necrosis of the pancreatic tissue
[1], with the loss of endocrine and exocrine function of the
pancreas [2]. Alcohol is the most common etiology of CP in 64.8%
and idiopathy (unidentified) in 18.2%. Sarles et al. reported that
60-70% of patients with CP have a 6-12 year history of alcohol
abuse [3]. In addition, regarding the relationbetween smoking and
CP, smoking rates of CP patients are high (74.7%in men, 26.0% in
women). Furthermore, lifestyles that include drinkingand smoking
are strongly associated with the onset and progress ofCP. The
clinical course of CP engenders a high rate of morbidity
andmortality over a 20-25 year period. Moreover, CP is recognized
as a riskfactor of pancreatic cancer: patients with CP are 16 times
more likely todevelop pancreatic cancer than normal individuals are
[4]. In view ofthese facts, current efforts emphasize establishment
of early diagnosisto commence intervention that can positively
affect the natural historyof the disease: follow-up of CP in a
rigorous manner is necessary usingvarious modalities.
Endoscopic ultrasonography (EUS) is a well-established and
less-invasive modality for CP diagnosis [5-10]. Although endoscopic
retrograde pancreatigraphy (ERP) has been regarded as the gold
standard for CP diagnosis, ERP cannot investigate the parenchymal
changes. In that respect, the higher imaging resolution provided by
EUS enables detection of subtle pancreatic abnormalities, not only
parenchymal, but also ductal changes that are undetectable using
other
modalities. In this review, the authors describe the role of EUS
in CP diagnosis, especially in the early stage.
Normal Pancreas on EUSAn understanding of normal pancreas on EUS
is extremely
important for making EUS diagnosis of CP. The normal pancreatic
parenchyma is uniformly depicted in equal or a slightly less
hyperecho to the liver; it presents a so-called fine reticular
pattern. The main duct dilation, duct irregularity and side branch
ectasia are not visualized within the parenchyma [8]. Furthermore,
the main ductal wall is observed as a uniform and slightly
hyperlinear echo: 2.4 mm diameter in the head, 1.8 mm in the body,
and 1.2 in the tail [6]. The EUS image of CP is defined based on
these views. The EUS image of a normal pancreas is presented in
figure 1.
EUS Features of Chronic PancreatitisCP is characterized by
fibrosis of parenchyma along with ductal
changes in the pancreas. These changes of fibrosis have been
characterized as hyperechoic using ultrasound [11-13]. The
superiority of EUS is not so high in the case of advanced CP
because typical CP findings such as atrophy, calcification, main
duct dilation, duct irregularity, cyst are readily observed even
using other modalities. However, it is difficult to observe minute
changes of pancreatic parenchyma using means other than EUS. Among
patients with chronic pancreatitis, EUS will reveal all pancreatic
abnormalities. Typical EUS findings are shown in figures 2-6.
Diagnosis of CP using EUSTraditional EUS criteria for diagnosis
of CP
Several studies have compared EUS findings with ERP (Cambridge
classification) for CP evaluation [14]. Results of these studies
suggest that ductal and parenchymal abnormalities detected using
EUS correlate with the presence of CP. From these studies, the
traditional EUS criteria
Figure 1: Normal pancreatic parenchyma on EUS. Homogeneous and
finely reticular patterns are visible in parenchyma without dilated
ducts.
-
Citation: Yamabe A, Irisawa A, Shibukawa G, Abe Y, Nikaido A, et
al. (2013) Endosonographic Diagnosis of Chronic Pancreatitis. J
Gastroint Dig Syst S2: 005. doi:10.4172/2161-069X.S2-005
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J Gastroint Dig Syst Gastrointestinal Endoscopy ISSN: 2161-069X,
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for CP are recognized as follows: hyperechoic foci, hyperechoic
strands, parenchymal lobularity, irregular pancreatic duct margins,
hyperechoic pancreatic duct margins, visible pancreatic side
branches, pancreatic duct dilation, shadowing calcifications and
cysts. Opinions vary among researchers, but the presence of CP was
diagnosed when EUS revealed at least 2-3 of the features described
above. Our investigation also showed the over 80% patient who
showed changes over ‘equivocal’ in Cambridge classification had
more than three EUS findings [12]. In addition, the EUS is able to
evaluate the severity of CP depending on the number of criteria
present with high sensitivity and specificity. The disease severity
was classified as mild (2 or 3-4 features), moderate (5-6
features), and severe (more than 7 features), based on ERP findings
as a gold standard [8-10].
New EUS criteria for CP diagnosis
Several investigators have reported the total number of EUS
criteria, which is not only useful for diagnosis of CP but also for
assessing severity. However, individual EUS criteria are
considered
to have their own importance in each ERP grading. Consequently,
to discriminate against EUS features in every stage of CP, each EUS
criterion was made as a point of reference for comparison between
normal and varying degrees of CP. Irisawa et al. [12] reported the
important EUS features in each severity: hyperechoic foci in mild
CP, hyperechoic foci/visible side-branches/duct dilatation in
moderate CP, and visible side-branches/duct dilatation/duct
irregularity/calcification in severe CP (p
-
Citation: Yamabe A, Irisawa A, Shibukawa G, Abe Y, Nikaido A, et
al. (2013) Endosonographic Diagnosis of Chronic Pancreatitis. J
Gastroint Dig Syst S2: 005. doi:10.4172/2161-069X.S2-005
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J Gastroint Dig Syst Gastrointestinal Endoscopy ISSN: 2161-069X,
an open access journal
as ‘with shadowing’ or ‘without shadowing’; Lobularity is
subclassified as ‘with honeycombing’ and ‘without honeycombing’.
However, as pancreatic duct findings, Calcification/stone in main
duct are added to findings proposed previously such as Duct
irregularity and Side branch dilation and Main duct dilation and
Hyperechoic duct margins. Including subclassification, diagnostic
criteria are produced based on 12 items described above about EUS
findings and its grade. Creation of the newer Rosemont
classification carried the hope of accomplishing the following:
higher accuracy, better interobserver agreement, more well-received
descriptors used by referring doctors (‘consistent with’,
‘suggestive of ’, etc.) than the more conventional descriptors of
‘high probability’, ‘indeterminate’, or ‘intermediate probability’,
etc.). However, it was reported that most patients had the same
diagnosis irrespective of the criteria that had been used [16]. No
clear conclusion has been provided yet for whether traditional
criteria or Rosemont classification is superior for CP
diagnosis.
Proposed diagnostic criteria for early stage CP
Since the establishment of the landmark classification of
pancreatitis at the Marseille symposium in 1963 [17], many
classifications and diagnostic criteria have been proposed for
chronic pancreatitis. However, general diagnostic criteria for CP
are set for diagnosing advanced CP. They are unlikely to improve
patients’ prognoses. In 2009, the Research Committee on Intractable
Pancreatic Diseases supported by the Ministry of Health, Labour and
Welfare of Japan, the Japan Pancreas Society and the Japanese
Society of Gastroenterology
revised the criteria, including through the standpoint of
diagnosing early CP using EUS [18]. It is a challenge aimed at
improvement of the long-term prognosis of CP patients by early
diagnosis and therapeutic intervention in this disease.
This criteria comprise six items: (1) characteristic imaging
findings, (2) characteristic histological findings, (3) repeated
upper abdominal pain, (4) abnormal pancreatic enzyme levels in the
serum or urine, (5) abnormal pancreatic exocrine function, and (6)
continuous heavy drinking of alcohol equivalent to or more than 80
g/day of pure ethanol, as determined in accordance with criteria
for alcoholic CP reported by Ammann [19]. According to these
criteria, early CP is diagnosed by the presence of characteristic
imaging findings for early CP together with more than two items
among (3)-(6). The characteristic imaging findings for early CP
were set as the following seven EUS features (five parenchymal and
two ductal features): (1) lobularity with honeycombing, (2)
lobularity without honeycombing, (3) hyperechoic foci without
shadowing, (4) stranding, (5) cysts, (6) dilated side branches, and
(7) hyperechoic main pancreatic duct (MPD) margin [15] (Table 3).
More than two among the seven features including any of (1)-(4),
which are most likely to reflect fibrous changes in pancreatic
parenchyma, are judged to be sufficient for the EUS findings of
early CP [9-12,20,21]. It remains as a challenge for future study
to ascertain whether early CP diagnosed using these criteria
progress to advanced CP.
Correlation between EUS and histological findings
Several researchers have investigated whether EUS features of
CP
Rosemont criteriaParenchymal criteria Duct criteria
Major A Hyperechoic foci (>2 mm in length/width with
shadowing) MPD calculi (echogenic structure[s] within the MPD with
acoustic shadowing)
Major B Lobularity (≥ 13 contiguous lobules =
'honeycombing')
Minor Cyst (anechoic, round/elliptical with or without
septations) Dilated duct (≥ 3.5 mm in body or >1.5 mm in
tail)*Hyperechoic strands (≥ 3 mm in at least 2 different
directions with respect to the imaged plane) Irregular MPD contour
(uneven or irregular outline and ectatic course)
Hyperechoic foci (>2 mm in length/width with no shadowing)
Dilated side branch (>3 tubular anechoic structures each
measuring ≥1 mm in width, budding from the MPD)Hyperechoic MPD wall
(echogenic, distinct structure >50% of entire MPD in the body
and tail)
Table 1: Endoscopic ultrasound criteria for the diagnosis of
pancreatitis.
Rosemont criteriaConsistent with CP Suggestive of CP
Indeterminate for CP Normal
A 1 major A feature (+) ≥ 3 minor features 1 major A feature (+)
< 3 minor features 3 to 4 minor features, no major features ≤2
minor features, no major features
B 1 major A feature (+) major B feature 1 major B feature (+) 3
≥ minor features major B feature alone or with
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Citation: Yamabe A, Irisawa A, Shibukawa G, Abe Y, Nikaido A, et
al. (2013) Endosonographic Diagnosis of Chronic Pancreatitis. J
Gastroint Dig Syst S2: 005. doi:10.4172/2161-069X.S2-005
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J Gastroint Dig Syst Gastrointestinal Endoscopy ISSN: 2161-069X,
an open access journal
are correlated with histology. Specific criteria such as
hyperechoic foci, hyperechoic strands, and lobularity, which are
identified only by EUS, were estimated as correlated respectively
with histological findings as follows: focal fibrosis, bridging
fibrosis, and interlobular fibrosis (Table 4) [11].
Varadarajulu et al. [22] reported that EUS features were
significantly associated with histologic abnormalities in a
prospective study of 42 non-calcific CP (NCCP) patients.
Parenchymal EUS features that were significantly associated with
histopathologic NCCP were echogenic foci (p
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Citation: Yamabe A, Irisawa A, Shibukawa G, Abe Y, Nikaido A, et
al. (2013) Endosonographic Diagnosis of Chronic Pancreatitis. J
Gastroint Dig Syst S2: 005. doi:10.4172/2161-069X.S2-005
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more likely to develop pancreatic cancer than normal individuals
are. Strong evidence indicates the association of hereditary
pancreatitis and pancreatic cancer [4]. Therefore, the physician is
frequently faced with difficult decisions about how to manage the
risk. Nevertheless, the identification of pancreatic cancer in
advanced CP is extremely difficult. Some reports in the literature
demonstrate that EUS detectability of pancreatic cancer in patients
with CP is around 60% [32], and 54-74%, even if using combined
EUS-FNA [33-36]. Therefore, the follow-up of CP from early stages,
which is not detected using traditional modalities (e.g., CT,
ERCP), will be important to detect smaller cancer nodes.
ConclusionEUS is a useful and safe technique for detecting
pancreatic
parenchymal and ductal abnormalities, which are suggestive of
CP. Medical intervention for CP in the early stage, can improve the
CP prognosis.
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This article was originally published in a special issue,
Gastrointestinal Endoscopy handled by Editor(s). Dr. Rohan R.
Walvekar, LSU Health Sciences Center, New Orleans, USA
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TitleCorresponding authorAbstractKeywordsIntroductionNormal
Pancreas on EUS EUS Features of Chronic Pancreatitis Diagnosis of
CP using EUS Traditional EUS criteria for diagnosis of CP New EUS
criteria for CP diagnosis Proposed diagnostic criteria for early
stage CP Correlation between EUS and histological findings Issues
of CP diagnosis by EUS
Role and Future Development of EUS in CP Diagnosis
ConclusionFigure 1Figure 2Figure 3Figure 4Figure 5Figure 6Table
1Table 2Table 3Table 4References