American Pancreatic Association Practice Guidelines in Chronic Pancreatitis

Abstract

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

Diagnosis of Exocrine Pancreatic Insufficiency

“…The observation of 96 fat droplets per high power field is indicative of fat malabsorption. This threshold may not be reached until there is 920 g stool fat/day; so, this analysis is insensitive for mild disease [9].…”

Endoscopic ultrasound (EUS) guided fine needle biopsy (FNB) with the Procore™ needle provides inadequate material for the histological diagnosis of early chronic pancreatitis

“…Four and three Rosemont features of CP were observed via EUS in nine and two patients respectively. Eight patients were mild drinkers and smokers, whereas the remaining three patients had no risk factor for CP (4,22).…”

“…Severe morphological changes such as pancreatic calcifications, atrophy and a disturbed morphology of the pancreatic duct can be demonstrated by routine imaging techniques. These include computer tomography (CT), magnetic resonance imaging (MRI), transabdominal ultrasound and endoscopic ultrasound (EUS) (3,4). However, these methods are not sensitive enough for the detection of early changes that occur in CP.…”

“…However, these methods are not sensitive enough for the detection of early changes that occur in CP. In addition, mild morphological changes that may be detected are not specific to CP, thus making early diagnosis a challenge (4,5).…”

Pancreatic Diabetes Mellitus and Heavy Drinking are Risk Factors for the Development of Liver Fibrosis in Alcoholic Chronic Pancreatitis

“…CP was diagnosed on the basis of morphological diagnostic criteria [23,24]. Abdominal ultrasonography (US) and computed tomography (CT) were performed in all patients.…”