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: irisawa@fmu.ac.jp

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, an open access journal

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

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

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

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