Diagnosis of Chronic Pancreatitis: ERCP and other modalities

1
Diagnosis of Chronic Pancreatitis ERCP and other
modalities
THIS SLIDE WILL GO. GARG WILL HAVE 6

• Pramod Garg,
• AIIMS, New Delhi

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Garg Diagnosis of CP ERCP and other modalities
CP Diagnosis

• CP pathologyEarly parenchymal changes, subtle
  ductal changes, diagnosis difficult
• Advanced dilatation, calculi, stricture,
  fibrosis, atrophic pancreas, diagnosis easy on
  US, CT
• Diagnostic investigations ERCP
• MRCP
• EUS
• Manometry
• Issues Interpretation
• Sensitivity and specificity
• Correlation with staging
• Etiological differentiation
• When to order which test?

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Garg Diagnosis of CP ERCP and other modalities
ERCP

• Ductal Changes
• Main pancreatic duct
• Side branches
• Diffuse or local (lt1/3rd of gland)
• ERCP Cambridge classification
• MPD Side Br.
• Equivocal N lt3 abnormal
• Mild changes N gt3 abnormal
• Moderate Abnormal -do-
• Marked changes Abnormal -do-
• dilatation, obstruction, filling defect
• (Axon et al. Gut 1984)

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Garg Diagnosis of CP ERCP and other modalities
ERCP usefulness

• Sensitivity 66-89, specificity 89-100
• Etiology alcoholic/tropical Stricture i, large
  stones, smooth dilatation
• CP vs. Ca Pancreas focal obstruction with smooth
  dilatation
• ( Saraya A, Tandon RK 2002)

Obstructive CP vs. CCP Autoimmune pancreatitis
MPD thinning Pancreas divisum Abnormal
Pancreato-biliary ductal union ? Association with
CP separate openings in 80 alcoholic
pancreatitis (Mishra SP, Anand BS. Ind J Gastro
1991)
ProblemsNo correlation with severity/ staging
no definite correlation with parenchymal
dysfunction no additional information in
advanced CP Complications (hpancreatitis,
sepsis)
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Garg Diagnosis of CP ERCP and other modalities
MRCP

• Sensitivity and specificity 90-95
• Early CP i sensitivity
• Secretin MRCP in suspected CP
• h sensitivity
• MPD 65?97, side br. 4?63
• Duodenal filling exocrine function
• (Manfredi et al. Radiology 2000)
• Problems
• Cost
• Low sensitivity in early CP
• No tissue sampling
• No therapy

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Garg Diagnosis of CP ERCP and other modalities
EUS

• Early CP Parenchymal, subtle duct change
• EUS diagnostic criteria for CP
  ParenchymalHeterogenous architecture, echogenic
  foci, small cystic areas, honeycombing
  Ductalirregularity, increased calibre,
  hyperechoic wall, intraductal protein plugs,
  stricture
• Sensitivity 85, Specificity 67
• Other information mass, tissue sampling,
  microliths
• Therapeutic pseudocyst drainage, celiac plexus
  block
• Pitfalls Low specificity False positive ? NUD,
  AP, Elderly High inter-observer disagreement
  Technically demanding High cost of equipment

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Garg Diagnosis of CP ERCP and other modalities
Manometry

• SOD association with CP controversial
• Ugljesic M et al 1996 no association
• Tarnasky PR et al 2001 association
• Rios GA good response to surgery
• Not useful clinically
• Increased risk of pancreatitis

Conclusion Advanced CP No role for diagnostic
ERCP Early CP EUS ERCP Secretin MRCP